The Health 202: The VA is still struggling to reform. Now its boss is gone.

In his now-signature firing style, President Trump let Shulkin go with a tweet yesterday evening, ending months of speculation about whether Shulkin could survive mounting scandal over his charging taxpayers for luxury travel expenses and infighting among his senior aides, The Post's Lisa Rein, Philip Rucker, Emily Wax-Thibodeaux and Josh Dawsey report.

Trump announced he was replacing Shulkin with his personal physician, Ronny Jackson.

“In the early months of Trump’s administration, Shulkin was one of the president’s favorite Cabinet secretaries, in part because he was seen as advancing one of Trump’s key campaign promises, improving veterans’ care,” my colleagues write. “Veterans are a key constituency for the president, who vowed during his campaign to shake up what he called a ‘broken’ system in Washington that he said treats undocumented immigrants ‘better than our vets.’”

But Trump was frustrated by months of negative headlines and infighting at the VA – which even led Shulkin to post an armed guard outside his office – and senior officials had told the president Shulkin had been dishonest in his dealings with West Wing officials. Plus, there was that recent inspector general report criticizing the secretary’s trip to Europe last summer.

It all culminated yesterday, when White House Chief of Staff John Kelly called Shulkin in the afternoon and told him he was losing his job, a White House official told my colleagues. “It was just a courtesy. Thanks for your service,” this person said, describing the call.

“The firing of Shulkin, who was the sole Obama-era holdover in Trump’s Cabinet, is the latest tremor in a broad shake-up of Trump’s administration,” Lisa, Philip, Emily and Josh note. In March alone, Trump replaced his secretary of state (The Health 202 wrote about Rex Tillerson’s departure here), national security adviser and top economic adviser and is planning to soon name a new White House communications director.

From Josh:

Despite all the controversy, Shulkin had strong support from members of Congress on both sides of the aisle. And there is evidence he was making some long-awaited changes a top priority at the VA, an $186 billion budget agency which employs 360,000 people, serves a growing population of veterans in need and is suffering from a shortage of doctors, nurses and mental health experts.

ABC News's Ali Rogin: 

For example, Shulkin recently announced an overhaul of senior leadership overseeing almost two dozen troubled hospitals in the Washington area, New England, Phoenix and parts of California. At a March 7 news conference at Washington Medical Center, he said one senior regional official had been reassigned, two others retired and that he appointed 24 new facility directors in the last year, after outside teams identified low-performing hospitals, Lisa and Emily reported at the time.

Shulkin had also been pushing hard for the VA to finish updating its old-fashioned and unwieldy medical records system, a multi billion-dollar project that was started in 2001, stalled in 2010 and which he restarted a few years ago, although not without big ongoing hiccups.

In January, he’d admitted to lawmakers that the VA’s contract with the firm Cerner had been put on hold over disagreements over the meaning of interoperability – a widely-used term in the health policy world that refers to the ability of different electronic medical records systems to share data.

“My objective when it comes to health-care for our veterans is to have a fully integrated, interoperable, operationally efficient health-care system that’s easy for veterans, employees and community partners to navigate,” Shulkin told the Senate Committee on Veterans Affairs.

In an op-ed published this morning by the New York Times, Shulkin wrote "it should not be this hard to serve your country."

"As many of you know, I am a physician, not a politician. I came to government with an understanding that Washington can be ugly, but I assumed that I could avoid all of the ugliness by staying true to my values," he wrote. "I have been falsely accused of things by people who wanted me out of the way. But despite these politically-based attacks on me and my family’s character, I am proud of my record and know that I acted with the utmost integrity. Unfortunately, none of that mattered."

Trump is replacing Shulkin with Ronny Jackson, the longtime White House physician who gained widespread attention early this year when he effusively praised the 71-year-old president’s physical and mental health. While Jackson is an active-duty rear admiral in the Navy, he has no background in management, prompting some to question whether he can deliver on the president’s campaign promise to fix the government’s second-largest bureaucracy.

