V.A. Medical System Staggers as Chaos Engulfs Its Leadership

The Veterans Choice Act allowed more veterans to get care from private providers, but it created an avalanche of paper at Veterans Affairs facilities.

At first, it was one doctor quitting the tiny Ukiah Veterans Affairs Outpatient Clinic in Northern California. Then another left, and another, until of the five doctors there a year ago, only one remained.

The Veterans Choice Act, passed by Congress amid scandalous stories of hidden waiting lists at Veterans Affairs hospitals, allowed more veterans to get care from private providers, but it created an avalanche of paper at Veterans Affairs facilities as outside doctors sent in information on patients. Veterans Affairs doctors had to enter so many medical records manually into the aging department health records system that it crippled their ability to see patients.

“I was working nights and weekends, holidays, and I couldn’t keep up,” said Dr. Neal Elkin, a primary care physician who left the Ukiah clinic in January. “I was so stressed, I couldn’t sleep. My asthma started getting bad, and I just burned out.”

In Washington, the leadership of the department had been working to streamline private care and overhaul its computer system to cut paperwork. Then President Trump plunged the department into turmoil. He fired the Veterans Affairs secretary, Dr. David J. Shulkin, by tweet in March after weeks of infighting. His handpicked replacement, Dr. Ronny L. Jackson, saw his nomination collapse last week amid a barrage of accusations related to his work as the White House physician. Meanwhile, a string of departures at the highest level of the agency has left it adrift.

Unable to find replacement doctors, the Ukiah clinic conducted appointments using remote doctors and video screens.

“You’ve got a huge vacuum of leadership,” said Robert A. McDonald, a Republican tapped by President Barack Obama to lead the department in 2014 after the wait-time scandal brought down his first secretary. “Not only do you not have a secretary, but many of the experienced people who could provide continuity are leaving.”

Legislative efforts to fix the private care program, known as Veterans Choice, have been stalled, in part because of lawmakers’ own disagreements. The contract for a new $16 billion electronic health records system to replace the one built in-house decades ago was put on ice months ago. And lawmakers, veterans advocates and current and former department leaders fear that sinking morale could erase the progress the department has made in recent years.

“The V.A. for months has been hemorrhaging career officials at an alarming rate as one after another is either pushed out or decides to run, not walk, for the door,” said John Hoellwarth, a spokesman for Amvets. “I’ve never known the enthusiastic mass exodus of an organization’s most knowledgeable and experienced personnel to be an indication that all is well.”

Current and recently departed staff members describe the central office in Washington as eerily quiet. Political appointees hold meetings without career staff members and talk openly about purging anyone they see as friendly to the former secretary, according to one former official familiar with the comments.

The department’s No. 2, Deputy Secretary Thomas G. Bowman, has been isolated by Trump White House appointees who see him as too moderate and want to drive him out, current and former officials said. The acting secretary, Robert Wilkie, in charge since March, has been a quiet presence and has not met with key staff members overseeing issues like the Choice program.

Trump administration officials say the department is pushing ahead with a review of the electronic health records contract that should allow a final decision within weeks. The department is working with Congress, they said, to try again to pass long-awaited legislation to improve the private care programs.

An agency spokesman, Curt Cashour, argued that high staff turnover actually benefited the department, allowing the administration to replace high-level officials not fully committed to Mr. Trump’s policies.

“Under President Trump, V.A. has had its most productive year in decades,” Mr. Cashour said in a statement.

He continued, “This has understandably shaken up V.A.’s Washington bureaucracy, and in many cases employees who were wedded to the status quo and not on board with this administration’s policies have departed V.A. — some willingly, some against their will.”

Mr. Cashour said White House appointees have not been threatening to purge anyone. “Only one person talked about a purge,” he said, referring to Mr. Shulkin. “He no longer works at V.A.”

Mr. Cashour noted that the department’s 33,000 vacancies — out of a work force of more than 360,000 — had actually declined considerably since the beginning of the administration.

In a statement, Mr. Wilkie said that “all of us are committed to implementing the president’s agenda for veterans.”

Mr. Wilkie and Mr. Bowman declined to be interviewed.

