On Jan. 11, 2017, then President-elect Donald Trump announced his intention to nominate President Obama’s current Under Secretary of Veterans Affairs for Health, David J. Shulkin, MD, to become the next Secretary of Veterans Affairs (VA). Dr. Shulkin will lead the government’s second-largest agency with nearly 370,000 employees and an annual budget of more than $166 billion.
Tenure as Under Secretary for Health
Dr. Shulkin is a board-certified internist who came to the VA during President Obama’s second term, when he was nominated to Under Secretary for Health for the U.S. Department of Veterans Affairs on March 18, 2015. Three months later, Dr. Shulkin was unanimously confirmed by the United States Senate for his post as Under Secretary in charge of the Veterans Health Administration (VHA). In this role, he has overseen the care of about nine million veterans at nearly 1,000 VA clinics nationwide. Dr. Shulkin has strived to improve the quality of care being provided for our veterans. This past December, the VA made public its internal ratings system of the VA medical centers around the country. Ratings are based on dozens of factors, including death and infection rates, instances of avoidable complications, and wait times. Since his confirmation, 120 of the 146 VA Medical Centers have seen improvement. The 26 centers that did not show improvement are receiving extra scrutiny and help from national VA officials. Dr. Shulkin indicated that if these centers still don’t show sufficient progress, hospital management could be replaced. In a recent interview, Shulkin described the VA’s efforts to improve by saying, “We are working to rebuild the trust of the American public and, more importantly, the trust of the Veterans whom we are proud to serve…We are serious about our work to improve access to health care for our nation’s Veterans.”
VA Wait Times Scandal
As Under Secretary and nominee for the Secretary’s position, Dr. Shulkin recognizes the tremendous work needing to be accomplished to provide the quality of health care America’s veterans have earned. He took over VHA following a scandal that emerged in 2014 when the long wait times for veterans seeking health care were exposed, along with subsequent cover-up efforts. In a recent interview, he touted the number of veterans waiting over a month for urgent care has decreased from 57,000 when he took office to 600. During the same time period, the VA completed more than 57.36 million appointments, representing an increase of 1.6 million appointments from the previous year. In a move to further address staffing and wait time issues, Dr. Shulkin recently announced the implementation of a new regulation granting full practice authority to advanced practice registered nurses (APRN) when they are acting within the scope of their VA employment. Dr. Shulkin stated that “amending this regulation increases our capacity to provide timely, efficient, effective and safe primary care, aids VA in making the most efficient use of APRN staff capabilities, and provides a degree of much needed experience to alleviate the current access challenges affecting VA.” This action expands the pool of health care professionals authorized to provide primary health care and other related health care services to veterans without the clinical supervision of a physician.
Suicide Prevention
In addition to reducing the wait time for appointments, Dr. Shulkin is concerned about the high rate of suicide among veterans. In a USA Today editorial published Sept. 15, 2016, Dr. Shulkin wrote, “Losing even one veteran to suicide is unacceptable…We know that we save lives when we get veterans into treatment. This past year, VA has expanded our suicide prevention efforts providing greater access to our services, and we are continuing to ensure same-day access for urgent mental health needs at every medical center.” During Shulkin’s tenure, in response to the crisis, the VA has doubled the size of the Veterans Crisis Line and instituted business practices to improve its capacity as a call center and its effectiveness as a lifesaving resource. However, Dr. Shulkin recognizes the problem cannot be addresses by the VA alone. Of the 20 veterans who take their lives each day, 14 were not connected to the VA for care in the past year. Thus, the VA has begun to broaden the network of mental health professionals available for veterans by enhancing its relationship with community based-providers. As Secretary of Veterans Affairs, Dr. Shulkin will continue the Department’s efforts to address this public health crisis.
Views on Privatization
While there has been a growing movement to close the VA medical centers and instead have veterans get their care from the private sector, Dr. Shulkin has stated his realization as Under Secretary that the VA provides patients with “a different model of care, which treats the physical along with the psychological, the social and the economic aspects of health, all of which contribute to the well-being of the patient.” Dr. Shulkin believes that the medical centers should continue to provide the care in which the VA specializes, specifically those situations dealing with post-traumatic stress disorder, traumatic brain injuries, and warriors who have lost limbs. He has indicated that he would be willing to consider discontinuing services that the private sector could better provide, such as obstetrics and gynecology. However, Dr. Shulkin has spoken out against drastically reducing the federal government’s role in VA health care, previously saying that it “would be a terrible mistake, a terrible direction for veterans and for the country, to essentially systematically implement recommendations that would lead to the end of the VA health care system.”
Sleep Disorders and Veterans
Among the many issues that will cross Dr. Shulkin’s desk as the Secretary of Veterans Affairs is the connection between sleep disorders, military service, and the level of VA coverage. Recent research has demonstrated an increased risk of sleep disorders among combat veterans. In fact, a VA study published in July 2016 demonstrated a six-fnew increase in the age-adjusted prevalence of any sleep disorder diagnosis over an 11-year period among U.S. veterans. According to the authors, the growth in sleep disorders diagnosis will likely continue for the foreseeable future. With nearly 2 million military personnel returning from the Iraq and Afghanistan theaters of operation over the last 15 years, Dr. Shulkin’s Department must address how to provide access to care for soldiers and veterans who have sleep disorders, while encouraging all service personnel to maintain healthy sleep habits.
Conclusion
Dramatic administrative and procedural changes will occur at the VA during the Trump administration, and the president believes that Dr. Shulkin is the person to correct the VA’s course. During President Trump’s announcement, he stated that Dr. Shulkin’s mandate is “to serve our veterans and restore the level of care we owe to our brave men and women in the military. Sadly, our great veterans have not gotten the level of care they deserve, but Dr. Shulkin has the experience and the vision to ensure we will meet the health care needs of every veteran.”
