The president-elect’s selection of David Shulkin as Secretary of Veterans Affairs has drawn praise, but some advocates still worry about privatizing the agency.

Last week, President-elect Donald Trump surprised many by tapping David Shulkin, an Obama administration official, as his nominee for secretary of the Department of Veterans Affairs (VA).

Shulkin, a New York-area physician, and author, who is currently a VA undersecretary, is known for significantly improving care at Beth Israel Medical Center in New York as president and chief executive officer from 2005 to 2009.

He’s also known for working closely with current VA Secretary Robert McDonald on various reforms at the VA.

Shulkin’s ties to President Obama make him an unlikely choice for Trump, say multiple veterans’ advocates.

“I have no doubt Dr. Shulkin will be able to lead the turnaround our Department of Veterans Affairs needs,” Trump said at last week’s press conference. “His sole mandate will be to serve our veterans and restore the level of care we owe to our brave men and women in the military.”

In a statement, Shulkin said, “President-elect Trump’s commitment to caring for our veterans is unquestionable, and he is eager to support the best practices for care, and provide our Veterans Affairs’ teams with the resources they need to improve health outcomes.”

In Healthline interviews with more than two dozen veterans and veterans’ advocates, there wasn’t a single source who had anything negative to say about Shulkin, though some expressed minor concern that he will be the first nonveteran to lead the VA.

America’s veterans, who voted for Trump by a 2-to-1 margin, are hoping Trump can cut through the red tape that has plagued the VA, despite some successful efforts by McDonald and Obama to reform the embattled agency.

However, veterans interviewed for this story expressed a combination of hope and anxiety over what the president-elect will do to the department.

Read more: Where the presidential candidates stand on veterans’ health issues »

Shulkin’s father was an Army psychiatrist and his grandfather was a World War I veteran who later worked at the VA in Wisconsin.

Shulkin inherits a department that is now the second largest bureaucracy in the United States after the Department of Defense.

The VA has a budget of more than $180 billion, and nearly 350,000 employees.

It also has some persistent problems. Among them include:

  • An average of 20 veterans take their own lives each day in the United States. They account for 18 percent of all suicides by Americans.
  • The VA backlog in disability claims has received a lot of negative attention.
  • The agency is still struggling to meet the unique needs of a growing population of women veterans, as Healthline detailed in a November story.
  • There remains a shortage of quality doctors and nurses.
  • There is the ongoing problem for veterans who wait to see a doctor, Healthline reported in late 2015.

The scandal over wait times exploded nearly three years ago when it was revealed that employees at the Phoenix VA had been lying about how long veterans had to wait to see a doctor, and patients were dying as a result.

It was ultimately revealed that more than 60 VA hospitals were doing the same thing. And thousands of veterans were affected as a result.

Read more: Painful headaches plaguing many U.S. war veterans »

Progress has been made on several fronts, say many veterans interviewed for this story.

Wait times for veterans seeking doctors are down, in some clinics at least. And the backlog of disability claims is down, although disability claim appeals are not.

McDonald, who vowed reform after coming to the agency from the corporate world, has been effective, at least in some areas, say veterans’ advocates.

They express the hope Trump will allow that progress to continue.

Six weeks ago, John Rowan, national president of the Vietnam Veterans of America, the largest and most active Vietnam veterans group, sent a letter to President-elect Trump’s transition team urging that Shulkin be re-nominated as undersecretary for health.

That he was promoted to run the VA is even better, said Rowan.

“Dr. Shulkin has assembled a gifted staff to integrate community care into VA healthcare, enabling the VA to live up to the challenge of providing the best care available,” Rowan said in a statement. “All veterans ought to applaud Mr. Trump’s decision.”

Rowan said that Shulkin, a board-certified internist, is “intimately familiar with the challenges facing the VA, including the urgent need to improve access to VA healthcare services.”

Rowan also noted that in the course of his career, Shulkin has been named as one of the Top 100 Physician Leaders of Hospitals and Health Systems by Becker’s Hospital Review in 2014, as well as one of the 50 Most Influential Physician Executives in the Country by Modern Healthcare.

“Dr. Shulkin came out of the private sector less than two years ago,” Rowan explained. “He has been relentless in his pursuit of improving medical care for veterans, working to increase timely access, all the while holding managers and other VA staff accountable.

“We will do everything we can to assist Dr. Shulkin in his mission to right the wrongs in the VA, to improve veterans’ access to healthcare, and to remedy the unacceptably long time to resolve claims and appeals for disability compensation.”

