The Department of Veterans Affairs has never enjoyed a reputation for doing its job well, no matter who was in charge — doctor, CEO, or soldier, Democrat or Republican.

Even before current VA Secretary David Shulkin came under fire for his travel expenses; before wait-time scandals, doctored records, and employee misconduct; even before the Iraq, Afghanistan, and Vietnam wars glutted the system with veterans in need, the department had its well-publicized problems.

The first official VA administrator, Frank Hines, resigned after World War II amid criticism that veterans were receiving shoddy treatment; his replacement, war hero and retired Gen. Omar Bradley, got savaged by the American Legion for leaving too many vets behind. “What we need in charge of the VA is a seasoned businessman, not a soldier, however good a soldier he may be,” the Legion’s national commander complained in 1946. (Businessmen, it turns out, have fared no better; Bob McDonald, appointed VA secretary in 2014, was the CEO of Proctor & Gamble. But even the Koch-funded pro-business vets’ group Concerned Veterans for America trashed his tenure as “an extension of the dysfunctional status quo,” a legacy of “lies and incompetence.”)

To the vet who sits in a huge VA waiting room, sweating out an appointment or a claim or a benefits review, the face in the wall photograph may change, but not much else seems to. More than a few have asked: Does it really matter who runs the VA? Is there a reason I should care?

Looking past Shulkin

That question is being asked more and more now, as Shulkin’s tenure looks increasingly in doubt. Until recently, Shulkin — appointed in the Obama era to run VA’s health system, and unanimously approved as the department secretary by the Senate in February 2017 — was what one veterans service organization official called “Trump’s good-news cabinet member” in conversations with Task & Purpose. That changed after a Feb. 14 inspector general report alleged Shulkin and his top staff committed “serious derelictions” in expensing a 10-day trip to Europe last year.

Though Shulkin has since repaid the expenses, the incident has followed him. Immediately following the report, stories emerged of a VA at war with itself. Many civil servants — including Shulkin himself — have suggested they’re being targeted by pro-privatization forces operating within the department, who sense an opportunity to remake the VA and outsource many of its functions. Amid these charges and counter-charges — calculated leaks, internal power struggles between career staff and political appointees — the White House’s patience with Shulkin seems to shift daily.

But if the embattled Shulkin were to depart soon, where would that leave the department? And could a replacement really change things up in ways that impact veterans walking through the door of their local VA clinic?

‘One of the most difficult jobs in government’

The VA is one of the federal government’s largest bureaucracies, with 360,000 employees and a budget of $186 billion — second only to the Department of Defense. It oversees education funding for veterans using the GI Bill and similar services; manages the nation’s military cemeteries; handles disability compensation benefits for those with service connected injuries; and its medical arm, the Veterans Health Administration, provides care to some 9 million enrolled veterans, making it the largest integrated healthcare system in the country.

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Like any other federal agency, it’s guided by a single individual. Given the size and scope of the VA’s mission, it may well be “one of the most difficult jobs in government,” Rep. Tim Walz of Minnesota, the ranking Democrat on the House Veterans Affairs Committee, told Task & Purpose.

“A good VA secretary understands healthcare systems, understands large organizations, figures out where the IT piece of that is, and has those skills to interface with the VSOs and then provides the leadership piece,” Walz explained. “That’s a lot, but that’s what it takes.”

The ‘P’ word: privatization

Many veterans’ advocates and lawmakers like Walz worry that a changing of the guard at the department would lead to a chaotic transition at best. At worst, they say, it could open the doors to privatization of the VA’s medical arm, parceling its functions off to the profit-seeking private sector — and prioritizing the welfare of health corporations over that of veterans.

“The VA is being used as the proving ground for privatization, and that’s something that the secretary has had to fight against,” Walz told Task & Purpose.

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Cabinet posts are inherently political; a change in presidents almost always comes with a change in department secretaries. But Shulkin, the Obama holdover, had the full confidence of the Senate and of President Trump last year; if he gets removed now, Walz said, “this wouldn’t be a shift that would happen with a switch in administration. This is a forced ideological shift that is coming and capitalizing on shortcomings that the secretary showed on those travel decisions.”

Along with rumors of Shulkin’s ouster have come suggestions for replacements — the names floated have included Trump’s secretary of energy, Rick Perry, and Pete Hegseth, a Fox News Channel contributor and former president of CVA, both of whom vocally support privatization in general. If Shulkin were replaced, the new nominee — whoever he or she is — would be the sixth person to sit in the secretary’s office in four years.

Some reforms need more time than politics allow

A sudden change in leadership, some veterans advocates worry, could also jeopardize ongoing efforts to improve systemic challenges facing the VA — many of which began under McDonald, Shulkin’s predecessor.

McDonald took the helm at the VA in 2014, succeeding Eric Shinseki, a respected retired general whose tenure was marred by the wait-list scandals. Following McDonald’s confirmation, the department saw a marked increase in completed patient appointments, and many veterans got more options for care outside of the VA through the Choice program, which permits recipients to see approved health providers in their community. A 2016 Rand report found that the quality of care provided at VA facilities was equal to or better than care delivered in the private sector.

