It Shouldn't Be This Hard to Serve Your Country

1

Wild Goose Chase

I WAS TYING UP THE LOOSE ENDS OF MY TENURE AS UNDER SECRETARY for health of the Department of Veterans Affairs and racing to a meeting with Texas congressman Beto O’Rourke when I received a call from Michael Cohen.

I had met Cohen in New York City when I was running a hospital system there and he was trying to join the board. I didn’t want to keep the congressman waiting, and I thought about letting the call go to voicemail, but given that Cohen’s most notable client had recently been elected president of the United States, I decided to answer.

“I need you to speak to someone right away,” he blurted out, which was typical of Michael. Always insistent, rarely forthcoming.

“I’m going into a meeting,” I told him. “I’ve literally got one foot in the door.”

“Just hold on.”

I stepped back into the corridor and heard a strange electronic gurgle, and then Cohen introduced me to someone named Ike.

“Mr. Trump asked for my advice,” this gentleman explained in a thick Israeli accent. “He wants me to help with the VA.”

With Donald Trump’s inauguration only a couple of weeks away, we Obama appointees were being shown the door, and I doubted that my schedule would be heavily booked once the new team took over. If only to be polite, I told “Ike” that I looked forward to meeting him at some point in the future.

“Good. So dinner tonight.”

At first I thought he was joking. But he wasn’t, and I sensed that he was not going to take no for an answer. I paused. “I’ll look at my schedule,” I said. “Let me try. Where would you like to meet?”

“At my club in West Palm.”

There was no “obviously” attached to this absurd proposition, but it was implied. Who was this guy? How could a man I never met expect me to fly from Washington, DC, to Palm Beach, Florida, for dinner on a few hours’ notice? I guess this was the kind of entitlement that came from being in Trump’s inner circle—or maybe this was the kind of entitlement it took to be in Trump’s inner circle.

Members of my staff had already gone ahead into Beto’s office, and now heads began poking out, accompanied by hand motions to let me know that the congressman was waiting and I needed to hurry up and get off the phone.

“I need to go,” I told Ike. “I’ll call you back after my meeting.”

But Ike didn’t take the hint. Every few seconds a different head appeared, and each time the hand motions were more animated, but Ike kept talking as if we had all the time in the world. I would’ve cut him off, but if he really was a conduit to Trump, I thought that he might be my one chance to stay in my current job and continue the work I cared about: helping veterans. Maybe I was grasping at straws, but at the very least, this guy in Florida could be a way of getting my concerns registered with the incoming administration.

At this point, the congressman himself peered out into the hall, giving me a look that asked how much longer I would be.

Ike pressed me for an answer on a West Palm meeting. He told me he would have his assistant set up the details. I hung up and stepped into Beto’s office.

What I had no way of knowing was just how much this moment marked the transition between two very different worlds. The men I had just spoken with on the phone, Michael Cohen and Marvel Comics chairman Ike Perlmutter, represented a dealmaking culture that often made it difficult to ascertain genuine motivations. The congressman I was about to meet with represented something much more straightforward.

Beto O’Rourke has since become a political celebrity, but I first knew him simply as one of the more involved members of the House Veterans Affairs Committee. With the Obama administration packing up to leave at the end of their term, I was most likely going to be looking for a new job. For his part, Beto was giving up his House seat in order to run for the Senate against Ted Cruz.

When I first came to Washington, Beto let me know that he had no patience for VA failures and VA excuses. At our initial meeting, he told me he had developed his own proposal for the El Paso VA; Beto had a plan to focus on behavioral and primary care and to collaborate with the University Medical Center (a private hospital) for most other services. Beto and I had developed a strong relationship built on trust, and we both wanted to make sure that a proper transition plan was in place for veterans’ health services in his district. We did not want to lose momentum during the time it took for a new under secretary to be nominated and confirmed.

When I stepped into the room with Beto, I apologized for the interruption occasioned by Cohen and Perlmutter before sitting down to delve into the VA situation in his district once again. Beto wanted me to update him on how we were going to position his plan for implementation under a new under secretary in the next administration.

I tried to focus on the issue at hand, but I had gotten out about ten words when my phone rang again.

It was Ike. I had to take it.

“There’s one more flight today from DC to Palm Beach,” he said. “You need to be on it.”

I hung up, gave Beto a pained look, and said, “I’m sorry. I have to go.”

