David Shulkin - It Shouldnt Be This Hard to Serve Your Country: Our Broken Government and the Plight of Veterans

A S BOTH A PHYSICIAN AND FORMER VOLUNTEER FIREMAN, PART OF my attraction to rushing into crisis situations is not knowing what Ill find when I get there. The same was true when I entered government. I had little preparation for my transition from the private to the public sector. Because government presents an entirely new set of rules and a culture completely different from anything Id ever experienced, I had to reset expectations and quickly develop an approach that I thought would work.

This book is the story of my service, first as under secretary, then as secretary of the US Department of Veterans Affairs (VA). When I was first summoned to Washington, there were chilling reports of excessive wait times for VA medical care in many parts of the country. There was also an unacceptable breakdown in delivery of mental health and addiction care, which left veterans of Iraq and Afghanistan to fend for themselves during epidemics of traumatic brain injuries and posttraumatic stressneglect that led to myriad suicides and overdoses. The VA health care system was all but publicly declared to be on life support.

So when the call came, I knew I could not say no. It was my time to serve.

Many of my colleagues questioned my decision to enter government service, insisting that coming to the VA would expose me to reputational risk, while others pointed out that it would be a financial blow. But my sense of civic responsibility easily overshadowed those voices. I went in knowing that running the VA would be the greatest test of my managerial skills and that it would require putting to use everything I had learned during my past thirty years in health care management.

There are more than twenty million American veterans, more than 40 percent of them living in rural areas, and many of them rely on VA benefits just to get by. More than nine million of our veterans rely on VA health care, a system that is spread across the entire country, with approximately one thousand facilities and more than 350,000 employees. Its the largest health care system in the country and one of the most complicated organizations in the government. Dealing with the size and scope, budget realities, capital deficits, and political pressure surrounding the VA is nearly impossible under the best of circumstances.

Working for two different administrations under two very different presidents also presented special challenges and insights. President Obama was analytical, pensive, and at times appropriately cautious. This approach ensured that improvement initiatives were carefully planned, but it also led to a slower adoption of change. President Trump and his team shot first and aimed later, but this tumultuous and frenzied environment actually allowed me to take more risks, move faster, and in many cases make more meaningful change.

Using the experience I gained in the Obama administration and the freedom I was given in the Trump administration, I took advantage of the opportunity to change the VA. We broke new ground by publishing our wait times and quality data, expanding benefits for mental health services, and adding benefits for those with Other-Than-Honorable discharges. We dramatically increased our technological sophistication through greater reliance on telehealth and by moving toward a new electronic health record system that would connect seamlessly with the Department of Defense. We made real advances in timely access to care, and we implemented important changes that resulted in veterans having more choice in where they received their care. In large part, we found a formula for moving away from the status quo and getting the system back on track.

Part of that formula involved working more closely with the private sector and making the VA more competitive with industry practices. This was essentially a middle ground between a fully government-run organization and privatization. With Americans polarized over almost every issue, I hoped that caring for veterans wouldnt get entangled in the usual DC gamesmanship. The longer I was in the capital, the more I was sorely disappointed.

Much of my narrative deals with the factions pushing me to simply close the VA or at least large parts of it that werent working well. But I didnt see how shutting down a system specifically designed to care for veterans could be in the veterans best interests. My strong belief is that my job was to find solutionsno matter how many problems plagued the VAin order to make the existing system work better.

We made real progress during my time at the VA. The morale of the workforce was growing. We were passing new legislation. We were working more closely with our community partners, and we were making the structural changes to ensure sustainable improvements. I had found a way to get things done despite the turmoil within the Trump administration, and things seemed to be running smoothly.

Until they werent.

To be clear, I did not set out to tell the story of how much the VA accomplished in three years and how I was fired by a Trump tweet on the eve of passing the most important bill in the history of veterans medical care because I wanted anyone to feel sorry for me. I am telling my story because, in my opinion, the VA is still in grave danger. Its doctors, its administrators, and most importantly our veterans are at risk as never before.

In large part, Washington works not just when you have the right plan but also when you have the right alignment of interests. Much of what I did as secretary was to work with the veterans groups, Congress, VA employees, and the administration to find the right path forward. Ultimately the political chaos that became evident within the Trump administration overtook the ability to get the job done. My struggle with the internal political appointees and their outside allies became the biggest challenge of my tenure in government.

The VA was once thought to be the only part of the federal government that was above politics. But under President Trump, the VAs mission and resolve were undermined by the people we used to refer tojokingly for a while, until it was no longer funnyas the politicals. Some of them are associated with the Koch brothers empire, which many people believe has the shortsighted goal of dismantling the VA, based on the mistaken belief that private industry can necessarily care for veterans more effectively.