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"Veterans for Trump" bumper stickers sit on a chair before a campaign event with Donald Trump, presumptive 2016 Republican presidential nominee, on veterans reform in Virginia Beach, Virginia, U.S., on Monday, July 11, 2016. Trump said he expects to choose his running mate for the GOP presidential ticket in the next three or four days and is leaning toward a political pick to balance out his outsider status, according to a Monday interview with the Washington Post. Photographer: Andrew Harrer/Bloomberg via Getty Images

Can President Trump keep his promises to veterans?

As a candidate, Donald Trump made veterans services a top issue. He promised to overhaul the Department of Veterans Affairs, saying often that veterans aren’t treated with the respect they deserve. He put out a 10-point policy plan, and even went so far as to say he would personally respond to veterans’ complaints if he won the election.

President Trump’s campaign plan for reforming the VA, though light on specifics, boiled down to two main goals: holding the agency’s employees more accountable and improving veterans’ access to health care.

Now, nearly three months into his administration, Mr. Trump is facing a number of barriers to achieving one of his main promises on the campaign trail.

Of course, the VA’s problems began long before Trump took office. It has struggled to reduce wait times for veterans seeking health care and hire employees in understaffed facilities. And the department’s decades-old infrastructure is in desperate need of costly upgrades, even while the agency has been criticized for wasteful spending — all issues which extend back several administrations.

Secretary David Shulkin, the person Trump appointed to lead the agency, has already faced questions from critics about his ability to enact meaningful change. In a phone interview, Shulkin said Trump had already taken steps to deliver on his promise to improve veteran care. Still, Shulkin acknowledged the president’s mission won’t be easy.

“I do think it is going take a combination of investing in the right types of devices to modernize the system as well as managing the system differently to fix the VA,” Shulkin told the NewsHour. “The president and I have talked about what it’s going to take to get the VA fixed, and he has provided us with the budget and the resources in order to accomplish that.”

Holding the VA accountable

Tapping Shulkin to lead the VA represented Trump’s first step towards reforming the agency. It was in many ways an unexpected choice from an outsider president who opted for non-politicians — like Rex Tillerson at the State Department and Steve Mnuchin at Treasury — to lead other federal agencies. Shulkin, a medical doctor, served as the VA undersecretary of health under former President Barack Obama. He is the only cabinet member who served under the previous administration.

After Shulkin was nominated, some lawmakers were openly skeptical, fearing his appointment meant the department would not get the overhaul it needed with an insider at the helm. It was a question Sen. Dan Sullivan, R-Alaska, put to Shulkin during his confirmation hearing.

“How can you assure veterans [that] some of the big focuses that President Trump has talked about are going to happen on your watch, when, to be honest, you’ve been part of the outgoing administration?” Sullivan asked. Shulkin responded that he should be replaced as secretary if he can’t deliver on Trump’s promises.

Others saw Shulkin’s nomination as an opportunity to move more quickly on reform.

“There’s still a lot that Dr. Shulkin has to prove to us as secretary, but given some of the options and names that were tossed around, we landed in a place we are pretty optimistic about,” said Allison Jaslow, a former Army captain and the chief of staff for Iraq and Afghanistan Veterans of America. “People didn’t need a secretary spending six months on getting the building to work for him.”

U.S. President Donald Trump and Secretary of Veterans Affairs David Shulkin (2nd L) meet with representatives of veterans organizations at the White House in Washington, U.S. March 17, 2017. REUTERS/Jonathan Ernst - RTX31JEQ

President Donald Trump and Secretary of Veterans Affairs David Shulkin, center, meet with representatives of veterans organizations at the White House on March 17, 2017. REUTERS/Jonathan Ernst

Veterans groups have met with Shulkin several times since Trump took office, and advocates say they feel they have input with policymakers at the agency.

Still, under Shulkin, the VA’s efforts to increase accountability have been met so far with mixed results. A recent report on the veterans suicide hotline, in particular, offered a reminder of how far the agency still needs to go to meet veterans’ basic needs.

An inspector general audit in March found that nearly one third of all calls to the Veterans Crisis Line were transferred to an outside contractor because of busy phone lines, potentially putting some veterans on hold for 30 minutes or more.

The House Veterans Affairs Committee questioned agency officials about the problem earlier this month, warning the VA that it needed to follow through on promises to fix the issue. The agency has answered nearly 2.6 million calls from the hotline and dispatched emergency responders in nearly 70,000 cases, according to the panel’s chairman, Rep. Phil Roe, R-Md. But VA data shows on average 20 veterans still commit suicide every day, Roe said.

“There is very clearly a need for more to be done — and soon — so that we can be assured that every veteran or family member who contacts the VCL [Veterans Crisis Line] gets the urgent help he or she needs every single time without fail or delay,” Roe said at the hearing.

Shulkin told PBS NewsHour the inspector general report was using outdated information. In recent weeks, 99 percent of phone calls have been answered, Shulkin said, thanks to the hiring of 200 new crisis line responders.

The controversy played out as Republicans have sought other ways to improve accountability at the VA.