I ran to my car, where my VA-assigned driver waited for me in front of the Capitol. “Let’s get to the airport, Dennis. I have a plane to catch.” Dennis smiled and stepped on the gas.

The VA is a massive bureaucracy that employs 377,805 people. (Microsoft, by comparison, employs 134,000; General Motors, about 180,000.) Established in 1930 and made a cabinet-level department in 1989, the VA provides near-comprehensive health care services for nine million eligible veterans at VA medical centers and outpatient clinics located throughout the country. Beyond health care, the agency provides disability compensation, vocational rehabilitation, education assistance, home loans, and life insurance. It also provides burial and memorial benefits to eligible veterans and family members at 135 national cemeteries. But 85 percent of what the VA does is to provide medical services for veterans, which is the 85 percent I managed as under secretary for health under President Obama.

In 2015, when I was first approached about coming to the VA, many of my colleagues expressed concern that the job was a no-win situation for me. They felt it was a surefire way to ruin my career leading large hospital systems—a career that had been marked by distinction. They warned that the VA was simply too big and complex to change. Others pointed out that it did not make sense to accept a dramatic pay cut in return for such enormous headaches. But I took the job because I felt a sense of responsibility to our nation’s veterans. The VA had been in crisis mode for years before I arrived, but after seventeen months as under secretary and a great deal of progress on many fronts, I felt optimistic, energized, and even more responsible than ever, which is why I dashed out of a congressman’s office to meet with a stranger in Florida.

En route to the airport, I called my wife. “I need you to see if I can get on the next flight to Palm Beach,” I said. “I don’t have time to explain. Just drop what you’re doing and call me back. Please!”

As always, Merle came through, and I made the plane.

Just before takeoff, Ike’s assistant, Marisol, called to tell me that since the flight wasn’t arriving in Florida until early evening, she had moved the meeting from dinner to breakfast. She informed me that she secured a room for me at Mar-a-Lago, the old Merriweather Post estate built in the 1920s and acquired by Donald Trump in 1985. With 126 rooms and private quarters measuring 62,500 square feet, it would soon become known as the Southern White House. I thanked Marisol for her thoughtfulness but refused the offer and booked myself a room at an inexpensive hotel nearby. Then I buckled up for what I expected would be a bumpy ride.

2

The Power of Adaptation

I HAVE ALWAYS BEEN A PROBLEM SOLVER. FOR YEARS, MY WIFE HAS called me Mary Poppins, saying that I pop into situations where there is trouble, fix the problem, and then pop out to do the same thing somewhere else. The day I turned sixteen, I joined the local volunteer fire department. Later, after I left academic medicine to launch a start-up that measured hospital quality, I became a volunteer fireman once again. I keep a small emergency kit in my car and frequently pull over to offer help when I see an accident with injuries. Especially as a health care administrator, I am drawn to turnarounds, which is exactly the kind of transformation the VA needed.

I came of age just after the Vietnam War, during a time of relative peace and an all-volunteer army, and as a result, I never served in uniform. But I was born on a military base in Highland Park, where my dad was an army psychiatrist. One of my most vivid childhood memories is seeing how my dad contained his emotions as he watched his patients struggle to overcome psychological wounds. Sometimes he brought these men home and paid them to work around the house. I often found strangers trimming our bushes or painting a part of the house even though we had done these chores ourselves just a few weeks before. When I asked him about this, he simply smiled and explained that we were helping them help themselves.

I spent my twenties focused on my medical education, and by the time I finished my training, I had worked in three VA hospitals. VA hospitals were fantastic places to learn because, at that time, there was little supervision by attending physicians, which meant that we interns and residents got to do much of the care ourselves. I specialized in internal medicine, but when I saw the huge problems our country faced in health care delivery, I took management training and rose through the ranks of hospital administration.

Through it all, though, I maintained my clinical work. I enjoy seeing patients. I also believe that the only way for hospital administrators to truly see whether their efforts are creating the desired effect is for them to stay in close touch with the patients themselves. During my time at the VA, I did more than just see individual patients, though. Especially during my first months as the VA’s under secretary for health, I traveled extensively to tour VA facilities, get to know veterans and staff, and observe firsthand the type of overall care veterans were receiving.

My first chance to really get to know some of the people I was working for—and some of the obstacles they were working to overcome—came when I attended a winter sports clinic in Aspen, Colorado, one of the eight adaptive-sports events the VA runs each year.