Many of the policies that began under McDonald, from the Veterans Experience Program to appeals modernization and the Choice program have been carried forward during Shulkin’s tenure.

“A large and complex organization such as the VA requires continuity of effort, from one administration to the next, precisely because of the challenges it faces,” John Hoellwarth, a spokesman for AMVETS, told Task & Purpose. “And the road toward overcoming those challenges [is] often just as large and complex.”

Among the things that you can fix, but not overnight: efforts to end backlogs in claims and legacy appeals, reduce wait times, and overhaul the department’s electronic medical health record system. And sometimes those processes move slower to make sure they’re moving in a way that’s fair to vets, employees, contractors, and taxpayers.

“Programs and policies designed to address those challenges take time to plan, implement, evaluate and adjust,” Hoellwarth said. “In the absence of that continuity, you’re left with a situation in which the inconsistency of your solutions is precisely what’s enabling the persistence of your problems.”

Think of the VA secretary as a ship’s captain: trying to stay on track with small course corrections as the vessel navigates hazardous waters; directing the crew to make repairs; and fighting off the occasional mutiny.

It may be cliche, but the VA “is a giant, lumbering vessel that requires a lot of time and energy to right its course,” Griffin Anderson, a spokesman for the Democrats on the House Veteran Affairs Committee, told Task & Purpose. “To say the least, it takes a lot of effort, from a lot of people, to get it moving in the direction you want it to go. And the only way you’re going to be able to do that successfully is if you have people who know how to drive it.”

Trust still matters, even in Washington

Policy consistency is one thing, but consistent leadership is even more vital, Lou Celli, the American Legion’s national director for veterans affairs and rehabilitation, told Task & Purpose. A good leader at the top, he said, enables stakeholders — veterans, their respective service organizations, and advocates — to establish trust with the agency, which can help assuage fears over risky ventures.

Take the $1.3 trillion 2018 federal budget bill, which initially included additional VA funds to send more veterans to private sector providers through the VA’s community care programs. “There’s some risk there with the VSOs, as to how much community care will be shopped out into the community, versus how much of the veteran’s care will stay central to the VA,” Celli said. “We’re very concerned and watching very closely to ensure that VA isn’t cannibalized and that those dollars don’t just arbitrarily get spent in the community.”

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Shulkin’s strong relationship with veterans service organizations gave them a sense of ownership over the plan and helped reassure them it was consistent with VA’s mission; The American Legion and seven other major VSOs eventually signed onto the reforms, even though House Democrats succeeded in keeping them out of the final approved spending bill. (Handicappers say the reforms don’t have a chance of making it to the president’s desk as a standalone bill.)

“Without a secretary that we trust… we never would have gotten behind it, because there were so many risk factors involved,” Celli added. “And we only supported it because we believe that the secretary who’s in place now shares the same vision as the veterans and veteran service organizations have, and that is to ensure that the VA will remain central to all veteran care.”

A VA secretary is only as good as their president… and their Congress

As the House Dems showed when they quashed VA community care expansion in the budget bill, a VA secretary can make proposals, engage stakeholders, and build consensus, only to have the whole plan blown up by politics as usual.

That’s pretty much been a theme of Shulkin’s tenure. While he has remained largely bipartisan during his time at the VA, he’s faced conflicting pressures from the White House, lawmakers, and veterans service organizations on the Hill, as Task & Purpose previously reported.

“I don’t see Dr. Shulkin as an ideologue, I see him between a rock and a hard place,” Rep. Mark Takano, a California Democrat on the House Veterans Affairs Committee, told T&P March 20. “He’s under tremendous pressure from those on the right to privatize and then he has to deal with Congress and veterans service organizations who, for the most part, are not into privatization. As a result, he’s been very squishy on the issue.”

But a Veterans Affairs secretary also ultimately serves at the request of the elected president and his agenda, Dan Caldwell, the executive director for Concerned Veterans For America, told T&P.

“I do think it matters who the VA secretary is, but it ultimately matters more who’s president and what their veterans agenda is,” Caldwell added. “The VA secretary can be an incredibly powerful position, but the White House has a say here, and that’s with any administration. It just depends on how the White House decides to insert themselves or not insert themselves.”

The question, though, is how even a well-intending VA secretary can operate for the good of all veterans when he deals with so many political actors, all of whose calculations of “what’s good for the veteran” can differ dramatically. Can a secretary whose priorities necessarily zigzag with every election, budget fight, or late-night tweet really serve the veteran?

Yes and no. It largely depends on a leader — and a department — being able to keep their eyes on the ultimate goal, no matter the obstacles that may obscure it.

On that front, Shulkin has done well, Walz told T&P.

“Now, when you ask a VA employee who they work for, they say ‘for the veteran,’” he said. “They used to say whoever their supervisor was, and that’s the wrong answer.”

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