The grisly work of VA secretaries

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David Shulkin will be expected to play at least three roles if he is confirmed as President-elect Donald Trump’s Secretary of the Department of Veterans Affairs (VA): veterans’ advocate, fiscally responsible bureaucrat, and dependable political appointee.

As Sen. Alan K. Simpson, (R-Wyo.Y), put it in August 1982, at the height of a scandal surrounding Ronald Reagan’s first VA chief,  “It’s the greatest no-win shot I’ve ever seen in Washington.”

In some ways, David Shulkin is an aberration. He is the first non-veteran, and the second doctor, to be tapped to oversee the VA. He also does not fit the mold of a string of Cabinet nominees who, some fear, and others hope, will dismantle their respective departments. But his nomination makes perfect sense given the history and challenges of the agency he has been nominated to lead.    

{mosads}Before David Shulkin, there was Harry Walters. Two weeks after being nominated by President Ronald Reagan to oversee the Veterans Administration (VA) in Nov.ember 1982, Walters made his opening remarks to the Senate Committee on Veterans’ Affairs, and raised a thorny issue before anyone else did.

“As you know, I am not a combat veteran.”

Walters knew that some in the room were concerned that he was the first VA Administrator nominee to have served on active duty only during peacetime.

“I will never feel personally the emotions that millions of our combat veterans experienced, nor the pain and anguish they suffer,” he told the committee. But, he added, he had seen the faces and “torn bodies” of his friends, and had come to empathize with the “terrible effects of war.”

Walters, like Shulkin, was nominated at a moment of turmoil – to replace Reagan’s first VA Administrator, Robert Nimmo, who had proven to be, as an assistant to the president told the Los Angeles Times in July 1982, “a nightmare.”

A decorated World War II veteran, Nimmo refused to support studies on the long-term impacts of Agent Orange and publicly wondered whether the chemical’s effects were any worse than a case of “teenage acne.” As he advocated for cutting spending on veterans’ benefits, investigations revealed that he spent thousands of dollars redecorating his VA office and hiring a chauffeur to drive him to and from work.

A remorseless Nimmo told the New York Times in August 1982 that his workspace needed refurbishing because its bright blue furniture and wallpaper were “unsettling.” As for the driver, he was hesitant to park on his own in the garage near his office, because it was “big,” “empty,” and “dark,” he explained. “There is simply no security.”

It hardly helped Nimmo’s case, according to the Times, that the previous head of the VA, Vietnam veteran and triple amputee, Max Cleland, proved perfectly capable of driving himself to and from work every day.

In the wake of Bob Nimmo, Harry Walters’ lack of combat experience was a drop in the bucket, and veterans’ advocates widely supported his nomination.

In fact, Walters’ limited service experience may ultimately have helped during his tenure. As a veteran of neither World War II nor Vietnam, he was less likely to be accused of prioritizing one group over another. He could weigh the concerns of aging veterans, who feared new limits on their entitlement to free medical care, with those of Vietnam veterans who worried that the VA was not doing enough to combat the impacts of Agent Orange and PTSD.

Shulkin, too, is something of an outsider, and his nomination comes on the heels of widespread reports that the VA — especially its healthcare system, which serves aging veterans alongside a new generation — is in need of reform.

Even though advocacy groups are mindful that Shulkin is not a veteran, they generally support his nomination, in part because they recognize that veteran status is one of a bevy of qualifications for a job that is none too easy to fill. Trump said his team interviewed more than 100 candidates before settling on Shulkin.

Many were likely unwilling to take a job that has long been recognized as challenging and thankless. Omar Bradley wrote in his autobiography that he was “devastated” to be tapped by Harry Truman to head the VA in 1945. Frank Hines, who led the agency between the two World Wars, told the New York Times in 1922 that his friends wondered why he would leave a cushy position at a steamship company to take “a devil of a job” in Washington.

Hines, like other VA heads, was selected because of his military, government, managerial, and business expertise, but he had no background in medicine. It was not until George W. Bush’s 2007 nomination of physician James Peake that a doctor was tapped to lead the agency.

During his Senate confirmation hearings, Peake noted that he would seek to “complement” the efforts of his Undersecretary of Health: “With my medical background, I anticipate being able to more quickly make the decisions that he might bring to me since I do not anticipate needing ‘Medicine 101.’”

Shulkin’s selection highlights the centrality of VA health care in the overall benefits system, and a tacit recognition of the complexity of the problems it faces.

As the current VA Undersecretary of Health, he can hit the ground running and, presumably, base recommendations and decisions on professional experience and hard evidence rather than politics or ideology.

He has unique perspective on studies like one produced in 2015 by the RAND Corporation, which examined, among other things, how to combat the problem of long wait times for services. The top three policy options, according to RAND: growing the number of VA physicians, expanding virtual care, and formalizing “full practice authority” for some nurses. “Options with a policy objective of increasing access outside the VA system,” RAND found, “have considerable uncertainty related to potential impact.” Sending veterans to non-VA providers could, for example, bring about new challenges in terms of “care coordination.”

That data calls into question the extent to which Donald Trump’s preferred approach of expanding access to private care would help veterans.

Shulkin, like his predecessors, is faced not only with the burdens of convincing veterans he is fighting in their best interest and showing Congress that he is fiscally responsible, but also with considering policy solutions like those presented by RAND, which could run counter to the political aims of his boss, the president of the United States.

To return to the wise words of Sen. Simpson: “I can’t imagine a grislier task.”

Jessica L. Adler is an Assistant Professor of History and Health Policy & Management at Florida International University. Her book, Burdens of War: Creating the Veterans Health System, will be published by Johns Hopkins University Press this summer.

The views expressed by contributors are their own and not the views of The Hill.

Tags David Shulkin Department of Veterans Affairs Donald Trump Healthcare
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