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Change is coming to the most maligned of cabinet agencies, even if big fights still lie ahead. 

Secretary of Veterans Affairs David Shulkin, probably the most unlikely member of Trump’s cabinet, is off to a quick start. Shulkin served as undersecretary of health at the VA during the last two years of the Obama administration, and didn’t have a military background — in fact, he’s the first non-veteran to head the department. Shulkin himself told the New York Times that he had packed up his office, expecting to be dismissed by the new secretary. During the transition, quite a bit of speculation about the next secretary focused on former Concerned Veterans for America CEO Pete Hegseth, who had defended Trump on Fox News during the campaign. 
 
But Trump’s ambassador to Israel, David M. Friedman, recommended Shulkin to the president, and after impressing Trump he proceeded to win unparalleled support on Capitol Hill; he was the only member of Trump’s cabinet confirmed unanimously. 
 
In Shulkin’s five months on the job, the VA has been a whirlwind of activity: 
-The department announced last week that between President Trump’s inauguration and July 3, it had fired 526 employees, demoted another 27, and temporarily suspended another 194 for longer than two weeks. 
-In April, the department launched a new website that lets veterans compare the wait times at its facilities and view Yelp-style reviews of each facility written by previous patients.
-Veterans Health Administration’s Veterans Crisis Line — designed for those struggling with PTSD, thoughts of suicide, and other forms of mental stress — is now answering “more than 90 percent of calls within 8 seconds, and only about one percent of calls are being rerouted to a backup call center.” A year ago, an inspector general report noted that “more than a third of calls were being shunted to backup call centers, some calls were taking more than a half hour to be answered and other callers were being given only an option to leave messages on voicemail.” 
-At the end of June, Shulkin unveiled the world’s most advanced commercial prosthetic limb — the Life Under Kinetic Evolution (LUKE) arm — during a visit to a VA facility in New York. Veteran amputees demonstrated the technology, a collaboration among the VA, the Defense Advanced Research Projects Agency, and the private sector. (The name alludes to the lifelike robotic hand that Luke Skywalker is fitted with in The Empire Strikes Back.) 
-In May, Shulkin said the department had identified more than 430 vacant buildings and 735 underutilized ones that cost the federal government $25 million a year. He said that most of the buildings are not treatment facilities and could profitably be closed or consolidated. Of course, if he actually attempted to close or consolidate some of the buildings, he might face a controversy along the lines of those touched off by military-base-closing announcements in recent decades. 
 
Shulkin has also gotten some help from Congress during his short time on the job. At a time when Republican legislators have had enormous difficulty passing big pieces of legislation, they’ve made great progress on VA reform. 
 
One particular law designed to make the VA more accountable is arguably the most consequential legislation President Trump has signed so far. It establishes speedier procedures for firing employees, gives the department the authority to recoup bonuses and pensions from employees convicted of crimes, adds greater protections for whistleblowers who report errors and scandals, and expands employee training. 
 
“Our group was driving accountability reform efforts since 2012, and we couldn’t have driven the measure across the finish line without a VA secretary who embraced it,” says Dan Caldwell, policy director for Concerned Veterans for America, a veterans group that is part of the Koch Brothers–funded Seminar Network. “[Shulkin] knew that legislative action was necessary to give him the authority he needs to clean up the toxic VA culture.” 
 
“On balance, [Shulkin]’s off to a good start,” says Joe Plenzler, a spokesman for the American Legion. “He’s been very responsive to our concerns, and is a good listener. We’re very excited to see what he can do with the increased authority to hold people accountable.” 
 
The rapid series of changes is reassuring past VA critics that Shulkin is eager to disrupt the status quo. The rapid series of changes is reassuring past VA critics that Shulkin is eager to disrupt the status quo. “I’ve been impressed by his knowledge of ongoing issues at VA, his dedication to getting things right for veterans, and his honesty about the work ahead to change the culture at VA,” says Representative Phil Roe, who chairs the House Veterans Committee. “While there is much work to do at VA — from holding bad employees accountable to bringing common sense to IT and construction projects — I believe Secretary Shulkin is the right man for the job.”
 
