WASHINGTON - As a White House physician under three presidents, Ronny Jackson often went to extra lengths to win over the officials he was on hand to assist. He helped George W. Bush clear brush at his Texas ranch. He supplied Barack Obama with Nicorette gum and even as he urged him to quit the nicotine substitute. He once was so eager to deliver a sling to Vice President Dick Cheney for a sore arm that his sprint toward the presidential helicopter caught the attention of Secret Service agents, a friend said.
That kind of enthusiasm drew ridicule in January, when Jackson said at a news conference that President Donald Trump "might live to be 200 years old" if he had a more healthful diet. But his performance received lavish praise from the president, who shocked Washington a few months later by tapping the former combat surgeon to run the Department of Veterans Affairs - one of the federal government's largest and most fraught bureaucracies.
The job would place Jackson - a Navy rear admiral who led a team of fewer than a dozen surgeons in Iraq and now heads a staff of 70 at the White House - atop an agency of more than 375,000 employees and a budget of more than $185 billion.
Jackson's propensity to please puts him on a markedly different footing than that of David Shulkin, who was fired as VA secretary after battling with Trump appointees over the president's agenda to outsource more veteran services to private providers. Jackson has told lawmakers that he opposes privatization. But because Jackson has little track record in public policy, his views remain largely a mystery, and some veterans' advocates fear he would be inclined to follow his boss's lead.
It's "impossible" that Jackson could be up to speed about the demands of such a large organization, said Paul Rieckhoff, executive director of Iraq and Afghanistan Veterans of America.
Carl Blake, executive director of Paralyzed Veterans of America, said: "We still know very little about him at this point or his philosophy on key issues."
Jackson, 50, declined a request for an interview. He has said that he never thought he'd keep his job under Trump and that he did not seek the VA nomination.
He is now preparing ferociously for the Cabinet post, colleagues say. This week, he began making the rounds on Capitol Hill ahead of his April 25 confirmation hearing, and he has welcomed a string of VA officials to the White House for hours-long briefings on the minutiae of the agency.
It is a show of ambition that pushed him from a small town in Texas into the Navy, through years of training in emergency medicine and trauma surgery, and then into the White House.
There, he has had unmatched proximity to power - and learned how to navigate it.
"He knows how to read a room really, really well," said Sean Spicer, Trump's first communications director, who like many presidential aides over the past 12 years spent hours with Jackson in motorcades, on flights and inside the White House. "The thing that I think has been fascinating about watching him is that he really understands how to interact with people. He knows when to dial back and when to engage."
Now, Jackson faces the ultimate test of that ability, and of whether it is enough to propel him into the biggest job of his career.
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Jackson began his White House tenure in 2006 as part of a team responsible for caring directly for the president, his family and more than 7,000 employees.
He was just days into his new job when the vice president stopped by for help. Cheney was headed out of town and asked for a sling to rest his arm in flight.
"Ronny was new, and didn't know where slings were kept, so he scrambled around looking for a sling," recalled Capt. Thomas Craig, a fellow Navy doctor and longtime friend. "He found one and tore out of the White House running like a scalded dog toward Marine One to catch up with the POTUS and Dick Cheney."
There was one problem, Craig said: "Nobody can just run up on the POTUS without getting into all kinds of trouble." Agents stopped Jackson in his tracks - but not before he delivered the sling to Cheney.
Jackson became Obama's personal physician in 2013, a role he retained with Trump. As he has at other moments of his career, he has offered an aw-shucks explanation for his success, claiming modestly to the Lubbock Avalanche-Journal in Texas this month that he "kind of got catapulted" to the top of the organization.
Much of Jackson's work over the past 12 years at the White House has involved the routine repair work of a small-town practitioner, with a twist: giving flu shots, passing out cold medicine - and helping plan assassination contingency plans when the president leaves Washington. It required extensive travel and hours of face time with the chief executive. Jackson has played basketball with Obama and spent time with Trump at his Florida home, Mar-a-Lago.
"It's a very intimate job," said Reggie Love, a former personal assistant to Obama who regularly rode with Jackson in flight and in the limousine that accompanies presidential motorcades. "Even when you're in the middle of the desert in Riyadh, the guy's got a smile on his face and he's happy to be there."