Read more: VA choice card program having problems »

While there is widespread optimism about Trump’s choice, there is also palpable anxiety about what he might ask Shulkin to do.

These alternatives include perhaps privatizing the agency, which most of the nation’s largest veteran service organizations oppose.

So far, Trump has given only broad clues as to what he will do, but privatizing appears to be a priority.

On Trump’s website page titled Veterans Affairs Reform, the next president lists 10 broad reforms for veterans but no specific solutions.

On that page, Trump says he will ensure veterans get the care they need with no more waiting or red tape. He adds he will “make the VA great again” by firing corrupt and incompetent VA executives and hiring ones who aren’t.

He also vows, without any specifics, to ensure every veteran has the choice to seek care “at the VA or at a private service provider of their own choice.”

And this is what has many veterans’ advocates particularly concerned.

Robert Walsh, an attorney and veterans’ advocate who has represented thousands of veterans with disability claims at the VA, said there are several perils to privatizing the department.

The most troubling, he told Healthline, is that it would negatively affect “the special nature of the veterans as patients and clients.”

“Healthcare professionals who deal with special patient populations understand. The elderly, cancer patients, disabled children, and the mentally ill are a few examples,” he said.

The VA effort to contract for compensation and pension examinations for veterans from non-VA physicians has been a disaster for veterans seeking disability benefits, Walsh explained.

“The contracted individuals either don’t understand the issues surrounding the claims, there is a lack of familiarity with combat or sexual trauma-related post-traumatic stress (PTSD).”

The VA has undertaken to privatize some elements of its care, including its Veterans Choice program. That was established in 2014 in the wake of the wait times scandal to make it easier for a veteran to see a private doctor if he or she cannot promptly see a VA physician.

But as Walsh described, Veterans Choice “has been a slow-moving train wreck. Veterans are a very special demographic. In many cases they require a special outlook or set of skills to treat them properly.”

Read more: Vietnam veterans still have PTSD 40 years after the war »

Shulkin hasn’t yet said much about what he hopes to accomplish. But he has given the public an idea of what he thinks of privatizing the VA.

When a congressional commission last year recommended that the federal role in veterans’ healthcare be reduced, Shulkin told the Daily Press in Virginia:

“This would be a terrible mistake, a terrible direction for veterans and for the country, to essentially systematically implement recommendations that would lead to the end of the VA healthcare system.”

And veterans’ advocates agree.

Earlier this year, Glenn Towery, a Vietnam War combat veteran and veterans’ advocate who runs the Veterans Suicide Prevention Channel, a nonpartisan nonprofit, was asked to do a news report on VA privatization in Dallas, Texas.

“I spent the day video recording statements from retired generals, colonels, and other veterans who talked about the perils of privatization of the VA,” he told Healthline. “I was given an impressive tour of the Dallas VA hospital by VA personnel.”

The area that impressed him the most, Towery said, was the area where they treat traumatic brain injury (TBI).

“The chief physician of the department gave us a personal tour and explained the fantastic program in place to treat these traumatic brain injuries,” he said. “I don’t believe any civilian medical center could equal the care that I saw there.”

Towery said it would be a “travesty and a shame” to get rid of the present system that has been in existence for veterans for many years “because private industry wants to make a dime on veterans’ healthcare.”

Towery said despite the VA’s problems, a privatized system doesn’t take into account the military culture.

“Veterans would become less comfortable participating,” he said. “When veterans visit a VA facility they know they’re at a place that has studied the problems that plague veterans both mentally and physically.”

Towery said doctors at a VA system are trained specifically to handle veterans and their concerns.

“VA hospitals send a message and a promise to veterans that their service will be cherished and honored as men and women who have volunteered to put themselves in harm’s way for the benefit of preserving and protecting America’s freedom,” he said.

Without VA hospitals and VA research, Towery added, “veterans would find a longer, more daunting road to recovery and wellness.”

Towery said VA hospitals should always be about wellness for veterans and not about profit.

Louis Celli, national director of Veterans Affairs & Rehabilitation for the American Legion, one of America’s largest veteran service organizations, agrees.

He told The Washington Post last week that Shulkin’s selection “says to me that Trump has faith in the direction VA is going with healthcare. I think this is a huge reality check for a group of people who want to privatize VA.”

Read more: Gulf War veterans still fighting serious health problems »

That group of people Celli is referring to undoubtedly includes Concerned Veterans for America (CVA), a right-leaning group funded largely by the Koch Brothers, that seems to have Trump’s ear.

