Dr. Shulkin forced the fight into the open, running a one-man media operation via his own cellphone while betting that the White House would eventually offer reinforcements. On Monday, after meeting with the White House chief of staff, John F. Kelly, Dr. Shulkin signaled that his gamble had paid off.
He said in an interview that President Trump and Mr. Kelly supported his making changes at the department, including the removal of any staff members who did not support him. Mr. Kelly made no mention of finding a new secretary, Dr. Shulkin said, and the White House press secretary, Sarah Huckabee Sanders, publicly expressed her support.
Staff changes could be announced on Wednesday, Dr. Shulkin said, without providing details. Whether he can prevail in actually firing the officials — rather than just having them transferred elsewhere in the government — remains to be seen. Political appointees serve at the pleasure of the president, and it was not clear whether Mr. Kelly or Mr. Trump would back their ouster.
At the root of the dispute is a long-running battle over how to deliver health care to the nation’s veterans. The department, the federal government’s second largest, operates more than 1,200 hospitals and clinics across the country where about nine million veterans receive treatment at little or no cost. In limited cases, it pays for veterans to see private doctors.
Policymakers in both parties argue that offering veterans unrestricted choice between the public veterans health care system and private medical providers would be too expensive and lead to the dismantling of the Veterans Affairs system. They have generally favored a more measured approach that would allow the department to approve the use of private care when waiting times are too long at veterans’ hospitals or when veterans live too far from the department’s facilities.
Enter the Trump administration: Mr. Trump has promoted greater choice as a top priority and surrounded himself with several conservative advisers supportive of greater privatization. Darin Selnick, a former senior adviser to the Koch-funded group, serves as the veterans affairs adviser for the White House’s Domestic Policy Council.
Dr. Shulkin, who led the department’s health care system under President Barack Obama, has aligned himself with the more moderate position. As more conservative officials see it, that has put him out of line with the White House view on the department’s most pressing policy issue.
In addition to the two top communicators — Curt Cashour, Dr. Shulkin’s press secretary, and John Ullyot, the assistant secretary responsible for communications — Dr. Shulkin is likely to target several officials close to the White House. They are Jake Leinenkugel, the White House senior adviser on veterans affairs, and Camilo Sandoval, a former data manager for the Trump campaign who was given a political post at the department.
Mr. Leinenkugel, a former brewery executive, wrote an email to Mr. Sandoval in December outlining his falling out with Dr. Shulkin over policy issues. Mr. Leinenkugel proposed using a then-continuing inspector general investigation to oust Dr. Shulkin’s chief of staff; replacing the deputy secretary, Thomas G. Bowman, with Mr. Leinenkugel; and replacing Dr. Shulkin with a “strong political candidate” with ties to the Koch-based group.
The dispute boiled over last month when the department’s inspector general released a scathing report on a business trip that Dr. Shulkin took to Britain and Denmark last year. The report found “serious derelictions” related to the trip and concluded that the secretary spent much of it sightseeing and improperly accepted a gift of Wimbledon tickets. It also accused Dr. Shulkin’s chief of staff at the time of altering an email to justify the department’s paying the airfare of Dr. Shulkin’s wife.
Political appointees trying to wrestle away control of the department seized on the report to force the secretary’s ouster. Shortly after its release, Mr. Cashour and Mr. Ullyot called a prominent House staff member to ask for backup, according to a Republican congressional aide familiar with the call. Mr. Ullyot told the staff member, Jonathan Towers, that Dr. Shulkin would be gone by the weekend and asked if House Republicans would advocate the secretary’s removal, the Republican aide said.
Mr. Towers, who works for the chairman of the House Veterans Affairs Committee, Representative Phil Roe of Tennessee, told Mr. Ullyot “no” on the spot, the aide said, and pointed out that Mr. Roe had released a statement of support for the secretary just a day before.
Mr. Cashour and Mr. Ullyot have disputed that account. The purpose of the call, they said, was to warn Mr. Towers that doubts raised about the inspector general report by Dr. Shulkin were unfounded. Tiffany McGuffee Haverly, a spokeswoman for Mr. Roe, said on Monday that the chairman continued to have confidence in Dr. Shulkin.
Dr. Shulkin, meanwhile, disputed the report’s conclusions and went around his press office to personally reach out to the news media and publicize concerns that appointees in his office were “trying to undermine the department from within.”
There were other examples. In recent months Dr. Shulkin began to use a new, more inclusive motto for the department, changing the phrase “To care for him who shall have borne the battle and for his widow, and his orphan” so that it included female veterans, a former department official said.
Mr. Ullyot, carrying out orders from the White House, reversed the decision, and Dr. Shulkin relented.
The secretary has not spoken directly with Mr. Ullyot in three weeks, since the report’s release. His critics within the administration said he had isolated himself and become paranoid.
Allies of Dr. Shulkin have suspected that the same faction could be behind ominous-sounding reports that have appeared in the press saying that the inspector general was on the verge of releasing another damaging report, this time about Dr. Shulkin’s use of his in-house security detail — a report that could provide a final blow to the secretary. A spokesman for the inspector general did not reply to a request for comment.
Asked about Monday’s meeting, Mr. Cashour replied with a seemingly unrelated statement. “President Trump tasked Secretary Shulkin with reforming the V.A. so it could better serve the men and women who sacrificed to protect our country,” Mr. Cashour said. “Many reforms have already been enacted, many more are still needed, but nothing will distract the president, the secretary and the department from finding the best ways to provide care and benefits to our country’s heroes.”