November 08, 2019

David Shulkin

Former Department of Veterans Affairs Secretary David Shulkin joins Firing Line to discuss his tenure in the Trump administration before the president fired him by tweet. Shulkin explains his argument against privatization of the VA, a policy dispute that he believes led to his dismissal. He also addresses Trump’s leadership style and defends his controversial travel while in office.

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He says he was shocked when President Trump picked him to lead the Department of Veterans Affairs and then again when he was fired, this week on ‘Firing Line.’

I’ve come here for one reason and that’s to improve the lives of veterans and that’s what I’m focused solely on doing.

The only holdover from the Obama administration to join Donald Trump’s cabinet, Secretary David Shulkin inherited a V.A. that had been plagued with problems.

A congressional report laid out what it calls profound deficiencies in the system.

Shulkin says he was on the way to fixing the country’s largest healthcare system…
In order to get this fixed, I believe I was on the right track.

…but disagreed with key Trump advisers on how to do it.

I wasn’t happy with the speed with which our veterans were taken care of.

With care for millions of veterans on the line, what does David Shulkin say now?

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Secretary Shulkin, welcome to ‘Firing Line.’

I’m glad to be here.

You were the Secretary of Veterans Affairs under President Trump, and you were the Undersecretary of Veterans Affairs under President Obama.
You served both presidents, Democrat and Republican.
And you are a physician by training.

Yes.

And a healthcare executive.
You’ve now written a book — ‘It Shouldn’t Be This Hard to Serve Your Country.’

Right.

I’d like to start at the beginning.
When you were being interviewed by Donald Trump, something that you said, ‘an interview you had like no other.’

Right.

You’re sitting there across from Donald Trump at the desk.
What does he say to you?

Well, you know, this is when I was first beginning first time I met the President-elect and began to learn that he doesn’t do things necessarily like you expect or the way that I had anticipated.
And so it was it was difficult to sort of adjust quickly.
But he’s very quick.
And the very first thing that he said to me was, ‘You’re good-looking.’
So that sort of caught me off guard.
You don’t know how to respond to that, but it was a very, very easy conversation.
He is quick to ask questions, he’s quick to offer his opinions about things, and so we were able to cover a lot of ground.

And so you left not knowing whether you got the job or not.
And then, this happened on television.

By the way, speaking of veterans, I appointed today the head secretary of the Veterans Administration, David Shulkin.
He’s fantastic.
He’s fantastic.
He will do a truly great job.

Is that the moment you learned that you had been appointed?

When I met with the President-elect, I didn’t think that this was a job interview.
I thought that this was more of an exit interview.
As an Obama appointee, I was preparing to leave on January 20th.
I had my letter of resignation prepared.
So, I wasn’t thinking along those lines.
And watching that clip, it was a little bit like watching the Oscar moment.
You know, he was — he had a piece of paper, and he was fumbling for it.
And so, I was somewhat surprised by that.

You’re the first V.A.
secretary not to have been a veteran.
How do you think that changed your experience?

For me, I felt a special responsibility to really be close to our veteran community to make sure that I was representing their needs and what they wanted.
So I would put on my white coat as a doctor, and I would go to V.A.s, and I would take care of patients and veterans, and that really helped me understand why this was a special place.

You wrote in your book that you were not the new kid on the block.
You understood how the V.A.
worked, and you were able to to leverage your experience in a new administration that didn’t really know how Washington operated when you started.

During the first year that I was secretary, this ability to have a White House that was still somewhat loose so it gave me the opportunity to have direct access to the president and because I had a plan on how to reform and essentially improve the V.A., I was able to go to him and say, ‘Mr. President, I think that we need to do the following things,’ and he would usually ask whether this was a good thing for veterans, and if so, he would tell me to go ahead and do it.

So, you had more access to the President than you did under the Obama administration.

Yes.

And that was a good thing for the V.A. and for veterans.

I think we got a lot done, and I think that was a good thing for veterans.