Last month, The House of Representatives passed the “VA Accountability First Act of 2017,” a bill that would expand the VA secretary’s authority to fire or demote employees based on poor performance or misconduct. The bill passed on a largely party-line vote, with support from only 10 Democrats.

But it’s facing opposition from unions who argue the measure would hurt job security and workers’ rights.

“Backhanded efforts to eliminate employees’ workplace rights do nothing to improve the VA or veterans’ care,” J. David Cox Sr., the president of the American Federation of Government Employees union, said in a statement. “In fact, it leaves our nation’s veterans without the advocates who are empowered to speak up on their behalf every day.”

Veterans’ health care funding

Delivering on Trump’s other main veterans-related campaign pledge — improving health care accessibility — is arguably even harder. Depending on who you ask, the root cause of the problem has to do with a lack of federal funding, or the agency’s inability to operate more efficiently with the funding it has.

Currently, nearly 57 percent of the agency’s budget is taken up by mandatory spending on veterans benefits programs such as pensions, insurance, and compensation for families of soldiers killed in the line of duty. The remaining 43 percent of the budget is discretionary spending — and 88 percent of that funding goes towards medical programs.

Trump included $78.9 billion in discretionary spending for the VA under his proposed budget, a 6 percent increase from current fiscal 2017 levels. The president also asked Congress for an additional $3.5 billion to continue the Veterans Choice Program, the system by which veterans receive health care from private providers. Congress voted last week to extend the program, which was set to expire in August 2017.

Most veterans groups praised the proposed budget increase, saying it showed the president is making veterans a priority. Trump “said veterans deserve it, and we agree,” American Legion Executive Director Verna Jones said.

The Carl T. Hayden VA Medical Center is pictured in Phoenix, Arizona June 11, 2014. Federal Bureau of Investigation agents will investigate allegations of wrongdoing at an Arizona office of the Veterans Affairs department that became a political problem for President Barack Obama and forced the VA chief to resign. On Monday, the VA released an internal audit that found more than 100,000 veterans were subjected to a wait of 90 days or more for healthcare appointments, and widespread instances of schemes to mask the delays to meet targets for bonuses. REUTERS/Samantha Sais (UNITED STATES - Tags: POLITICS MILITARY HEALTH CRIME LAW) - RTR3TAA8

The Carl T. Hayden VA Medical Center in Phoenix, Arizona was at the center of a controversy in 2014 over wait times for patients and widespread instances of schemes to mask the delays to meet targets for bonuses. An internal VA audit led to the resignation of then-VA chief Eric Shinseki and reforms in Congress. Photo by REUTERS/Samantha Sais

But previous attempts to reform the VA indicate that flooding the agency with more money isn’t enough to improve veterans’ health care. Under Obama’s watch, the VA’s annual budget increased 85 percent over eight years to more than $160 billion a year by the time he left office, though most of the boost in funding was for mandatory spending on non-health care programs.

Yet despite the uptick in funding — the agency’s budget increased every year under Obama — health care outcomes haven’t improved as much as some policy experts would like.

“If you look at the budget of the VA and simply divide it by the number of people enrolled in the VA, there’s more than enough money to fund veterans’ health care,” said Avik Roy, a health care policy advisor and president of the Foundation for Research on Equal Opportunity. “The problem is too much of the money is being spent not on veterans’ health care, but on other institutional priorities like keeping open empty facilities that nobody uses.”

A 2017 NPR investigation found that at least some of the money already allocated to improve veterans health care has failed to do so.

The VA hired roughly the same number of people it would have brought on without the $2.5 billion Congress set aside through the 2014 Veterans Choice Act to hire more medical staff, according to data compiled by NPR. The report also found that the extra staff was not used to address the agency’s greatest need: the VA hospitals with the longest wait times. (Shulkin responded to the criticism, in an appearance on NPR, by pointing to the fact that Congress only gave the department 90 days to create the Veterans Choice Program. He said if the VA had been given more time, things would have been done differently.)

Those who follow the VA say the hiring issue goes beyond funding.

“The VA is short staffed, but the root of that problem isn’t necessarily having more money to hire more people,” said Dr. Kenneth Kizer, an under secretary of Veterans Affairs in the Clinton administration. “The problem is the hiring process.”

Kizer, who is credited with overhauling the agency in the 1990s, said human resources rules have become so burdensome that it often takes the department a year after deciding to hire someone to get them into the job.

U.S. Republican presidential nominee Donald Trump speaks to the Veterans of Foreign Wars conference at a campaign event in Charlotte, North Carolina, U.S. July 26, 2016. REUTERS/Carlo Allegri - RTSJQMO

Trump speaks to the Veterans of Foreign Wars conference in Charlotte last July. Photo by REUTERS/Carlo Allegri

In the days after Trump took office, veterans groups feared his federal hiring freeze — announced in a presidential memorandum soon after inauguration — would compound the VA’s staffing problems. But the freeze allowed exceptions for public safety, and the VA took advantage of that language to exempt 41,000 out of 45,000 vacant positions. The Trump administration rolled back the hiring freeze Wednesday, with a top official cautioning that agencies still would not be able to hire “willy-nilly.”