Love recalled Obama's travel director, Marvin Nicholson, once hitting his head during a helicopter ride in Ghana. "Ronny stapled and glued him up. There's no panic. There's no like, 'What are we going to do?' "
Jackson also stitched up Love's chin once. "I think it was the night of the White House Correspondents' Dinner," Love said. "He said, 'Good luck not getting your tuxedo bloody.' "
More than a dozen current and former colleagues interviewed for this article described Jackson as a popular colleague and an excellent doctor.
"He was a joy to be around," said David Axelrod, who was an adviser to Obama.
One trait universally cited is Jackson's storytelling ability. He has regaled colleagues with one particular tale about administering stitches on an intimate part of his body. He even recounted it for Bush after cutting himself with a hoe at the president's ranch in Texas.
As he prepared to stitch up his leg, Bush protested. "It's OK, I've sewn myself up before," Jackson replied, then told the president about his earlier injury, according to people familiar with the episode. That earned him an admiring nickname from Bush: Scrote.
Most former colleagues demurred when asked about the doctor's preparedness to lead VA.
Jackson "understands the stakeholders," Love said. But addressing the department's challenges is like "trying to move a battleship. It's going to be a lot of work."
At the White House, Jackson has been involved in few large-scale policy decisions beyond his role working on assassination preparedness and running the medical operation for big events such as the G-8 summit at Camp David in 2012. In Iraq, he led about eight doctors - and volunteered for the additional duty of helping new arrivals find housing at the sprawling Al-Taqaddum Air Base.
People who know him were taken back by Jackson's glowing praise for Trump's health in the news conference earlier this year. He described the president's overall health as "excellent," using nearly identical words he had written in a medical report about Obama four years earlier.
But Jackson went even further with Trump. "The answer to your question is that he has incredibly good genes," Jackson responded to one reporter during the news conference, "and it's just the way God made him."
Critics accused him of playing to the sensitivities of a uniquely praise-hungry president, and even friends wondered about his choice of words that day.
"It wasn't really Ronny," Craig said.
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The blood was often still warm from its donors when the surgeons of Al-Taqaddum in central Iraq pumped it into the blown-up bodies of the wounded - as much as 40 pints into a single patient. Most of it bled back out onto the hospital floor, but it kept U.S. troops alive while they waited their turn for surgery.
For eight months beginning in July 2005, Jackson led the emergency medicine unit at TQ, as it was known - a 24-hour operation where casualties came in day and night. Sometimes it was two, sometimes 15. Most of the injuries resulted from improvised explosive devices, or roadside bombs.
"This guy risked his life for his country, he's been out in the thick of it, he understands what war is all about, he's had people die in his arms," said Sen. Lindsey Graham, R-S.C., who has known Jackson for a while and plans to introduce him at his confirmation hearing next week. "That's what I want the next VA guy to understand. We're not playing games here."
According to Peter Rhee, a retired Navy captain, and other colleagues who served with Jackson, Al-Taqaddum was a combat-zone hospital where troops and civilians alike were taken because they were unlikely to survive the 20 or 30 extra minutes it would take to reach more extensive hospitals in Baghdad or Balad.
In the operating room, surgeons including Jackson sometimes had to slice open their patients from sternum to pelvis to stop internal bleeding - then send them on to one of the bigger hospitals without even closing the incision.
Craig, who serves at the Naval Medical Center Portsmouth, in Virginia, said troops who arrived with no hope of survival - legs blown off to the pelvis or gaping head wounds - were heavily sedated and wheeled to the side. But TQ had a high survival rate - about 97 percent, he recalled. Wounded troops often described feeling grateful for arriving at TQ, because it meant they probably would be okay, he said.
Obama press secretary Josh Earnest, who spent hours on the road and in the White House with Jackson, said he can see the connection between the doctor's work in combat and his later role in the White House. Both appeal to an excitement junkie.
"In some cases, that is treating soldiers under fire in a war zone, and in some cases, that is putting in place the arrangements to protect the life of the president of the United States as he's traveling around the world," Earnest said. "So I think there is a consistent thread of his personality that runs through all of this."
