Perlmutter did not answer specific questions about this episode. His joint statement with Moskowitz and Sherman said, “None of us has gained any financial benefit from this volunteer effort, nor was that ever a consideration for us.”

Perlmutter also facilitated a series of conference calls with senior executives from Apple. VA officials were excited about working with the company, but it wasn’t immediately obvious what they had to collaborate on.

As it turned out, Moskowitz wanted Apple and the VA to develop an app for veterans to find nearby medical services. Who did he bring in to advise them on the project? His son, Aaron, who had built a similar app. The proposal made Apple and VA officials uncomfortable, according to two people familiar with the matter, but Moskowitz’s clout kept it alive for months. The VA finally killed the project because Moskowitz was the only one who supported it.

Moskowitz, in the joint statement, defended his son’s involvement, calling him a “technical expert” who participated in a single phone call alongside others. “Any development efforts, had they occurred, would not have involved Aaron or any of us. There was no product of Dr. Moskowitz’s or Aaron’s that was promoted or recommended in any way during the call,” the trio said. “Again, none of us, including Aaron, stood to receive any financial benefit from the matters discussed during the conversation—and any claims to the contrary are factually incorrect.”

Moskowitz had more success pushing a different pet cause. He has spent years trying to start a national registry for medical devices, allowing patients to be notified of product recalls. Moskowitz set up the Biomedical Research and Education Foundation to encourage medical institutions to keep track of devices for their patients to address what he views as a dangerous hole in oversight across the medical profession. At one point, the foundation built a registry to collect data from doctors and patients. Moskowitz chaired the board, and Perlmutter’s wife was also a member. Moskowitz’s son earned $60,000 a year as the executive director, according to tax disclosures.

Moskowitz pushed the VA to pick up where he left off. He joined officials on weekly 7:30 a.m. conference calls in which officals discussed organizing a summit of experts on device registries and making a public commitment to creating one at the VA. In an email to Shulkin, the VA official in charge of the project referred to it as the “Bruce Moskowitz efforts.”

When the summit arrived, on June 4, Moskowitz and his son did not attend. It’s not clear what role they will have in setting up the VA’s registry going forward—their foundation has shut down, according to its website, and Moskowitz’s son said he’s no longer involved. But in his opening remarks at the summit, Peter O’Rourke, then the acting secretary, offered a special thanks to “Dr. Bruce Moskowitz and Aaron Moskowitz of the Biomedical Research and Education Foundation” as “driving forces” behind it.

Over the course of 2017, there was growing tension within the Trump administration about how much the VA should rely on private medical care. During the campaign, Trump championed letting veterans see any doctor they choose, inside or outside the VA system. But Shulkin warned that such an approach was likely to result in poorer care at a higher cost. His preferred solution was integrating government-run VA care with a network of private providers.

In September 2017, the Mar-a-Lago Crowd weighed in on the side of expanding the use of the private sector. “We think that some of the VA hospitals are delivering some specialty healthcare when they shouldn’t and when referrals to private facilities or other VA centers would be a better option,” Perlmutter wrote in an email to Shulkin and other officials. “Our solution is to make use of academic medical centers and medical trade groups, both of whom have offered to send review teams to the VA hospitals to help this effort.”

In other words, they proposed inviting private healthcare executives to tell the VA which services they should outsource to private providers like themselves. It was precisely the kind of fox-in-the-henhouse scenario that the VA’s defenders had warned against for years. Shulkin delicately tried to hold off Perlmutter’s proposal, saying the VA was already developing an in-house method of comparing its services to the private sector.

Shulkin also clashed with the Mar-a-Lago Crowd over how to improve the VA’s electronic record-keeping software (the one episode involving the trio that has previously surfaced, in a report by Politico). The contract, with a company called Cerner, would cost more than $10 billion and take a decade to implement. But Moskowitz had used a different Cerner product and didn’t like it. He complained that the software didn’t offer voice recognition, even though newer versions of Cerner’s product do. For months, the Mar-a-Lago Crowd pressured Shulkin to put the contract through additional vetting.

On Feb. 27, 2018, Shulkin flew to Mar-a-Lago—not to see Trump, who was back in Washington, but to meet with Perlmutter, Moskowitz and Sherman. The trip was supposed to close the deal on the Cerner contract, according to two people familiar with the meeting. By then, Shulkin’s stature had been badly diminished by an ethics scandal, and he expected he didn’t have much longer in the job, but he wanted to finish the Cerner deal first.

Shulkin brought O’Rourke, an ex-Trump campaign aide who stepped in as chief of staff after the ethics scandal led to the departure of Shulkin’s top aide. O’Rourke took the opportunity to ally himself with the Mar-a-Lago Crowd. “It was an honor to meet you all yesterday,” he wrote in a follow-up email. “I want to ensure that you have my VA and personal contact information.” He then provided his personal cell phone number and email address. (Using personal email to conduct government business can flout federal records laws, as President Trump and his allies relentlessly noted in their attacks on Hillary Clinton during the 2016 campaign.) “Thank you for your support of the President, the VA, and me,” O’Rourke wrote. (O’Rourke didn’t answer requests for comment.)

