David Shulkin is out as secretary of veterans affairs

A minor scandal and a major policy disagreement forced him out after weeks of rumors.

Secretary of Veterans Affairs David Shulkin is out of the Cabinet, President Trump announced on Twitter on Wednesday night, a near-inevitable result of low-boil tensions between Shulkin and other political appointees at VA and ultimately the White House. Trump plans to appoint Dr. Ronny L. Jackson, an admiral who’s currently the physician to the president, to replace him.

It’s a fairly stunning turn of events for Shulkin, a man who was confirmed by the Senate in a 100-0 vote and spent most of 2017 as the Trump administration’s least controversial Cabinet member.

And yet over the past few months, Shulkin’s position had quietly become untenable, and rumors of his departure have percolated for weeks. Shulkin’s relationship with his own staff at Veterans Affairs has become toxic to the point where he’s posted an armed guard outside his office door. As part of the breakdown, the VA communications team has been openly trashing their boss to the press. In response, Shulkin has freelanced in his own communications with the media, going outside normal administration channels.

Somewhat oddly, Shulkin wasn’t in the hot seat because anything is particularly wrong with the VA’s work. It’s not even really because of anything he’s done — Shulkin was caught up in a scandal about travel and spending that included improperly accepting Wimbledon tickets, but other Cabinet members have weathered scandals like these in the Trump administration.

The real issue is that Shulkin isn’t doing enough for conservatives’ tastes to overhaul and privatize the VA. Instead, he’s in line with the preferences of most veterans groups, taking a deliberate pace toward reform rather than pushing to blow up the agency with a big push for privatization.

There’s no particularly good reason for Trump to ensnare himself in a contentious fight with veterans groups in order to pursue a conservative ideological hobbyhorse — and, in fact, he initially appointed Shulkin precisely to avoid doing that. But the very lack of policy knowledge and inattention to detail that often gives Trump’s governing style a sheen of moderation serves, in practice, to consistently empower the most radical and right-wing elements inside the GOP coalition.

It all goes back to the big VA scandals

The origins of Shulkin’s tenuous position inside the Trump administration date back to the scandals that rocked the VA health system in early 2014. The basic story there came down to three parts:

1. The VA’s hospitals didn’t have the doctors and nurses to see veterans — many from the Vietnam War and a growing number from the Afghanistan and Iraq wars — in a timely manner.
2. The VA set wait time goals, which were backed by bonus payments, to see patients within 14 days of a requested date of appointment.
3. The VA’s central office in Washington, DC, engaged in very little oversight over its sprawling system of local hospitals and medical centers.

The upshot of this was that rather than responding to inadequate resources by reporting the problems up the chain, officials in the field responded to financial incentives by falsifying records and ultimately compromising patients’ care.

Conservatives hoped to use the resulting scandal to push for big structural changes to how veterans’ health care works in the United States, with a much larger role for private providers and much less direct government provision of health care. A big problem with that vision, however, is that veterans organizations have traditionally opposed it — they want the VA to provide an excellent standard of care but are committed to the basic vision of special purpose institutions who exist to serve veterans’ health care needs.

Ultimately, Sens. John McCain (R-AZ) and Bernie Sanders (I-VT) struck a major compromise that only tinkered around the edges of privatization by creating a pilot program that reimburses private care for veterans who live more than 40 miles from a VA facility or experience long wait times. Primarily, however, the legislation was dedicated to pumping new funds into the system and correcting some of the previous incentives that created problems. Concurrently, retired Gen. Eric Shinseki was forced out as secretary of veterans affairs and replaced by Bob McDonald, a veteran and Procter & Gamble executive whose political contributions over the years had gone exclusively to Republicans.

Armed with new authority and new money by the McCain-Sanders legislation and backed by an overwhelming 97-0 confirmation vote, McDonald set about to clean house. And it basically worked.