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It was Rhee who told Jackson about the appeal of presidential medicine in the mid-2000s, when Jackson was in trauma training under him in California. Rhee said he would recount stories about a short-term Navy assignment in 1998 accompanying President Bill Clinton to China. Rhee described the experience as exhilarating: first-class travel, a front-row seat to history, an up-close view of the personality of a president.
"I didn't just see China; I got the presidential tour of China," Rhee said.
Once he was at the president's side, Jackson used his post to build relationships and champion issues of personal importance to him. He regularly accompanied Obama on his quarterly visits to Walter Reed National Military Medical Center to visit wounded troops. And he kept Obama apprised in the aftermath of the shooting of Rep. Gabrielle Giffords, D-Ariz., in January 2011.
By then, Rhee had retired from the Navy and was leading the trauma department at the Tucson hospital where Giffords was treated. He said he received daily calls from Jackson wanting to know how the congresswoman was doing.
Rhee credits Jackson for his invitation to sit in the first lady's box a few weeks later during Obama's 2011 State of the Union address - and to attend a White House state dinner for the president of South Korea the following October.
Many of Jackson's friends think that his political finesse and compelling wartime experience could be enough to win confirmation as the next VA secretary.
What happens after that, however, is less certain. Craig said he has spoken to Jackson in recent days about his intense preparations for his upcoming hearings.
"What I took from him is that it's a sense of obligation to serve his country even more," Craig said. "He's not looking at it like he's being thrown into a deep fryer. But you and I know that it's just going to be a quagmire of pain."
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The Washington Post's Seung Min Kim, Lisa Rein and Emily Wax-Thibodeaux contributed to this report.
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Video: President Trump has nominated Navy Rear Adm. and White House physician Ronny L. Jackson to head the Department of Veterans Affairs.(Jenny Starrs/The Washington Post)
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Mississippi's governor just signed a law, more restrictive than in any state, banning abortions after 15 weeks. Iowa's state Senate is trying to go even further and stop abortions at around six weeks. And 20 Ohio legislators have proposed outlawing all abortions, even if the woman's life is in danger.
In many state capitols, Republican lawmakers are backing unusually strict antiabortion laws. Many are emboldened by President Donald Trump, who has been more supportive of their agenda than any president in decades. Conservative lawmakers also are eager to get more restrictions on the books in case November's elections bring a surge of Democrats hostile to them.
Federal courts have immediately blocked many of these antiabortion laws, including Mississippi's. But they still have a purpose: to set up legal challenges to Roe v. Wade, the Supreme Court decision that legalized abortion nationally, at a time when Trump could appoint the justice who helps overturn it.
"Trump has given hope to the pro-life movement," said Ron Hood, a Republican state representative who introduced the total abortion ban in Ohio.
Under Hood's bill, women could be criminally punished for aborting an "unborn human." In an interview, Hood said prosecutors would decide what charges to seek, just as they do in cases of manslaughter or murder.
For years, many antiabortion groups have argued that laws should penalize the doctor, not the woman, but Hood - who calls abortion an "atrocity" - said about a quarter of his colleagues in Ohio's 99-member House chamber are lined up behind his bill.
"We are seeing extremism on many fronts in the United States today," said Nancy Northup, chief executive of the Center for Reproductive Rights, which supports abortion rights. "Those who oppose abortion rights are seeing this as a time to push for the most extreme measures."
About 1 in 4 women have an abortion in their lifetime, according to a report by the Guttmacher Institute, a reproductive rights research organization, recently published in the American Journal of Public Health.
In the Trump era, the long-running abortion wars are heating up again, and the country is increasingly divided when it comes to the availability of abortions.
Many Republican-controlled states are ratcheting back access - establishing waiting periods, outlawing common medical procedures and cutting off Medicaid funding.
At the same time, Democratic-controlled states are expanding access to contraception and reproductive health; in Washington state, the governor just required insurers to cover abortion costs.
Charles Donovan, president of the research institute of the Susan B. Anthony List, which promotes politicians who oppose abortion, said the looming midterm elections "certainly do add a push" to get antiabortion laws in the pipeline for a potential Supreme Court challenge.
In 2017, Trump's first year in the White House, 19 states passed 63 antiabortion restrictions, according to Guttmacher.
Collectively these measures send a loud message, Donovan said. "It's a cultural message, not just a legal message, to the court," he said.
