Ever since Donald Trump fired Secretary of Veterans Affairs David Shulkin late last month, veterans groups have been on high alert. Ostensibly, Trump ousted Shulkin because a February report found he’d used about $4,000 in public money for personal expenses—bringing his wife on a European trip with him—and improperly accepted a gift of Wimbledon tickets last July. But Scott Pruitt and Ben Carson have committed greater indiscretions and still have their jobs, so an alternative narrative has emerged: Shulkin was ousted because he didn’t support the privatization of the VA. With Shulkin out, many fear, conservative forces in the Trump administration and at the VA will now push hard to privatize veterans’ healthcare, something most major veterans group in the US oppose.

Privatization is an old concern for these groups. But now, said Kris Goldsmith of High Ground Veterans Advocacy, “just about everybody in the veterans advocacy community is freaking out.”

Still, this VA drama doesn’t seem to have stirred up all that much, or at least long-lasting, popular outrage. This may be because talk of creeping privatization is always fairly vague. Or because it’s not entirely clear at first blush what could actually happen with respect to privatization with Shulkin gone.

When politicians or advocacy groups talk about privatizing veterans’ health services, they usually mean gradually moving the nation’s 22 million vets away from government-run care and into the private sector. (About 9 million vets currently actively use VA services, which are spread out over more than a thousand facilities nationwide.) As with all privatization schemes, the basic argument is that private competition and choice will offer veterans better, more efficient care.

Some veterans advocates doubt that’s really what privatizing their health services is about, especially given that VA healthcare is already equal or superior in quality to most private options. Will Fischer of the progressive group Vote Vets believes such initiatives would “dash the hopes of there ever being universal healthcare” in the US and line the pockets of private companies. Rick Weidman of the Vietnam Veterans of America thinks striking down the still-popular system would be a mile marker for radical conservative agendas. “If you can destroy the Veterans Health Administration,” he said, “destroying the rest of the federal government is a piece of cake.”

No veterans’ group is entirely opposed to the VA working with the private sector. (One organization, the Koch-funded Concerned Veterans for America, supports privatization.) In 2014, a series of scandals revealed sometimes fatally long wait times for care at VA facilities. This led Congress to create the Choice Program, which allows vets who have to drive more than 40 miles or wait more than 30 days for VA care to use their benefits to receive equivalent care through a nearby private-sector health provider. This measure, supported by veterans and both political parties, was seen as a necessary stopgap to buy the VA time to fix internal problems—and in the years since, the agency has drastically improved its performance.

But last year the Choice Program had to be re-funded twice to buy the VA more time. And each time, there was talk of making that program permanent, or expanding the criteria under which vets could use their benefits for private care. Even Shulkin, largely seen as a defender of the existing system, voiced support for some expansion of Choice eligibility criteria. The fear, though, is that eventually Choice will expand so much and suck so many dollars out of VA-run healthcare, that the federal system will shrivel up and the VA will turn into more of a state-run insurance program for vets on the private market. “We’re already at the point where the Choice Program is costing a whole lot of money,” said John Hoellwarth of AMVETS. “There’s already reason to believe we’re already bleeding money and resources out.”

That may not sound like a terrible outcome in abstract, but most veterans’ groups oppose it because the Choice Program has not been a totally smooth and efficient project even at its current scale. Hoellwarth noted that no one is fully sure how the government can exercise oversight over scattered private providers to hold them accountable, as the VA has been held accountable these last few years, when they screw up. He added that there have already been plenty of reports of overbilling the VA.

Vets also face the same difficulties navigating the private healthcare system the rest of us do—figuring out which doctor is better for what, how much they actually charge, and what is covered by benefits. That makes it difficult for vets to find care of equal or better quality than the VA’s. These same issues also lead to unexpected denials of service under VA benefits, long wait times, and other dire glitches. “There are certainly stories,” said Fischer, “of people who’ve had their credit wrecked because they went off into the Choice Program and all of a sudden they were being asked to pay bills that they couldn’t.”