VA reform worked — that’s the problem

Candidate Trump loudly and frequently condemned the Obama administration’s treatment of veterans, frequently (and absurdly) arguing that under Obama, veterans were treated worse than undocumented immigrants. Trump, in his typical manner, rarely offered any particular policy critique of the Obama administration’s approach — he just vaguely invoked the scandals (which were better-publicized than the subsequent bipartisan legislation or successful reforms) and tossed it into the general stew of racial and cultural animosity of his campaign message.

Trump was, therefore, somewhat surprised to learn after taking office that veterans liked McDonald, thought he was doing a good job, and broadly opposed rocking the boat.

But on December 11, the nation’s largest veterans organizations — including the American Legion, Disabled American Veterans, Veterans of Foreign Wars, Vietnam Veterans of America, and Amvets — came together to tell Trump to keep McDonald.

“We all want McDonald,” Joe Chenelly, the executive director of Amvets, told the New York Times. “He has a good business mind, he is experienced and we feel we can trust him.”

Trump was not, however, willing to admit that his campaign rhetoric had been entirely inaccurate, so he insisted on firing McDonald anyway. As a compromise, he nominated David Shulkin, who had been the VA’s undersecretary for health affairs, to serve as secretary. That paired veterans’ goals of continuity with Trump’s goal of avoiding an admission of error, though, of course, the fact that Shulkin had been specifically tasked with running health programs was an implicit admission that the Obama-era reform process had in fact been successful.

And in a normal administration, it might have ended there — especially because many Democrats say Shulkin actually turned out to be more sympathetic to privatization than they’d anticipated — but this is the Trump administration.

Trump surrounded Shulkin with enemies

One oddity of the American system of government is that since political appointments are made by the president, Cabinet secretaries typically end up having relatively little say in the selection of their own subordinates. There are exceptions, of course, like James Mattis in the Trump administration or Hillary Clinton in the Obama administration, who have enough clout to effectively control personnel matters in their department. But the rule is that you have to deal with the people the president sends you.

Normally, though, an administration makes some sort of effort to send a coherent team that’s united around reasonably similar goals and priorities.

The Trump transition operation, however, wasn’t run that way. And while the president-elect personally selected Shulkin to carry out a mandate of continuity, the transition team generally staffed the VA with hardcore right-wingers who were committed to the conservative vision of VA privatization.

Trump himself, meanwhile, has neither the ability nor the inclination to actually parse this on the level of policy. But Shulkin’s enemies appear, according to Jonathan Swan’s reporting for Axios, to have successfully cast his problems with his staff as a question of loyalty to Trump personally. “In the view of senior officials,” Swan writes, “there’s a difference between discreetly and professionally handling staffing issues and publicly embarrassing and firing supporters of the president.”

And of course, there is a difference between those things. But Trump’s personality-focused view of the situation is also distracting him from the significant policy stakes here, where the American Legion, Vietnam Veterans of America, and other veterans groups continue to support Shulkin as a bulwark against privatization while the newer Koch-funded group Concerned Veterans of America advocates for it.

Trump may be stumbling into a big political fight

Most members of Congress hold safe seats, and most of the time, Congress’s many veto points can be counted on to prevent anything from passing. Consequently, it’s generally safe and easy for members of Congress to sign on as agreeing with their party base’s most aggressive ideological goals, secure in the knowledge that probably nothing will happen, and even if it does, your odds of being defeated on Election Day are objectively very low.

Presidents face a different situation — they are actually capable of influencing events, are generally held responsible by the public for outcomes, and need to run in fiercely contested national elections.

That’s why typically you find presidents acting as forces for caution on many issues. A president will usually have a handful of key priorities that he pushes aggressively while trying to put other things on the back burner. Why, for example, would an incumbent Republican president want to pick a big fight with veterans groups when veterans have generally been supportive of him and there’s no particularly urgent problem at the VA?

One answer, obviously, could be a deep, personal, ideological commitment to VA privatization. But Trump, of course, does not have any particularly firm policy convictions outside of immigration and trade. Instead, he seems to have been consistently pushed to the right on this topic less by conviction or policy argument than by the fact that his own lack of policy knowledge leaves him perennially vulnerable to manipulation and almost invariably drawn to the furthest-right positions available.

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