Joe Biden has picked former White House chief of staff Denis McDonough to become the next Veterans Affairs Secretary. For what challenges McDonough is likely to face and how to deal with them, Federal Drive with Tom Temin turned to former secretary Dr. David Shulkin.
Tom Temin: Dr. Shulkin, good to have you back.
Dr. David Shulkin: I’m glad to be with you.
Tom Temin: So imagine Denis McDonough being confirmed and it looks like he probably will be and he enters the VA building for the first day of work. What’s first on the plate would you say?
Dr. David Shulkin: I think first on the plate has to be dealing with the pandemic. This is a national crisis that’s unfolding, a national emergency. And the VA, let’s remember, is the largest health care system in the United States. It has more doctors, more nurses, more pharmacists, more healthcare professionals working in its system than anyone else. And it has facilities in every part of the country. And one of the real missions of the VA is to be a backup national emergency system. And frankly, I’ve been very disappointed that the VA has not yet really shown the country what its capabilities are. So if you take a look at the vaccinations, it should be the VA who’s stepping up to help get those vaccinations out there, and no one’s talking about that. So I think that has to be the top priority. I know it’s going to be the priority of President Biden when he comes into office on January 20. And I know it’s going to be a priority of the new next secretary of the VA.
Tom Temin: I guess if there are 300 or 400 million arms to stick, just simply having the capacity in the nation of qualified people to give the shots when this thing starts to crest could be an issue.
Dr. David Shulkin: Well, look, the VA has facilities, as I said, in almost every part of the country, and it has the medical personnel to be able to do it. So this is something that people in the VA have trained for. It’s what I call the fourth mission at the VA to have this national backup system in times of emergency. I have never in my life lived through a health emergency like this and not to see the VA step up and let the country know its tremendous capabilities and the type of people that work in the VA system who are the highest trained professionals, I think, is a huge misstep. And this would be the very top priority that I would have. And that I hope that Denis McDonough should he be confirmed, and I believe that he will be, is going to need to have.
Tom Temin: And how should he deal with other priorities, the ongoing challenges of VA that we hope will come to the fore after the pandemic eventually passes? Because he’s going to need a career staff to help him there too, isn’t he?
Dr. David Shulkin: Absolutely. I think most people recognize the VA as the second largest government organization, with a budget now of $230 billion a year, is a very large complex organization. So when you’re secretary, you’re really doing a lot of jobs all at once. Some of them are to deal with the problems that are happening right at the time, like the pandemic and trying to keep the operations of the VA going. But you also need to have your eye on how the make sure that this is a sustainable VA system. And that means looking into the future about creating a strategic vision for how to care for veterans and how to serve veterans, and work with Congress and work with veterans organizations and work with the executive branch to get the right policies and the right legislation in place. And I think that the VA needs significant reform of many of those longer term policies such as its disability programs, and examples of how we as a country deal with veterans who have had toxic exposures like with burn pits, and still dealing with Agent Orange that, frankly, have just been passed from administration to administration, with our veterans being left in places without the help that they need.
Tom Temin: And there’s some projects at VA replacing their technology base, updating the health record systems, those are expensive, they can drain away a lot of time and money if not getting the right attention. So would you say those should be high on his priorities also, the next secretary?
Dr. David Shulkin: I think they have to be. One of the things that really surprised me coming from the private sector where I was a chief executive of health systems coming into the government was how far behind the federal government was in terms of utilizing technology. So the modernization of the VA system, both in terms of its facilities, as well as its technology, like information systems, and the way that it deals with its people, in terms of human resource systems and financial systems, was woefully behind. And I took strong steps to try to modernize that, including moving away from a homegrown electronic health system to a commercial electronic health care system. That was a big expensive project. And I didn’t make that decision lightly. As many people might know, I’m a physician, and I would put on my white coat and go to VA and take care of veterans. So I actually used these systems myself. This wasn’t hypothetical. But I will tell you, it is more expensive not to make these investments, maintaining old systems that have to be constantly repaired, but also take much, much more in terms of human resources to run them is probably the most expensive option. So a new secretary will have to keep focused on this. And this is a big job to put in a new information system across the country, the biggest electronic health records implementation that the country has seen in health care, but it has to remain a priority because it’s the right thing to do for veterans and for our taxpayers.
Tom Temin: What are some of the pitfalls an incoming new secretary might face?
Dr. David Shulkin: Well, it’s a very tough, complex job. I think that’s one of the benefits of having somebody like Denis McDonough in that he understands the complexity of Washington, he knows what it takes to get things done, having served as the former chief of staff at the White House. And you have to have a combination of both understanding the issues that are important to veterans, understanding the complexity of running large systems and health care and benefits, but also understand how to get things done in Washington. And it’s rare that a new secretary comes in with a complete understanding of the full scope of what it takes to be secretary. In other words, there’s always a learning curve. But Denis McDonough, I think, at least comes with a significant amount of expertise to help take these priorities and these initiatives and move them forward.
Tom Temin: I guess he above almost anyone would know how important it is for a secretary to have a good clear line to the President also, not be out there functioning without any White House support.
Dr. David Shulkin: I think that that is absolutely one of the keys that the Secretary has to have a strong relationship with the President and the full executive branch, particularly the Domestic Policy Council in the Office of Management and Budget. They play key roles in supporting the initiatives at VA. But also has to have a good relationship with Congress and a good relationship with the veteran community. And without having strong relationships in each of those areas, it’s very hard to get things done. And I don’t want to forget that another key area for any secretary is to have the support of the workforce, the men and women who serve in the VA are terrific individuals, but they’ve seen a huge amount of leadership change over the past few administrations. And therefore it’s really important that a secretary be able to communicate their priorities, their vision and get the support of that workforce.
Tom Temin: And one of the issues there is this lack of a contract and this long negotiation. And at least as far as the unionized workforce is concerned, labor relations are pretty bad at this point. So it seems like that would be a high priority to fix, how you do that it’s kind of a tough one.
Dr. David Shulkin: Well, the only thing that surprised me is is that they’re not worse than they are because, frankly, this past administration has been directly hostile towards the workforce. And that’s something that was very disappointing for me to see how far the relationships degraded after I left, the lack of trust, the lack of support,. And of course, coming from the private sector, and I’ve certainly been the chief executive of large unionized hospitals, I understood how important it was to find the common ground and to find the alignments with the workforce and with the unions. And of course, that alignment focuses in on serving your customer. In this case the veteran. And the union wants to be able to provide good quality care, wants to see a strong sustainable VA because that means that you’re going to continue to employ its members and fulfill the mission. And so there really shouldn’t be as bad a relationship as what we’ve seen in the last three years happen at VA.
Tom Temin: Dr. David Shulkin is former Secretary of Veterans Affairs. As always, thanks so much for joining me.
Dr. David Shulkin: Sure. Glad to be with you.