“Trump prizes relationships and loyalty over traditional qualifications, and he quickly developed personal chemistry with Jackson,” my colleagues report. “The boss admires the man he calls ‘The Doc,’ according to aides, and cheered Jackson’s on-camera performance in the press briefing room in January, where he delivered the results of Trump’s annual physical as ‘very, very good’ and ‘excellent.’”

“Some people have just great genes,” Jackson told reporters at the time. “I told the president that if he had a healthier diet over the last 20 years, he might live to be 200 years old. . . . He has incredibly good genes, and it’s just the way God made him.” Watch a clip from that briefing here: 

Trump returned praise in a statement about Jackson yesterday. “Admiral Jackson is highly trained and qualified and as a service member himself, he has seen firsthand the tremendous sacrifice our veterans make and has a deep appreciation for the debt our great country owes them,” the president said.

Some context from Philip:

The Post's Ashley Parker:

As our colleague Jenna Johnson points out, Trump has a close relationship with Jackson: 

CNN's Jeff Zeleny: 

Ned Price, a former special assistant to President Obama:

Bloomberg's Jennifer Jacobs: 

PROGRAMMING NOTE: The Health 202 will not publish on Friday. Have a good weekend and we'll be back in your inbox on Monday, April 2. 

AHH: The Affordable Care Act dialed up taxes for the richest Americans while redistributing more than $16 billion to the poorest Americans, the Congressional Budget Office said in a report out yesterday. Due to several new levies, the ACA increased the average tax burden of the richest 1 percent of Americans by about $21,000 per year, decreasing their average annual income by about 1.2 percent, The Post's Jeff Stein reports. The richest 20 percent of Americans paid, on average, an additional $1,100 annually because of these new taxes, the biggest of which include a tax on investment income and another on health insurers.

CBO also found the ACA boosted incomes for those at the bottom of the income distribution, primarily through expanding Medicaid. "The law increased the average income of the poorest 20 percent of Americans by $690 per person, and the average income of people in the second-poorest income bracket by an average of $560 per person," Jeff writes. "Overall, Obamacare raised the average income of the poorest income bracket by nearly 4 percent. The law lifted the income of the second poorest bracket (with an average annual income of $42,000) by about 1 percent."

OOF: Trump’s latest travel ban could make it impossible for a U.S. citizen battling blood cancer to get a lifesaving bone marrow transplant, Reuters reports. Maziar Hashemi, a 60-year-old naturalized U.S. citizen, has been told by doctors a bone-marrow transplant is his best hope for survival. But his brother Kamiar, who is a rare 100-percent match, lives in Iran. And most travelers from Iran, Libya, Syria, Yemen, Somalia, Chad and North Korea are currently barred from traveling to the U.S.

“Although the ban allows for case-by-case waivers to be granted, including for medical need, Kamiar Hashemi has so far been denied a visa,” Mica Rosenberg writes. “Attorneys who regularly deal with visa issues say the waiver process is opaque. Visa applicants aren’t allowed to apply for waivers; they are simply granted or not without explanation. U.S. officials won’t say how they make their decisions or how long they generally take.”

Kamiar Hashemi began applying for a visa soon after he learned he was a bone marrow match for his brother, and Maziar Hashemi has hired an immigration lawyer to help with the process as well. Kamiar looked into traveling to India to have his bone marrow harvested and sent to his brother, but the legal team for the organization Be The Match found that the marrow could not be sent to the U.S. on its own because of sanctions on Iranian exports.

OUCH: A Planned Parenthood branch linked Disney princess memes and abortion politics in a tweet on Tuesday, but quickly deleted it after a backlash from abortion opponents, The Post's Avi Selk reports. The tweet:

“We joined an ongoing Twitter conversation about the kinds of princesses people want to see in an attempt to make a point about the importance of telling stories that challenge stigma and championing stories that too often don’t get told,” branch president Melissa Reed said in a statement. “Upon reflection, we decided that the seriousness of the point we were trying to make was not appropriate for the subject matter or context, and we removed the tweet.”