You also wrote in your book that President Obama was, at times, appropriately cautious, which led to the slower adaptation of change.

Right. I think — I think the style differences between President Obama and President Trump are pretty stark.
And I think President Obama was very analytic, questioned a lot, very thoughtful about any types of policy changes.
And given the need that we had to make major changes in the V.A., at times, I thought we could have gone faster on some things.
President Trump was exactly the opposite.
And so I think that, in the beginning, that really worked well.
And I think when you end up with some policy decisions being implemented that aren’t necessarily the right ones that that is problematic.
So, these two were very, very different.

Well, you came into the Veterans Affairs Administration and the Obama administration after a period of significant scandal.
There had been a whistleblower report.
There had been a period of time where wait lists were untenable, frankly.
Veterans were not receiving the care they needed.
Here’s a sample of some of the coverage of those scandals that were plaguing the V.A.
before you arrived.

Some of America’s military veterans, men and women, we all owe a tremendous debt to, are dying.

Patients were dying while waiting and waiting and waiting for care.

40 patients died at the V.A. hospital in Phoenix.

Managers were actually keeping two waiting lists — a sham list that made the hospital look like a model of efficiency and a secret list that showed the deadly reality.

Well, first of all, it’s still hard for me to watch those clips.
I was a private citizen.
I was the CEO of a hospital when I, like everybody else as a citizen, was watching what was happening to our veterans.
So when I eventually arrived in Washington, I arrived with a mandate.
We put in same-day services across every V.A. in the country so that veterans with the urgent problems could be seen that day.
We published all of our wait times publicly so that veterans and the public could see what those wait times are.
There’s still much more work to be done, but we made a significant improvement.

Another place where work has been done but more is left to do is in this epidemic of veteran suicides, especially recent returned veterans from Iraq and Afghanistan.
How did you tackle this as V.A. secretary?

Well, the first thing that I did was, I made sure that everybody understood that this was a significant problem, and I made reducing veteran suicide the top clinical priority of the V.A.
And I’m pleased that this has continued to be a top clinical priority for the V.A.
And when you begin to start looking at this issue, you realize V.A. can’t address this alone.
It needs the help of community partners.
And so this is going to be a long battle, and we’re gonna need to get very creative about finding research that can help veterans but most importantly to make sure that they know that they’re not alone.

So, when you left the administration, you wrote an op-ed in and the substance of the article was about privatizing the V.A.
And your argument was that the Trump administration saw you as an impediment to their desired privatization of the V.A.
Can you explain to me what your philosophy of the proper role between the V.A. and private healthcare should be?

Yeah. I have articulated a model for the V.A.
which was a hybrid model of a strong V.A., a sustainable V.A., that we modernize to focus on the services that veterans need that they can’t find in the private sector.
Traumatic brain injury, post-traumatic stress, prosthetics and orthotics, rehabilitation, behavioral healthcare services, and strong comprehensive primary care.
But that the V.A.
doesn’t have to do everything, that if a veteran needs super specialized care that the private sector does better or simple services that they can get more conveniently, they should be able to go into the private sector.
So it was this middle ground.
And as you know in Washington these days, it’s actually easier to be at one end of a political spectrum.
And so, the very left, it’s that the private sector should have nothing to do with government, and on the very right, it’s that government shouldn’t be involved at all in the delivery of services like healthcare.
And so, when you’re in the center, which is what I thought the right answer was, it can be a lonely place in Washington.

So just to get some specifics, something like eyeglasses.
Right? If you’re a veteran and you need glasses, should you have to go to a Veterans Administration facility?

Well, my answer is no.
And in the V.A., that does make eyeglasses now, it often takes three visits for a veteran to go and get fitted and to come back and get their glasses.
It often takes two to three weeks, and the selection is not great.
And so I don’t believe the V.A.
needs to be in the business of replicating things that the private sector does well where there’s not an access problem.
But now let’s take behavioral healthcare, where in the V.A., you have an incredible team of professionals who understand what veterans have gone through and are available for them.
And, unfortunately, in the private sector, when you tried to use your insurance in a — for mental healthcare services, it’s often very tough and complex.
And access is really tough to get high-quality care in some areas.
So I think we can’t just voucher out behavioral healthcare the way that we could with eyeglasses.