Before Trump ran for president, he publicly said he was "very pro-choice." But when he became a candidate, he promised to appoint judges to reverse Roe v. Wade and won over many Republican voters, including from the religious right, who remain among his steadfast supporters.
They applauded his nominee to the Supreme Court, Neil Gorsuch, who has never ruled in an abortion case and evaded questions at his confirmation hearings about Roe v. Wade but who has consistently voted with the court's conservative majority. Another vacancy on the court would give Trump a chance to increase that majority, a prospect that has thrilled Trump supporters.
The opportunity has not worked out in the past. Justice Anthony Kennedy was once thought to be the missing vote to overturn Roe but instead affirmed the right of women to seek an abortion.
And although Kennedy has been generally supportive of abortion restrictions, he joined the court's liberals two years ago to strike down a Texas law that was found to impose an undue burden on women.
But Kennedy is 81 and is said to be considering retirement. Two of the court's liberals, Ruth Bader Ginsburg and Stephen Breyer, are 85 and 79, respectively.
The chance to replace one of the three offers abortion opponents "something they never thought they would have: a potential majority on the Supreme Court" who would overturn this landmark decision, said John Weaver, a Republican strategist who has advised Ohio Gov. John Kasich.
While many in Washington are consumed with presidential scandals about alleged mistress payoffs and FBI raids, many people across the country care more about other issues, such as abortion, Weaver said.
"It's an issue that keeps them tethered to an untethered president," he said.
Northup said Trump has unleashed a "new level of aggression" among abortion opponents. Recent bills include those that would prosecute doctors who perform an abortion as early as six weeks, make no exception for rape, forbid women from getting an abortion if the reason is a high probability of Down syndrome and, as in Ohio, allow a prosecutor to seek criminal charges against women.
"People better vote on November 6th like their life depends on it," said Kellie Copeland, executive director of NARAL Pro-Choice Ohio. She said the discussion in Columbus of criminally prosecuting women "is so far out of the mainstream" that there is urgency for voters to turn out.
Democrats overwhelmingly support preserving the rights of women to end an unwanted pregnancy.
Democrats say energy is high and record numbers of women are running in November, and they are hoping for wins that could shift the power balance in state capitols.
Conservatives also say they are energized.
Susan Swayze Liebel, coordinator of the National Pro-Life Women's Caucus for the Susan B. Anthony List, said abortion opponents are working to turn out their base and "keep the momentum going in the states."
"The Trump effect is the hope effect for the pro-life movement," Liebel said.
More than 90 percent of abortions are performed before 13 weeks, according to the Centers for Disease Control and Prevention.
A Pew Research poll last year found that 69 percent of Americans did not want Roe v. Wade. to be overturned. That ruling gives a women the right to an abortion up to the point where the fetus is viable outside the uterus, which is generally considered around 24 weeks.
But Pew also showed a stark party split - 75 percent of Democrats said abortion should be legal in all or most cases, while 65 percent of Republicans believed it should be illegal in those cases.
A big Republican-wave election in 2010, after the election of Barack Obama, sharply increased GOP and conservative clout in states, and that clout remains today.
Since then, 33 states have passed laws to limit abortion.
In Texas, an increasingly hostile environment for abortion providers contributed to the closures of 20 clinics, abortion rights groups said, about half of those in the state. In the Republican strongholds of Mississippi and Kentucky, only one clinic is left.
In certain parts of the country, "it is unequivocally much harder now to access abortion care than any year since Roe v. Wade," Northup said.
Elizabeth Nash, the state policy analyst at Guttmacher, said abortion services are increasingly out of reach for many women because of the distance they would have to travel to a clinic and the cost. Women in Texas, Louisiana, Mississippi and other states have a far harder time than those on the West Coast and in many parts of New England, where ending an unwanted pregnancy is easier and cheaper.
About 75 percent of women who seek abortions are poor or have a low income, according to Guttmacher.
"Roe has already fallen in the practical sense for many women," said Copeland, of the abortion rights group in Ohio. "They are forced to continue pregnancy, sometimes even if it's not what is best for their health, because they cannot get past the travel and financial hurdles."
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The Post's Robert Barnes contributed to this report.