Getting off the forty-seat flight that took us from Denver up into the mountains, I counted eight service dogs and eleven wheelchairs. My seatmate on the short flight was a Vietnam veteran who had lost his left leg. Alex, his eighty-five-pound golden retriever service dog, slept peacefully on top of my feet the whole trip.

At the hotel, check-in was slow because several veterans were asking for bathrooms that were wheelchair accessible, rooms close to the elevator, and recommendations for where to buy dog food. In the lobby, we saw many veterans with one or two prosthetic limbs, others who were paralyzed, and some who appeared anatomically normal but suffered from invisible wounds of warfare and were accompanied by their emotional support dogs.

In clinical practice, I had always focused on the patient’s physiology. In Aspen, I began to understand the power and the necessity of a more holistic definition of health and well-being that framed the VA’s more comprehensive approach. It was also a humbling demonstration of the sacrifices these veterans had made for our country and of what we now owed them in return.

In the year or so before I came to Washington, the VA had made the wrong kind of headlines, when the length of time it took to get an appointment reached crisis proportions. There were allegations that forty veterans may have died while waiting for care in the Phoenix system alone. Other reports alleged that many thousands more nationwide were kept waiting too long or never received services. Pushing poor management into alleged malfeasance, staff were said to have manipulated wait times to make the data seem more acceptable. This rolling fiasco led to the resignations of both the VA secretary and the under secretary. By the time I arrived, the agency’s harshest critics were advocating that we simply turn off the lights, close up shop, and turn the job over to the private sector.

But here on the Colorado ski slopes, I saw the VA functioning with a passion and a compassion that can’t be accounted for in an efficiency report or a profit-and-loss statement. Instructors had come from VA hospitals all over the country, many of them paying their own way just to be part of this experience. To give me some small idea of what the veterans were experiencing in adaptive skiing, two of these instructors loaded me into a metal chair that pressed my knees together firmly and had two skis in the front and one in the back, took me up the chairlift, and then guided me down the slope. I’m not sure I’ve ever been more terrified. I cannot imagine how difficult the loss of mobility may be for anyone, let alone for veterans who previously prided themselves on their physical abilities but lost those abilities in service to their country. And for this same reason, I could understand why on this mountain so many found the experience to be freeing, exhilarating, and, for some, life changing.

The size and complexity of bringing four hundred disabled veterans to a ski resort was like a military operation in itself. Along with volunteers to help individuals, the VA brought trailers of equipment for adaptive skiing and technicians to customize the equipment for individual needs. VA staff set up a field hospital next to the hotel in a large canvas tent, complete with beds and procedure rooms. Everyone hoped this facility would not get much use, but the past several years had suggested that now and again, medical intervention would be necessary.

As the week progressed, and as I skied down the trail with some of the veterans, I could see the fear and anxiety of the first-timers give way to excitement and joy. Many who returned year after year told me that the ability to compete and to master a sport had renewed their hope and confidence. Some told me they had been depressed and even suicidal until they discovered adaptive sports. Others confided that they had been able to reduce or even stop medications after getting involved in these events.

After dinner one night, each of the veterans was invited to a reception for his or her particular military branch. The first one that my wife, Merle, and I attended was for marines. Of all the services, the marines may be the most tight-knit, and as though sensing that I might feel a little out of place, three of the veterans came to the front of the room and asked for everyone’s attention. Each of them was missing a limb or had a service dog. Asking me to join them up front, they presented me with a marine pin and began a small ceremony proclaiming me as an honorary marine. During my years as a physician, I’ve seen many heartrending dramas in emergency rooms and cancer wards, and I’m not someone easily moved to tears, but it was hard to maintain my composure while being recognized by these men who had given so much.

3

An Interview Unlike Any Other

ARRIVING AT MAR-A-LAGO TO MEET WITH IKE PERLMUTTER WAS like stepping into a James Bond film. My car rolled through majestic gates and up the long driveway to let me out at the canopied entrance. Entering the main building, I was greeted by a very pleasant young woman seated behind a bronze desk.

“Good morning, Dr. Shulkin,” she said. “Mr. Perlmutter is expecting you.”

She led me through a high-ceilinged hallway into a vast space with marble floors, gold walls, and glass chandeliers. This room opened onto a veranda with about thirty tables set for breakfast. Only one was occupied.

The two men sitting there looked to be in their early seventies. The first to speak was Ike, short but solidly built, who introduced himself and then with a gesture to his companion said, “This is Dr. Moskowitz.”