One longtime veterans’ advocate who asked for anonymity because this advocate still works with the government, told Healthline that if Trump both privatizes the VA and repeals the Affordable Care Act (ACA), “It would be a catastrophic ‘Lord of the Flies’ disaster for our veterans, the public, and the healthcare industry, with states and nonprofit groups rushing to fill an enormous and deadly chasm in access.”

That chasm, the advocate said, would include increased emergency room visits, treatment denials for preexisting conditions, and cuts in services for suicidal veterans.

The advocate said that as a result, the VA would ultimately become smaller. He added Trump might also take the valuable land on which many VA hospitals and clinics currently stand and profit from this real estate.

Multiple veterans’ advocates told Healthline that while there can certainly be improvements in public-private partnerships that benefit veterans, a complete privatization of VA would be a disaster.

“The ‘Privatize the VA’ movement is another example of a congressional attempt to adopt a bumper sticker slogan as policy,” Walsh said. “It is another knee-jerk reaction by Congress that will not resolve the long-term issues at VA, in either the benefits or the healthcare area. Policy in this complicated area needs more characters than are provided for in a tweet.”

Read more: The lingering health effects of Agent Orange »

Multiple sources told Healthline that the CVA is politically motivated and does not present an accurate or comprehensive picture of the American veteran experience.

CVA’s former leader, Pete Hegseth, recently stepped down and is now a Trump insider, and Fox News contributor, who was a front runner for the VA secretary position.

Thomas Bandzul, a veterans’ advocate and legislative counsel for Veterans and Military Families for Progress, has met with Hegseth several times.

He was left unimpressed.

“While there is the aura of concern for veterans from him, there is little substance,” Bandzul said. “He barely seems to understand the issues involving veterans and was only briefed on the topic at hand. It was as if he had no broader knowledge on any of the issues, the history behind various VSO [veterans service organization] attempts to address certain problems, and was lacking in solutions to many of VA’s complications other than the one he was directly working on.”

In meetings with a VSO roundtable sponsored by the House, Bandzul explained, “CVA was present but usually silent. Why? Because they act as a front rather than an organization with real concerns.”

Bandzul said Hegseth has left this group and is “seeking to be christened the savior of all veterans by privatizing all aspects of veterans’ care. His participation in the House-sponsored panel of experts, of which there were few veteran service organizations, was solely for the intent to promote himself and the cause of privatization.”

Read more: More than half of combat veterans have scarred brains »

So will Trump heed the advice of the overwhelming majority of veterans’ organizations and veterans’ advocates?

Anthony Hardie, a Gulf war veteran, and longtime advocate for his fellow veterans, has spoken before Congress many times on the profound harms veterans have suffered through exposure to multiple toxins while on duty. He is cautiously optimistic about what Shulkin can accomplish if given the chance.

“There’s a lot of very old swamp the new president could help drain, forcing the VA to finally fulfill its long-untapped potential to really help countless toxic-wounded veterans,” said Hardie, the director of Veterans for Common Sense.

Hardie believes the VA is “uniquely situated” to learn from and treat veterans with toxic wounds.

“Veterans with Agent Orange exposure, for example, have had many disability ‘presumptives’ approved by VA, but far too many Vietnam veterans have died young, leaving it all to surviving spouses and children,” he told Healthline.

Hardie added that one-third of his fellow 1991 Gulf War veterans with Gulf War Illness remain chronically ill because of toxic exposures.

“Yet they suffer an 80 percent VA claims denial rate,” he explained. “And post-9/11 veterans exposed to burn pits or Iraqi chemical warfare agents are even worse situated, and it doesn’t stop there.”

Read more: Female marine breaks silence on PTSD struggles »

But the key to real reform, say all who spoke to Healthline, is for Trump to be more open and accessible to veterans’ groups and veterans than he has been to date.

Denise Nichols, an Air Force nurse and Operation Desert Storm veteran who has helped tens of thousands of veterans, said that with Shulkin’s nod there will be some continuity to the positive changes that have already begun at the VA.

“His credentials are solid,” she told Healthline, but she added that the key to success for Shulkin, and Trump, is accessibility.

“We as veterans ask that he have an open-door policy and to interact with all veteran organizations and advocates on a routine regular manner,” she said. “Open communication can lead to faster responses to stop the bubble of legitimate concerns building to the volcano of problems that have existed. Only by listening and truly hearing the veterans will problems be solved.”

In his statement after being named by Trump to be the VA’s new leader, Shulkin vowed that he and Trump are “both eager to begin reforming the areas in our Veterans Affairs system that need critical attention, and do it in a swift, thoughtful, and responsible way.”