But outside the department’s headquarters, many doctors, lawmakers and veterans advocates expressed concern about morale and productivity throughout the sprawling agency, which includes some 1,200 hospitals and clinics.

“I’ve been doing this 30 years, and it’s the worst it’s ever been,” said Dr. Murray Altose, who was the longtime chief of staff at the Veterans Affairs hospital in Cleveland before retiring in April. “I try to tell all my staff, ignore the nonsense and noise in Washington and just stick to the mission.”

“But they worry, especially the younger ones,” he added. “They don’t know if they have a future here.”

Until recently, the Veterans Affairs Department was a rare spot of calm in the Trump administration. Dr. Shulkin, a former hospital executive, enjoyed support from lawmakers of both parties and influential veterans groups. Building on changes begun during the Obama administration, he pushed forward with a long-term overhaul to make the vast health care system more efficient and nimble. Mr. Trump showered him with praise.

But beginning last year, a rift split political appointees leading the department over how veterans should gain access to private care, with many administration officials pushing to let veterans have greater ability to choose private health care at government expense. That, combined with an excoriating inspector general report that found Dr. Shulkin misspent public funds on travel, eventually led to his ouster.

Dr. Shulkin’s proposed replacement, Dr. Jackson, withdrew from consideration after senators publicized accusations that he drank on the job, misused prescription drugs and oversaw a hostile work environment.

In that void, current and former career officials and veterans advocates say, the political appointees who clashed with Dr. Shulkin have made it clear that disagreement with the White House’s private care agenda will not be tolerated. The instability and partisan rancor have prompted a number of experts to resign.

Scott Blackburn, a former partner at the consulting firm McKinsey and Company who was overseeing the transformation of the department’s electronic health records system, quit in mid-April. Mr. Blackburn, a disabled veteran and a graduate of Harvard, was replaced by the former director of data operations for the Trump campaign, Camilo Sandoval.

Christopher Vojta, a health care executive with degrees from both the business and medical schools at the University of Pennsylvania, was helping run the department’s 1,200 hospitals and clinics until he quit abruptly last week.

Dr. Amy Fahrenkopf, a health care executive educated at Yale and Harvard, who had joined the department to streamline its $14 billion private sector Choice program, quit Monday.

Louis Celli, the national director of veterans affairs and rehabilitation for the American Legion, one of the largest and oldest congressionally chartered veterans organizations, said it was clear from his contacts within the department that there was a “corrosive culture building.”

“You have the majority of the 360,000 employees who go to work every day and perform the jobs they were hired to do,” he said. “What we are hearing, by and large, from the rank-and-file employees is that this is the worst it has ever been.”

The department planned to announce a major reorganization of its health care system administration this week, designed to avoid failures in care that have incited repeated scandals in the hospital system, according to three former officials with knowledge of the project. It did not happen.

Mr. Cashour said nothing has been delayed, and the completed reorganization plan is being reviewed.

This week the left-leaning veterans group VoteVets sued the Trump administration, saying the appointment of Mr. Wilkie as acting secretary violated federal law, and that the sidelined deputy secretary should have automatically been given the acting position. If successful, the lawsuit could nullify all decisions the current acting secretary makes.

And relations between the White House and veterans policymakers on Capitol Hill — particularly the leaders of the Senate Veterans’ Affairs Committee — have reached a low. Mr. Trump continues to savage Senator Jon Tester of Montana, the committee’s top Democrat, for his role in gathering and publicizing the allegations against Dr. Jackson. Privately, administration officials have also gone after the committee’s Republican chairman, Senator Johnny Isakson of Georgia, for supporting Mr. Tester.

The instability could persist. Administration officials are likely to take their time interviewing and vetting candidates for the top job this time around.

This week White House officials met with Jeff Miller, a former Republican chairman of the House Veterans’ Affairs Committee and relentless critic of the department. Others said to be in contention include Mr. Wilkie; Martin Steele, a retired Marine lieutenant general; and Joyce M. Johnson, a retired rear admiral who ran the Coast Guard’s medical unit.

Dr. Elkin, who is weighing whether he should return to the department after a medical leave, said the instability gives him pause.

“The V.A. seems like a jumbo jet over the Atlantic without a pilot right now,” he said. “There is chaos in the cockpit, and there is chaos in the cabin, too.”

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