In the 88 years since the founding of the modern Department of Veterans Affairs, presidents have mostly turned to retired military officers and politicos to run the massive agency. Most have failed. The agency’s size, complexities, and politics have flummoxed even the most capable of leaders.
Enter Ronny Jackson—a Navy doctor who saw combat in Iraq and went on to serve as White House physician, caring for three presidents including President Donald Trump. Jackson is now being nominated to replace David Shulkin at the helm of the government’s second-largest agency. Jackson’s impressive military medical record, and bipartisan support, will likely smooth the path for a relatively quick confirmation. But after that, a swamp of policy, political, and cultural fights awaits him at the VA.
The VA’s policy fights owe much to its size and complexity. The agency runs a portfolio that includes physical and mental health care, disability compensation, education benefits, home loan guarantees, life insurance, burials, and much more, consuming nearly $200 billion a year and requiring more than 340,000 employees. Most of the VA will be new to Jackson, whose professional life has existed within the relatively insular military.
At the VA, the biggest policy fight has to do with the future of VA health care, and the extent to which the government will purchase this care from the private sector or deliver it through the VA’s huge network of hospitals and clinics. Disagreement with the White House on this policy issue doomed Shulkin, and it is where Trump’s allies may expect the most deference from Jackson, given his relative lack of VA or private health care experience. But even if he concedes to the White House, there are no easy policy choices here, as two major assessments and commissions since 2014 found, and fewer safe political options. It doesn’t help that the VA has become embroiled in the broader conservative battle to shrink government and remove it from the health care marketplace altogether.
If health care were the only issue facing the VA now, Jackson could concentrate on one heavy lift. But if he takes over for Shulkin, he will inherit policy conundrums in nearly every part of the VA portfolio. On disability, for example, Jackson must answer tough questions about how to update the VA’s aging system for disability ratings and payments. On education benefits, he and the VA must better guard veterans from predatory behavior by for-profit schools. The VA is also crumbling under its own weight in many areas. Jackson will need to figure out how to shed aging infrastructure, update the VA’s electronic health record, and more. Solving these problems is easier said than done—and far more politicized than anything Jackson touched in the military.
These are hard policy questions; they are made more difficult by political conflicts within the Trump administration, disagreements between the administration and Congress, and tensions across the broader veteran community as well. Shulkin battled daily with Trump’s partisans; their relations deteriorated so badly that Shulkin reportedly barred several appointees’ access to the VA’s executive suite, and the White House barred Shulkin’s access to the press. Neither the White House nor Congress nor leading veterans organizations agree on how to resolve any of the policy dilemmas facing the VA. Jackson will walk into this crossfire—and do so during a contentious midterm election year.
Looming over these policy and political fights are deeper cultural questions about the future of the VA and its role serving veterans. There are huge demographic, social, economic, and political shifts underway within America’s veteran community as the conscription-driven cohorts of World War II, Korea, and Vietnam fade away and are replaced in smaller numbers by the all-volunteer cohorts of the past 45 years. These shifts have triggered debates about what, exactly, ought to be America’s social contract with those who have served. In concrete terms, the issues require figuring out which veterans get benefits, and precisely how much. Should the agency be small and focused just on disabled veterans who served in combat or who were injured in the line of duty—or large and focused on helping all veterans? Should the agency merely compensate veterans for injuries or illnesses sustained during service—or do more to help them thrive, such that their success is an incentive for military recruiting? Jackson will soon find himself at ground zero for these emotional and political arguments.
With his prestigious record and experience, Jackson has the raw material to understand the mission of the VA and learn how to be a good secretary. But he will be sailing into stormy waters that have only become more turbulent during the Trump presidency. What gets lost in the revolving door is that continuity of leadership is critical for leading large federal agencies like the VA. Budgets and programs live on cycles that last longer than the average Cabinet official’s tenure. Successful change requires years to implement. If the president truly cares about serving veterans, and making the VA better, he will give Dr. Jackson a longer period to prove himself than he gave Dr. Shulkin, and stick with him even when they disagree.