—Yesterday, FDA Commissioner Scott Gottlieb shared agency priorities at the CNBC Healthy Returns conference. Some highlights from his interview with reporter Meg Tirrell:

• Gottlieb said the agency is considering regulating e-cigarettes as an over-the-counter drug. "Right now, we're looking very actively at could we bring e-cigarettes into the over-the-counter regulatory pathway, which would give us many more tools to look at both safety and benefit,” he said, “and study whether or not an e-cigarette actually does promote smoking cessation and also give us many more tools to actually study the toxicology associated with it and see what effects it might have on the lung.” His remarks are the latest in a series of moves by the FDA to tackle tobacco regulation, including setting in motion steps to make cigarettes less addictive. (The Health 202 wrote about this earlier this month.)
   
• The FDA wants to focus on improving the manufacturing of branded biotech drugs in order to make it easier to replace them with cheaper “biosimilar” or copycat versions. Gottlieb criticized drug companies and pharmacy benefit managers for actions that make competition difficult and said the agency is working toward policies to help the path toward additional biosimilar drugs. “We're going to be putting out a set of policies to compel the branded drug makers who have biologics on the market to tighten up their manufacturing, to have less variance of their biologics that are currently on the market,” Gottlieb said. “We think once we do that, it's going to make it easier to copy those drugs in smaller studies.”
   
• Gottlieb also mentioned efforts to intercept drugs coming into the country through the mail as one way of tackling the ongoing opioid epidemic. Gottlieb said since he began at the FDA, he increased the number of workers inspecting packages at international mail facilities but he acknowledged more resources are needed. “Right now we're inspecting probably .04 percent of the packages that are presumed to contain drugs,” he said. “Now, we target our inspections effectively based on where they're coming from, who they're going to, what country they're coming from. So we think we're getting a good number of the packages that do have drugs. But we know stuff's getting through.”

—Surgeon General Jerome Adams announced his wife has experienced a recurrence of melanoma and had surgery. He also used the moment to raise awareness about the risks related to skin cancer. In a post on Facebook, Adams said his wife, Lacey Adams, used to tan frequently, and noted exposure to ultraviolet rays from the sun or from tanning beds can increase the risks of melanoma.

“Medical and public health professionals now very much discourage prolonged exposure to UV rays via being in the sun without proper protection (eg sun tan lotion, or clothing covering skin), or exposure via tanning beds,” he wrote. “Many places around the country have even instituted age limits for tanning bed use, due to the concentrated amount of UV light they can deliver in a short time."

In a later post Wednesday, he said Lacey was out of her surgery, which “went well.” “I am confident Lacey/ our family will beat this,” Adams wrote. “I also think things happen for a reason, and Lacey has me thinking that our reason may be to raise awareness about melanoma risk, prevention, and early detection.”

-- A few more good reads from The Post and beyond:

Spending bill addresses crushing backlog of federal disability claims (Terrence McCoy)

The food stamp fight that could kill the farm bill (Politico)

Genetics may make some babies vulnerable to SIDS or ‘crib death,’ study says (Ariana Eunjung Cha)

'I straight wanted to die': Michael Phelps wants USOC to help athletes cope with depression (Cindy Boren)

One of America’s largest health insurers has cut its opioid prescriptions by 25% (Business Insider)

Today

• FDA Commissioner Scott Gottlieb is scheduled to speak at the National Food Policy Conference.
• The Atlantic hosts “Cancer and the Community” in Pittsburgh, Pa.
• The American Enterprise Institute holds an event title “What happened to compassionate conservatism — and can it return?”

Here's why a former clown is running for Congress:

Asked about President Trump’s stance on the deaths of Alton Sterling and Stephon Clark, White House press secretary Sarah Huckabee said addressing police shootings is a matter for “local authorities:"