When you say ‘voucher out,’ what do you mean?

Well, the ultimate way that you would privatize the system is that you would give a veteran a voucher and say, ‘Go out and find your healthcare services and send the government the bill.’
I don’t think anybody is arguing that we have a responsibility.

Who is really arguing for full privatization?
I mean, there, of course, are always gonna be some think tanks on the right or the left that are arguing for something that doesn’t have means.
It doesn’t seem to me that there’s a lot of mainstream support for a full privatization of the V.A.
Am I wrong?

Well, I don’t think that there are many people that will publicly come out and say that, but I will tell you, having been in the position I am, there are many people who believe that government has no role in the delivery of services to its citizens, that government has a role in protecting the country, the government has a role in doing things that are unique —
Do you think there are people in the Trump administration that don’t believe that the government should be in the position of delivering any healthcare to veterans?

I believe that there are people in the administration who believe the best solution would be to take away the current way that we deliver care and let the private sector do it.
I believe everybody believes that Americans have a responsibility to our veterans and that they would be willing to pay for that.
I don’t think anybody wants to walk away from that.
But I believe that there is a argument and a debate about the best way to get there.

It seems to me that the debate is about choice.
Right? And it seems like there’s bipartisan support for veterans having more choice.
I want to show you a clip of bipartisan support for choice.

Veterans should be guaranteed the right to choose their doctor and clinics, whether at a V.A.
facility or at a private medical center.

It is important, in my view, for the nation to take advantage of the expertise that’s out there in the private sector.

I’ve always believed that veterans could choose and should choose.

Is it really about full privatization, or is it about allowing the private sector to fill the stop-gaps where the Veterans Affairs Administration is falling short?

I don’t think anybody argues that the private sector has a role in filling the gaps where the V.A. falls short.
I think that this is an issue of that we need to make sure that there is a V.A.
for those services that, frankly, veterans need that the private sector can’t supply.
If you simply just completely open up the system all at once without putting the resources into modernizing, strengthening those parts of the V.A., the concern is, is that the V.A. may not be strong enough to survive if there’s simply a mass exodus of resources from the V.A.

Can you explain that to me?

Yeah.
So, I think that the belief that veterans should be able to choose where they get healthcare is something that I feel strongly about.
I support that.
But in order to get there from where we are today, we have to make sure that we do this in a plan that allows that choice to happen in a timeframe that we also make sure that we don’t destroy the V.A. healthcare system.
So, the plan that I had put out was to modernize the services that are needed for veterans and strengthen them and, at the same time, begin to start opening the aperture to allow veterans to have the choice that we all believe they deserve.
When I first joined the V.A., 19% of veterans were getting their care in the community.
When I left, it was 36%. What I was trying to do, as an experienced healthcare executive, is to drive this change to give greater choice in a manner and pace that would allow us to be left with a strong, sustainable V.A.
and a strong partnership with the private sector.
And, unfortunately, people that did not have a good understanding of the complexity of healthcare and the complexity of driving this change became anxious that this wasn’t happening fast enough or that this wasn’t ideologically aligned with where they were going.
And I believe that this is why these decisions need to be left in the hands of professionals.

So, maybe we can get more specific so I can understand exactly what your complaint is.
Because, you know, a few months after you left, Congress passed the Mission Act.

Yes.

Which is named in part for the late Senator McCain, who supported it.
And it was modeled after many of your proposals.
What you write in your book is that even though you support the Mission Act, when you read it, you said the blood drained from your face.

Yes.

Why? What was so problematic about the Mission Act?
Which, by the way, is an act that allowed veterans to make more choices.