“Secretary Shulkin was an Obama appointee, but his attitude toward owning and dealing with the challenges at the VA has been refreshing,” says Caldwell. “The last VA secretary largely denied that these problems existed. Shulkin deserves credit for the hard work he’s done to establish more fiscal responsibility and eliminate needless bureaucracy within the department.”
 
Despite his early successes, Shulkin’s biggest challenges are likely to lie ahead: If he follows through on his previously stated desire to expand treatment options for veterans, it could jeopardize the bipartisan political capital he’s earned himself so far. 
 
In 2014, in response to the scandal of veterans in Phoenix and other locations facing interminable waits for needed care, Congress and the Obama administration established the Veterans Choice Program (VCP), allowing veterans who live more than 40 miles from a VA health clinic or who face a wait of more than 30 days for an appointment to get treatment from non-VA facilities. The VCP was intended as a pilot program and scheduled to end this August, but earlier this year President Trump signed legislation extending its duration until funding runs out. 
 
Demand for the program has increased rapidly, at a rate of 30 percent over the most recent fiscal year. But the program has hit some bumps in the road: Some veterans remain unaware of its existence, and those that do participate find that the scheduling and management of appointments at non-VA facilities is still managed by the department. 
 
“The rules are so complex, people are so confused, 20 percent of our claims are rejected,” Shulkin recently admitted during a briefing for reporters at the White House. “And that’s much higher that what you’d find in the private sector.” He noted that some doctors and health-care providers are increasingly frustrated with the VA’s ability to get them payments, “to the point that some of them are actually leaving our network.”
 
Forty members of the U.S. House signed a letter to Shulkin this week, complaining that the Veterans Choice Program’s slow process of reimbursement was starting to hurt patients’ credit scores. As of mid-May, the VA had received more than 57,000 calls “requesting assistance with adverse credit reporting resulting from the Veterans Choice Program.” 
 
Groups such as Concerned Veterans for America would prefer to see the VCP replaced with a broader menu of expanded options for all veterans, regardless of location or wait times. In 2015, CVA asked a panel of experts, including former senator Bill Frist, former representative Jim Marshall, and health-care-policy expert Avik Roy to put together a more comprehensive plan that would maximize the options for veterans. The result was the “Veterans Independence Act,” which proposed restructuring the VHA as an independent, government-chartered nonprofit, shifting to a premium-support model for certain veterans, and prioritizing veterans with service-related health needs. 
 
Last year, House Republican Conference chair Cathy McMorris Rodgers introduced a “discussion draft” that incorporated many of those ideas. Under her draft legislation, a new “Veterans Accountable Care Organization” would manage the VA’s brick-and-mortar health-care facilities while a new Veterans Health Insurance Program would manage patients’ insurance. Veterans who did not want to seek treatment at the VA would receive a “health-insurance support” payment to purchase private health coverage and grow their Health Savings Accounts (HSAs). Veterans eligible for Medicare would receive funding for a “Medigap” plan that defrayed the costs of Medicare’s premiums, deductibles, and co-pays. 
 
Critics, mostly on the Left, charged this was a backdoor attempt to “privatize the VA.” But Concerned Veterans for America insists it doesn’t want to eliminate or replace the department, which still boasts some facilities that are excellent, along with the unique expertise needed to treat those with PTSD, lost limbs, and other battle-related injuries. 
 
In June, Shulkin previewed a new initiative that might be seen as a half-step, called the Veterans Coordinated Access Rewarding Experience (CARE) program. It would allow VA clinicians to recommend patients see either a VA specialist or a provider in the community. 
 
“We may help veterans schedule appointments in the community, or in some circumstances, veterans can schedule the appointments themselves,” Shulkin told the Senate Veterans Committee. “We make sure community providers have all the information they need to treat the veteran. We get the veteran’s record back. We pay the veteran’s bill.” 
 
Though legislation has yet to be introduced, Shulkin said he hopes to push the new program through Congress by the end of September. With the prospects for Obamacare repeal, tax reform, and an infrastructure bill not looking so hot, a wide range of reforms at the VA may turn out to be the most significant accomplishment of the Trump administration’s first year.
 
— Jim Geraghty is National Review’s senior political correspondent.