Perlmutter welcomed the overture. “I feel confident that you will be a terrific asset moving forward to get things accomplished,” he replied.

The Mar-a-Lago Crowd grew frustrated with Shulkin, feeling like he wasn’t listening to them, and Perlmutter came to regret recommending Shulkin to Trump in the first place, according to people familiar with his thinking. That aligned them with political appointees in the VA and the White House who started to view Shulkin as out of step with the president’s agenda.

One of these officials, senior adviser Camilo Sandoval, presented himself as Perlmutter’s eyes and ears within the agency, two former officials said. For instance, in an email obtained by ProPublica, Sandoval kept tabs on the Apple project and reported back to Moskowitz and Sherman. “I will update the tracker, and please do let me know if this helps answers [sic] questions around Apple’s efforts or if additional clarification is required,” he wrote. Sandoval, who didn’t answer requests for comment, knew Perlmutter because he worked on the campaign with Trump’s son-in-law, Jared Kushner, who is also close with Perlmutter.

In December, White House adviser Jake Leinenkugel sent Sandoval a memo outlining a plan to upend the department’s leadership. Leinenkugel would not say who asked him to write the memo. But it was clearly not intended for Sandoval alone, since it refers to him in the third person. Three people familiar with the situation said the memo was sent to Sandoval as a channel to Perlmutter. The spokeswoman for Perlmutter, Sherman and Moskowitz said they didn’t know about the memo.

The memo recommended easing Shulkin out and relying on Perlmutter for help replacing him. “Put [Shulkin] on notice to exit after major legislation and key POTUS VA initiatives in place,” the memo said. “Utilize outside team (Ike).” Although several factors contributed to Shulkin’s downfall, including the ethics scandal and differences with the White House over legislation on buying private healthcare, three former officials said it was his friction with the Mar-a-Lago Crowd over the Cerner contract that ultimately did him in.

Perlmutter, Moskowitz and Sherman dispute that contention. “Any decisions of the agency or the president,” they noted in their statement, “as well as the timing of any agency decisions, were independent of our contacts with the VA.”

But it wasn’t just Shulkin—all the officials that the Leinenkugel memo singled out for removal are now gone, replaced with allies of Perlmutter, Sherman and Moskowitz. The memo suggested that Sandoval take charge of the Office of Information and Technology, overseeing the implementation of the Cerner contract; he got the job in April. The memo proposed removing Deputy Secretary Tom Bowman; he left in June, and the post hasn’t been filled. The memo floated Richard Stone for under secretary for health; he got the job on an acting basis in July. Leinenkugel himself took charge of a commission on mental health (the same topic Moskowitz had emailed O’Rourke about). O’Rourke, having hit it off with the Mar-a-Lago Crowd, became acting secretary in May.

Trump initially nominated White House doctor Ronny Jackson to replace Shulkin, with Pentagon official Robert Wilkie filling in on a temporary basis. On Wilkie’s first day at the VA, Sherman was waiting for him in his office, according to a calendar record.

Within a few weeks, Wilkie made a pilgrimage to Mar-a-Lago. He tacked it onto a trip to his native North Carolina, and O’Rourke caught up with him in Palm Beach. They visited a VA hospital and rehab facility, then headed to Mar-a-Lago to meet with Perlmutter, Moskowitz and Sherman, according to agency records.

The Mar-a-Lago Crowd gave Wilkie and O’Rourke rave reviews. “I am sure that I speak for the group, that both you and Peter astounded all of us on how quickly and accurately you assessed the key problems and more importantly the solutions that will be needed to finally move the VA in the right direction,” Moskowitz told Wilkie in a follow-up email.

Perlmutter was similarly thrilled with the new regime. “For the first time in 1½ years we feel everyone is on the same page. Everybody ‘gets it,’” he said in an email. “Again, please know we are available and want to help any possible way 24/7.”

Wilkie replied that the honor was his. “Thank you again for taking time to see me,” he wrote.

Soon after, Jackson’s nomination imploded over allegations of misconduct as White House physician. (Jackson denied the allegations, and they’re still being investigated.) At that point, Perlmutter’s endorsement cleared the way for Trump to nominate Wilkie.

Wilkie, who was sworn in on July 30, now faces a choice between asserting his own authority over the VA or taking cues from the Mar-a-Lago Crowd. Wilkie reportedly wants to sideline O’Rourke and Sandoval and restock the agency leadership with his own people. But people familiar with the situation said the Mar-a-Lago Crowd’s allies are pushing back on Wilkie’s efforts to rein them in. As his predecessor learned the hard way, anyone who crosses the Mar-a-Lago Crowd does so at his own risk.

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.

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