Providers have the potential to capture some of the healthcare population and federal dollars of the Department of Veterans Affairs, as The White House and legislators toss around the political football of privatization.
Whether providers should or would want to get into a market healthcare policy expert Paul Keckley calls an alternate universe remains hypothetical.
But under recently proposed reforms that didn't make it into the omnibus bill, some of the more than $180 billion budgeted to the VA had the potential to be diverted to the private sector.
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"Most providers would say, if the VA will pay me at Medicare rates, on balance it's not something we'd walk away from," said Keckley, who runs The Keckley Report. "I think you would find in many communities, 'I'm receptive, but we're not prepared for a lot of what veterans health is providing.'"
The government would have to give providers incentive through compensation models to take on a population they're not currently serving, said healthcare attorney Ben Fenton of the Fenton Law Group in Los Angeles.
Concerns about wait times and available beds at VA facilities is an argument in favor of government money going into the private sector, Fenton said.
"If it goes through and depending on how much is privatized, it will open up a new market for non-VA providers and hospitals," Fenton said.
Whether providers should or would be willing depends on their level of expertise in dealing with veterans health issues.
"Is the hospital going to be equipped to deal with post-traumatic stress?" Fenton said.
The big issue in overhauling the VA is the clinical profile of the nine million veterans who use the system, Keckley said.
On average each day, 22 veterans commit suicide.
"These folks have all kinds of social issues," Keckley said. "Typically their level of behavioral health issues is significant. From a clinical standpoint it's challenging."
Providers already have trouble in being able to offer access to mental healthcare.
"As an emergency physician educated in the United States, I served many shifts during my training in VA settings," said John D. Halamka, MD, chief information officer at Beth Israel Deaconess Medical Center and chief information officer and dean for Technology at Harvard Medical School. "The VA facilities that I worked at had a great understanding of the veteran population, providing for their medical and emotional needs. I worry that the existing U.S. private healthcare system would struggle to serve 9 million veterans, especially in areas like prosthetics and occupational therapy."
In his op-ed piece in The New York Times on Wednesday, fired VA Secretary David Shulkin said, "The private sector, already struggling to provide adequate access to care in many communities, is ill-prepared to handle the number and complexity of patients that would come from closing or downsizing V.A. hospitals and clinics, particularly when it involves the mental health needs of people scarred by the horrors of war."
Having more local provider care also means a collaboration between the Veterans Integrated Service Networks of the Veterans Health Administration and the private sector, according to Keckley. VISNs are divided into 21 areas and operate in a parallel universe with local providers.
"You're asking for these two systems to collaborate." said Keckley, who said he doesn't see this easily happening.
The politics of even partial privatization would make a transition difficult, Keckley said.
"It's heavily politicized, not just because of Shulkin," Keckley said.
Shulkin said he was fired because he disagreed with President Donald Trump's plans to privatize the VA.
The White House responded that it has no plans to privatize, but to give veterans more choice.
A Veterans Choice Program already in existence allows veterans who live more than 40 miles from a VA medical center or who have to wait more than 30 days before they get an appointment to visit a community provider, according to the Veterans Health Administration.
Reforms to the program were proposed for the recent omnibus spending bill, but were blocked by Democrats. The reforms would have, among other objectives, better integrated existing care and expanded options for access to private healthcare. Ultimately it would have shifted dollars from VA hospitals and clinics to the private sector, including possibly the use of private health insurance benefits.
Many veteran groups supported Choice reforms but oppose privatization. Democrats feared the expansion of veterans services into private healthcare was a stop along the way to privatization.
Democratic Leader Nancy Pelosi said on Wednesday after President Trump fired Shulkin, "The abrupt dismissal of Secretary Shulkin is a troubling step in the Trump Administration's ultimate goal of VA privatization."
Shulkin, who was appointed under President Barack Obama, said in his op-ed piece. "… I am convinced that privatization is a political issue aimed at rewarding select people and companies with profits, even if it undermines care for veterans."