Shulkin ousted from VA as Choice reforms are stalled

Embattled VA Secretary Dr. David Shulkin has been removed from his post, potentially releasing the stalled VA Choice reforms from their holding pattern but also throwing a wrench into his efforts to modernize the VA's electronic health records.

President Donald Trump announced Shulkin's resignation on Twitter Wednesday evening and tweeted that he would nominate presidential physician Dr. Ronny L. Jackson to be the new VA secretary.

Shulkin came under fire in February after an Office of Inspector General report found he had improperly accepted Wimbledon tickets and his staff had doctored emails to justify his wife traveling to Europe with him at taxpayer expense. Another blistering OIG report in recent weeks detailed often excruciating treatment of patients in VA health clinics due to lack of proper equipment. When the report came out, Shulkin announced a sweeping overhaul of medical center personnel, including two service network directors.

His removal comes at a critical point in what lawmakers say are urgent changes to the VA Choice program—debate over which had highlighted political tensions between Shulkin, lawmakers and the White House—as well as in the midst of his hefty effort to modernize the VA's EHR system.

On Wednesday, a White House official told Modern Healthcare that the next steps on VA Choice were waiting on the decision about Shulkin.

Congress has stalled in its attempts to pass these reforms since House Minority Leader Nancy Pelosi (D-Calif.) blocked them from the $1.3 trillion spending omnibus that passed last week. There is no other must-pass vehicle left this year.

Shulkin repeatedly stated that he opposed privatizing the VA, even as Trump officials pushed to expand private care options for vets. Last week, he pointed out to Senate lawmakers how tricky it was to strike a balance between opening up the Choice program to veterans who want or need private care while also shoring up the existing VA health system. The VA manages the healthcare of about 9 million veterans, roughly the size of Obamacare's individual market.

During one contentious hearing in February. Sen. Jerry Moran (R-Kan.), who had introduced rival legislation to the original bill passed out of the Senate Veterans' Affairs Committee, accused Shulkin of saying what both sides wanted to hear about the issue of veterans' access to community providers.

As the parties involved navigated that balance, House Democrats bristled over hard lobbying of the administration by the Koch-funded Concerned Veterans for America.

The most recent version of the compromise legislation, negotiated over the past few months between the Senate, White House, VA and House of Representatives, was resolved early last week but has not been released.

Political groups such as Concerned Veterans for America got involved, ruffling House Democrats in particular who blasted the administration for trying to privatize the VA.

Democrats are still worried about privatization, and depending on who Trump nominates as Shulkin's replacement these concerns may grow.

Shulkin's massive undertaking to modernize the VA's EHR system, and ease the sharing of records with the Defense Department, is another massive piece of unfinished business, completion of which could have defined his legacy.

The $1.1 billion initiative, which Shulkin has prioritized, has seen fits and starts since he awarded the contract to Cerner, leaving behind the VA's home-grown VistA EHR system. Congressional appropriators haven't been happy with the price tag, and the contract was held up over disagreement over the definition of interoperability. Shulkin has wanted to get the department's system to a point of interoperability and seamlessness that has so far stymied the VA.

The initiative was crucial for Shulkin, who jump-started the long-running effort to update EHRs that the VA had started in 2001 focused on VistA and stopped in 2010. The project would have ended in 2018 and cost a total of $11 billion.

Over the past few weeks, as rumors flew about Shulkin's potential ouster, lawmakers from both sides issued public statements of support for him.

"I think I speak for many on the committee that I hope in a year from now I hope to see Secretary Shulkin sitting in that chair," Sen. Sherrod Brown (D-Ohio) said at last week's Senate VA Committee hearing on Shulkin's proposed 2019 budget.

The committee's chair, Sen. Johnny Isakson (R-Ga.), reiterated Brown's praise and added: "I have pretty openly stated that on many occasions in the last two weeks, he's done a great job and veterans have a champion working for him every day."

House VA Committee Chair Phil Roe (R-Tenn.) earlier this month also affirmed his loyalty to Shulkin, whom he called the "right person" for a very difficult job because of his past experience as a healthcare executive.

"He understands healthcare; he understands large systems," Roe told Modern Healthcare. "He's the right person. It would be hard to find someone who would do a better job. Who are you going to get who would step in there and do that?"

Of the criticisms then swirling about Shulkin, Roe said, "I don't like everything that I do, either."

Rep. Brad Wenstrup (R-Ohio), who chairs the House VA health subcommittee, said simply: "We have gotten more done in the last year in a positive direction than we ever have in my more than six years on the committee. So I certainly stand by that."