The Mission Act is a good law and something that I strongly supported.
I worked on the elements of the Mission Act for over three years, and I’m glad that this is now law.
When we did the Mission Act and worked towards this, the area that I had the most concerns about was what are called access standards, and they are the rules that govern how a veteran actually decides to be able to get their care outside of the V.A.
I had felt strongly that access rules needed to be based on clinical criteria.
As a doctor, as a person who’s led large healthcare systems in the private sector, all of our systems in the private sector are based on the clinical need of a patient.
Unfortunately, when I read the access standards that were selected and now being used, they were based on administrative rules.
They’re based on how many minutes it takes you to drive to a V.A.
or how many days it takes to get an appointment at the V.A.
And my concern is, is that I don’t know any system that’s based on minutes and wait times.
That we need to make sure that every veteran has their clinical needs met.

What about veterans who live four hours away from the — from the closest V.A. hospital?
What happens to them?

Right.
So, if you live four hours away and you have a clinical problem that requires care in an urgent way, you should be able to go to the facility that’s closest to you, you should be able to access urgent care, and that’s all part of the Mission Act.

Which can be private and that’s —
Absolutely.

When you said the blood drained out of your face, does that mean that you are now opposed to the Mission Act?

The Mission Act did some very good things.
I absolutely supported it.
It put in place permanently the ability for veterans to be able to get care in the community when their needs are not met.
But these access standards are the ones I’m most concerned about.
And the good news is, it’s not part of the law.
So, at the Secretary’s discretion, they can be changed.
And if we continue to watch this and study it and if some of the concerns that I have are true, some of these unintended consequences, then we simply have to make the changes to the right access standards.
So I’m very optimistic about where this can go in the future.

It’s interesting.
As we’ve had a national debate about the best way to deliver healthcare to veterans over the course of our country’s history, and especially since 1974 when William F. Buckley considered this question on his program, the original ‘Firing Line,’ Max Fine, who was a healthcare advocate and in John F. Kennedy’s administration, joined William F. Buckley on the original program to discuss providing universal healthcare to all Americans.
And they discussed the stigma associated with socialized medicine.
Let’s take a look.

President Nixon really has confused this issue around socialized medicine because he keeps calling this bill that we’re supporting socialized medicine.
The last time was the day that he came out of the Bethesda Naval Hospital and he said when he goes in the hospital, he wants those doctors to be working for him, the patient, and not to be working for the federal government.
But all the doctors at Bethesda Naval Hospital are working for the federal government.
He doesn’t have anything against socialized medicine so long as the people don’t get in on it.

How do you reflect on the argument about socialized medicine and the stigma of socialized medicine?

Well, first of all, I hope 35 years from now, they’re looking at this film and saying that they were talking about important issues, as well.
But, you know, I tried to stay away from bringing politics into caring for veterans, and I worked very hard to keep the V.A. issues in a bipartisan way.
And so this issue about socialized medicine is really — I don’t think it’s particularly helpful.
I think we all recognize that veterans deserve the very best that this country can deliver, and I think that that means that there is a role for government and there is a role for the private sector.
So this is a open debate about the best way to get there.

So, I’d like you to take a look at something that President Trump said while signing a Veterans Affairs bill in 2017.

I also want to express our appreciation for Secretary Shulkin, who is implementing the dramatic reform throughout the V.A.
It’s got to be implemented.
If it’s not properly implemented, it will never mean the same thing.
But I have no doubt it will be properly implemented.
Right, David?

Absolutely.

Oh, it better be, David.
[ Applause ] [ Laughter ] Ah, we’ll never have to use those words.
[ Laughter ] We’ll never have to use those words on our David.
We will never use those words on you, that’s for sure.
[ Laughter ]
How do you reflect on that moment now?