I still had no clear idea why I had been summoned to Florida, but I sat down, ordered coffee, and listened as Ike began telling me how he had emigrated from Israel after serving in the Six-Day War of 1967. He also told me how much he cared about what was happening to our veterans and that he was not happy with the current situation at the VA. He also reiterated that the president-elect had asked him to help fix these problems.

“So, Bruce,” he said, turning to Dr. Moskowitz, “tell him—”

“I practice in West Palm,” Moskowitz began. “Everybody from migrant workers to some very wealthy people. I also treat a lot of veterans who can’t get good care from your VA.” I blinked.

He then went on to tell me how he had trained with Dr. Toby Cosgrove, the CEO of Cleveland Clinic. He also knew the CEOs of Johns Hopkins, Mayo Clinic, and Partners Healthcare—the group that manages the Harvard teaching hospitals. I was aware that the president-elect had met with some of these leaders to discuss running the VA. I also heard some talk of Dr. Cosgrove’s becoming Trump’s nominee for secretary of VA.

Ike and Bruce took turns asking me about my experience at the VA—what I thought was working and what was not. They asked me about VA staff, use of technology, and interactions with the private sector. The conversation flowed easily, but the purpose of the meeting still eluded me.

We talked for about ninety minutes before it was time to say goodbye. In preparing to leave, I made sure to express my wish, however unlikely, to remain as under secretary under President Trump in order to finish the job I had begun eighteen months earlier. A simple nod from each was their only acknowledgment of my request.

Before heading back to DC, I spent the morning touring the West Palm Beach VA. I had recently had my first success in recruiting a senior executive from the private sector to the VA, and she had just assumed the role of medical center director there. I promised her that I would visit and spend time with her management team, and this was my opportunity to do so before I left my job as under secretary. Afterward, I got a ride back to the airport and traveled home.

Back in the capital, I spent the rest of the afternoon in my office, then, as per usual, hopped on an Amtrak train to head home to Philadelphia, where my wife maintained her medical practice. Merle and I met in medical school and have been married for thirty-one years. She is a dermatologist in private practice and one of the few doctors I know who still loves to practice medicine as much as when she first graduated. We have two children. Danny, our oldest, graduated from NYU and earned his MPA there before starting to work for Horizon Blue Cross. Jennie was a nationally ranked tennis and squash player who completed her undergraduate studies at the University of Pennsylvania and then law school at Harvard. Following graduation, she became a law clerk to a federal district judge in the Eastern District of New York.

When my train arrived at Philadelphia’s Thirtieth Street Station in the midst of a snowstorm, Merle picked me up, and we drove to White Dog Café in Haverford, about twenty-five minutes outside Philadelphia. Given that the snow was really heavy, I pulled the car up close to the entrance to let her get out. Then, as I ventured across the parking lot to try to find a space, my cell phone rang.

Ike’s number flashed on my caller ID. I picked up. “Where are you?” he barked.

“Philadelphia.”

“No. You need to be in New York. Reince will call you with details.”

It didn’t seem wise to take a call from the soon-to-be White House chief of staff, Reince Priebus, in a noisy restaurant, so I decided we had to leave. I frantically motioned to Merle, who was already seated. Startled and a little upset, she got up from the table, and we left the restaurant without eating.

We went home and waited for a call, which was not exactly the way we had hoped to begin our weekend. Especially since the call never came.

Merle and I tried to get some rest, and the next morning, Saturday, January 7, I called Ike to see if he knew what was going on. “Donald is expecting to see you at Trump Tower today at 2:00 p.m.,” he said.

I hung up in a panic. It was a little after 11:00 a.m., and our home outside Philadelphia is a two-hour drive from Manhattan under the best conditions. Today’s conditions were approaching whiteout, but this was not a meeting to miss.

Without really thinking, I threw on the first suit in my closet, grabbed my car keys, and yelled to Merle to get her coat. She was barefoot, and I told her to just grab her shoes and put them on in the car. Moments later we swerved out of the driveway and made our way along the snow-covered roads toward the interstate. I drove faster than I should have, but few other drivers were crazy enough to be on the road in a blizzard like we were. After about an hour of sustained panic, my cell phone rang. It was Reince Priebus.

“Sorry not to have called sooner, but we’re all set. You’ll be meeting with the president-elect on Monday at 2:00 p.m.” Monday, not today.

We found the nearest exit, turned around, and headed back home.