Hoellwarth concedes that it might be possible to develop effective oversight protocols or other systems to rein in some of this confusion and frustration over time. But Goldsmith doubts that all of these issues can be resolved, especially if the Choice Program expands massively.

Plus, pointed out Louis Celli of the American Legion, “once costs begin to skyrocket due to the added expense of purchasing private care,” as most reports seem to indicate that they would, “our concern that the administration and Congress will agree to start making veterans pay for their care through co-pays, deductibles, and annual premiums.” Put another way, vets would have to start paying for what were once guaranteed benefits of service.

Arguably most importantly, though, advocates worry the overall quality of their healthcare would decline if they move into a fragmented private system. They key feature of the VA system, most of the vets I’ve spoken to agree, is that it is integrated and keyed to vets’ issues. “If a veteran goes in for an audiology appointment,” explained Fischer, “and someone looks at their records and sees where they served and says, ‘While you’re here, we’re doing a survey of veterans who served in the same time and place for burn pit exposure,’ all of a sudden that young woman or man may find out they suffer from a medical condition they didn’t even know to look for.”

“Is somebody from the private sector going to know that I’m a veteran?” he mused. “Are they even going to ask if I’m a veteran? Is it going to matter to them that I was wounded in combat? That I served in Fallujah, Iraq? That I served in 2004?” There’s good reason to believe not. A recent study found that in New York, the vast majority of private-sector physicians were not prepared to treat vets, lacking the specialist knowledge on issues afflicting vets specifically and how to treat them that the VA has built up over many years. “Many civilian care providers won’t even take veterans on as patients” at this point, noted Celli, due to their complex medical issues.

Sure, private providers may be able to build up expertise and start accepting more vets. But that would occur over the course of years. And fractured care would not be able to connect the same dots to detect emerging vet-specific health issues and react to them like the VA system can.

“When you do away with that integrated system,” Fischer argued, “you’re doing away with the ability of veterans to have knowledge about potential exposures they may have had in service.”

Accordingly, veterans’ groups have held firm against attempts to expand Choice, or any other privatizing proposal. Even Choice extensions have had to come with more tools to fix internal VA problems to decrease the need for Choice. There’s no reason to think legislators will suddenly start pushing hard for Choice expansion just because Shulkin is out. Even if Trump’s replacement for Shulkin, White House doctor Rear Admiral Ronny Jackson, an unknown entity with no real experiencing running a system like the VA, turns out to be more in line with Trump’s hazy but evident pro-privatization priorities, he won’t be able to move that needle. So the next time Choice runs out of funds, in May, its renewal probably won’t lead to privatization creep.

Still, Celli pointed out, the VA can gently push towards privatization sans legislation, through internal policies. Hoellwarth noted that nominating Jackson might have been a subtle act of misdirection, putting the focus on this curious figure and taking it off of the acting secretary who will be calling the shots for the next few months. He could enact any number of policies about, say, referring people out to private specialists, or develop partnerships between the VA and private healthcare systems, with minimal scrutiny.

Goldsmith worries that Shulkin’s ouster might be part of a long-term plan. “As long as you keep cutting the head off the VA and it has no consistent leadership,” he argued, “the VA is going to be chaotic.” Axing a pro like Shulkin—who Goldsmith believes made a transgression, paid his dues, and learned from it—in favor of a neophyte like Jackson could set back efforts to reform VA healthcare. That would in turn extend the need for the Choice Program, opening more and more doors down the line to expand it, thus furthering privatization agendas.

Nothing about Shulkin’s departure and its meaning is clear. But it is hard to deny that there are forces dedicated—whether out of well-intentioned ideological belief or self-interest—to slowly dismantling the current veterans’ healthcare system. What's more, these forces clearly have pull in the Trump administration. Veterans’ advocates have good reason to be concerned that Shulkin’s departure could lead to subtle yet substantive moves in their direction. They have even more good reason to fear that such moves would slowly degrade the quality of their healthcare.

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