Well, again, you know, we’ve seen this time and time again with President Trump.
He and I had a very good relationship.
It was focused on getting things done, and the President likes to get things done.
He loves to be making progress and sign bills.
And at the same time, he’s very quick to change his mind.
And so that’s the style that we’ve all had to get used to.
And so while he may be happy at one moment, like he was there, he can quickly change his mind.
And I was just as surprised when I got a tweet saying that I was being replaced.

I mean, getting a tweet has now become a euphemism for being ‘You’re fired.’

When I joined the administration, I didn’t even know that was possible.

Why do you think you were fired?

I think that the President felt that I was not moving in the direction that he thought that we should be going.

In other words, there was a substantive policy difference?

Yes.

And what was that policy difference?

The policy difference was, this was exactly at the time that we were trying to determine what these access standards were.
And I was not willing to compromise my principles in what I thought was the right decision for veterans.
And I believe strongly that we needed these clinical access standards.
And, in fact, the Senate committee had voted 14-to-1 in favor of the way that I thought that this should be done.
And the White House was siding with the one vote.

This seems like a reasonable policy disagreement, not something somebody should get fired for.

Yeah.
And, you know, I think that, in retrospect, I wish that the President had talked to me about this, because I believe that I was trying to do the right thing, and I believe that he wanted to do the right thing.

Ask for a meeting?

Not after I received the tweet.

So you didn’t have an opportunity to talk about the issue.

I did not have the opportunity.

You say policy differences for your firing, but the Inspector General had also investigated an overseas trip you had taken to Europe.
There were other embattled officials in the Trump administration, including Secretary Price, Secretary Carson, Scott Pruitt.
Let’s take a look at some of the coverage about all of you.

We’ve been tracking the spending by members of the President’s cabinet, taxpayer dollars.

The latest member of President Trump’s cabinet getting heat for high-priced travel.

The cost to taxpayers?
More than $122,000.

So it’s the same kind of scandal that ended the career of Tom Price that now threatens the tenure of EPA administrator Scott Pruitt.
But in the case of V.A.
secretary David Shulkin, it’s worse on several levels.

Was it worse on several levels?

Well, in my book, I’ve laid out everything in detail because I want people to read the book and make up their own mind on that.
You know, I maintain I did everything appropriately, that there was nothing that wasn’t approved.

The one thing the I.G. report said — suggested — is that you probably erroneously accepted tickets to Wimbledon.
Right? And probably should have paid for them.
Do you view that as an ethical lapse?

Look, here’s the — here’s the facts on this.
This was a Saturday afternoon.
Like many Americans, my wife and I went to a tennis game with friends.
And there was no government money involved.
The person who gave us those tickets had no dealings with the V.A., wasn’t even a citizen of this country, wasn’t looking for a job with the V.A., and had no relationship.
And so I don’t believe that that is a prohibited source, which is what the rule says, that you shouldn’t accept gifts.
But, look, regardless, you know, even though there was no taxpayer money, we’ve more than happily gave the money to the Treasury that represented what those tickets were.
Because, look, you know, the belief that anybody would go to government to take advantage of taxpayers — You know, I was a private sector CEO, and I went to government for one reason and that is to make this country’s system of caring for its veterans better.

So, why is it so hard to serve your country?
Taking from the title of your book.

The title the book has a double meaning.
First of all, it’s really written for veterans and about them.
So when you come back and you’ve served your country, it shouldn’t be hard.
You shouldn’t have to go through the bureaucracy and the hoops just to get the benefits that, frankly, you’ve earned.
But the second meaning of it is, is that we do need to be very, very careful about creating an environment in Washington where people will no longer be willing to come and to serve their country.
So I think it’s time for a reset in the environment in Washington.
I think that we need to stop attacking each other.
I think we need to start really respecting people in public service.
And particularly when it comes to veterans, we need to really re-create a bipartisan environment because we have much more in common when it comes to making sure that people who enter the military aren’t entering as a Democrat or Republican but they’re really entering for their love of country and their protection of the Constitution.

Secretary Shulkin, thank you for coming to ‘Firing Line.’

Thank you.

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