Later that afternoon, Priebus called again, this time with some questions for me—mainly, it seemed, to help him figure out how I had gotten on his call list. He wanted to know how I knew Trump. I told him I didn’t. He seemed perplexed that I had no connection to the Trump campaign. He also wanted to know how I became under secretary for Obama. I explained that there is a statutory commission that selects the nominee for a presidential appointment. I also told him that I was a doctor and that I had served as a chief executive of health care organizations for more than a decade. Without commenting on any of this, Priebus asked me to meet with him for lunch on Monday prior to my meeting with the president-elect.

On Sunday, still mystified but intrigued, I took a train to New York, this time with a carefully packed overnight bag. I stayed in our Manhattan apartment with our son, Danny, and slept on the couch in the living room. Late in the evening, Ike called to see if I was all set for the meeting. Clarifying some final details, he asked me if I wanted to enter Trump Tower through the main lobby or use a private entrance to avoid being seen. A year and a half into my service in Washington, I still didn’t quite understand optics and the strategy behind these kinds of decisions. I saw no reason to hide a meeting with the president-elect. “I’ll go through the front door,” I said.

The next day, I headed over to Trump Tower, around which the NYPD had set up a security corridor extending two blocks in all directions. I wasn’t quite sure what to expect, but even if this meeting was nothing more than an exit interview, I wanted the chance to tell the president-elect where progress was being made at the VA and what direction his new administration should take. At worst, this was my chance to give input to the people to whom I would be passing the baton. At best, I might convince the president-elect to let me stay in my position as under secretary and continue the work we were doing.

The police weren’t letting anyone through without ID, and those who passed the first check had to wait in long lines to be searched and scanned. Fortunately, from my days working in New York City, I had become an honorary NYPD police surgeon, so I flashed my badge and moved through without a word.

Just inside the building, I was met by several Republican National Committee staffers, who escorted me to the lobby restaurant. As Priebus and I shook hands, he told me that he no longer had time for lunch. I said I understood, but knowing that he was from Green Bay, I added, “By the way, congratulations on the Packers’ win this weekend.”

He smiled and said, “You know, maybe I do have time for a quick bite.”

Making our way through the small restaurant, we were stopped by swarms of diners who all seemed to want their picture taken with Reince, so I became the amateur photographer as table after table stood up to pose with him. We took a back table, ordered chicken Caesar salad, and spent most of our time casually discussing our families and nonpolitical interests. I gleaned nothing of substance and no explanation for why I was summoned to New York. After lunch, he escorted me upstairs.

As we approached the inner sanctum, Steve Bannon came out to greet us and escort me into Trump’s office, familiar to millions as the set of The Apprentice. Against a wall of glass, the president-elect sat at a huge desk covered with copies of Time magazine with his picture on the cover as Person of the Year. A part of me wondered where the secret cameras were hidden.

As we shook hands, Trump announced to his staff in the room, “He’s a good-looking guy.” He then quickly repeated, “He’s a good-looking guy, isn’t he?

Taken aback, I could think of nothing better to say than, “Nice to meet you, Mr. President-Elect.”

As various staff members came and went, he picked up one of the magazines and said to me, “See this, have you seen this?”

“Yes, I have, sir. Congratulations.”

Glancing around the room, I noticed that the one nonglass interior wall was filled with awards and plaques from events honoring Trump. I sat down in the only chair facing him, across the desk.

“Get me Ike Perlmutter on the phone!” Trump shouted.

He had an intercom but evidently chose not to use it. Whoever was taking orders on the other side of the wall never responded verbally, but in less than a minute, Ike was on speakerphone.

“Ike! I have Dr. Shulkin here.”

“Yes, Mr. President. I think you’ll be very impressed. I met with him last week, and I think he understands what’s going on at the VA.”

“Okay, Ike, I’m going to talk to him and see what I think.” Without saying goodbye, Trump pressed a button to hang up the phone.

It seemed by now that most of Trump’s inner circle were milling about in the room behind me—Jared Kushner, Kellyanne Conway, Steve Bannon, and Reince Priebus.

“Ike is an amazing guy,” Trump said. “He started with nothing, you know. Nothing but the clothes on his back, and now he runs Marvel Entertainment. You know he made four of the top ten movies? So how do you know him?”

“I just met him, Mr. President-Elect. Michael Cohen introduced me.”

I saw a flash of recognition across Trump’s face. “You know Michael?”

I nodded.