Shulkin argued the hiring freeze was part of the president’s push to make government work more effectively, and said his department would consider ways to downsize where needed.

“If we are not utilizing our facilities appropriately, I think we have to look at do we need those facilities,” Shulkin said in the NewsHour interview, a few days before the hiring freeze was lifted. He added that the question is “always going to be, how do we expand services where the need is there, and how do we shrink services where this a better way of doing it or a different way of delivering services.”

More private health care?

If Congress approves Trump’s proposed budget increase for the VA — which is a big if — Shuklin said he plans to use the majority of that money to provide better health care services at the local level.

Part of that includes creating a more integrated health care system between the VA and the private sector, likely through an expanded version of the Veterans Choice Program started under Obama.

The fight over the program’s policy details have exposed a broader debate over the privatization of veterans’ health care. Nearly a third of veterans now receive health care services from the private sector, but stumbling blocks remain to boosting access to private care.

The program was created in 2014, after reports of veterans waiting months to see a doctor in the VA system. An inspector general’s report found that 17 veterans died while waiting for treatment at a VA facility in Phoenix.

Congress responded by passing the Veterans Access, Choice and Accountability Act of 2014, a $16 billion program to hire more VA personnel and allow veterans to receive health care at non-VA facilities.

Despite those efforts, the agency has struggled to reduce wait times. The most recent VA data shows that of 4.5 million appointments at VA medical facilities in February, 96.8 percent were completed within 30 days. That is only slightly higher than the average of 96.5 percent in February 2016.

Individual facilities are also still being scrutinized for failing to make needed reforms. Just this week, an inspector general report found the VA’s Washington, D.C., medical center lacked effective systems to manage medical equipment and supplies. The facility’s director was fired shortly after the report was released.

“Patient safety is paramount, and we took these actions with that specific concern in mind,” Shulkin said at a press conference Thursday. “We will focus immediately on the items the inspector general listed in its report and look to address other concerns as we uncover those that are not in the report.”

Earlier this month, the VA launched a new website that lets patients track wait times and other performance data. Yet as the VA attempts to make needed changes, demand is expected to rise in the coming years, as more veterans from the wars in Iraq and Afghanistan require health services.

“If we don’t fix what is already a broken system, as our generation starts to uncover injuries, we’re going to have a harder time getting our care, or our care covered,” said Jaslow with the Iraq and Afghanistan Veterans of America.

A veteran watches as U.S. Republican presidential nominee Donald Trump speaks to the Veterans of Foreign Wars conference at a campaign event in Charlotte, North Carolina, U.S., July 26, 2016. REUTERS/Carlo Allegri - RTSJQPP

Veterans watched as Trump spoke to the Veterans of Foreign Wars conference in Charlotte last year. Photo by REUTERS/Carlo Allegri

For the VA to increase access to health care, many experts say it would also need to change a small but important provision in the Veterans Choice Program known as the 40-mile rule. The program currently allows veterans who live more than 40 miles from the nearest VA facility to apply for a Choice Card, which can be used at a private medical center. Some advocates say that is still too restrictive and are lobbying to reduce or eliminate the mileage requirement altogether.

Adjusting the mileage requirement would take an act of Congress, however. That could get bogged down quickly if lawmakers try to come up with a one-size-fits-all fix for veterans who are spread out across the country and have a wide range of health care needs.

“One of the problems is that Congress wants one rule that applies to everybody, which is really hard when you are operating a national system that operates in so many different environments,” Kizer said.

Transferring medical records between private and VA medical facilities isn’t easy. Advocates have also raised concerns about patient privacy if more veterans’ care is integrated with the private sector. And some critics don’t see the move towards private care as a good thing, while others view the Veterans Choice Program as way to let the private sector step up to fill in the gaps in the VA system.

“We think that is really what that future of VA care should look like. There should be more choice,” said Dan Caldwell, the policy director for Concerned Veterans for America, an advocacy group funded by the conservative billionaire Koch brothers.

Shulkin said he recognizes those challenges, and aims to build what he called “a system that is increasingly seamless between care in the community and care in the VA health care system.”

As Shulkin takes on health care and other veterans issues, he told NewsHour he’s focused on something less tangible: winning back veterans’ trust. “When we look at what our overall objective is, it’s really to regain the trust of the veterans we serve,” Shulkin said. “Everything we are doing is surrounding the ability for veterans to know we are there for them.”

That could be a tall order. In 2015, only 47 percent of veterans surveyed by the VA said they trusted the agency. Last year, the number crept up to 60 percent — a marked improvement, but still a long way from where many think it should be.

During a meeting last month with veterans advocates, Trump reiterated his commitment to improving veterans services. But many of his campaign promises, such as his pledge to create a “private White House hotline” for veterans, remain unfulfilled.

Trump promoted the hotline proposal in a speech at the Veterans of Foreign Wars’ national convention last July. He said: “I will instruct my staff that if a valid complaint is not acted upon, then the issue be brought directly to me, and I will pick up the phone and fix it myself, if need be.”

Correction: An earlier version of this article misspelled J. David Cox Sr.’s name.

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