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In metaphorical terms, the post of VA Secretary is the piece of rope that lies between two powerful opposing forces — one pulling for sending significantly more care for veterans outside of the Department of Veterans Affairs (VA), the other for keeping the VA healthcare system relatively intact – with neither side intending to relent. It’s not just the fact that Dr. Ronny Jackson, President Trump’s nominee to replace Dr. David Shulkin, will become the sixth leader of the VA in four years. It’s also the fact that the job has proven to be a career quagmire for leaders who had otherwise enjoyed success in other sectors, from the battlefield to the boardroom.

Despite Dr. Jackson’s insistence that he doesn’t intend to privatize the VA, the “privatization paradox” will be a major test for the incoming secretary. Since the 2014 Phoenix scandal, the VA has devolved into a demoralized institution characterized by accountability witch hunts (perhaps deservedly), long vacancies in critical leadership positions, and a constant barrage of negative media that had routinely eclipsed any positive press at every turn.

Even when leaders such as Dr. Shulkin had managed to snatch achievement from failure’s death grip, it was as if any success the agency enjoyed only served to accelerate the efforts of those who counted on its failure to justify further fragmenting it among non-VA and private sector healthcare providers. The idea of expanding options for veterans who need healthcare is not the problem, on its face. It’s whether one believes “cowboy capitalism” can indeed deliver better healthcare, as Dr. David Gratzer and others have argued. Or the counter notion that it’s the government’s job to provide care for those “who have borne the battle,” not profit-seeking corporations.

Dr. Ronny Jackson

This is the inheritance of a physician who’s leaving his relatively anonymous post as the White House physician since 2006, and he had better manage his expectations. So too must President Donald Trump. His pick for VA Secretary may have seen his last best day for quite some time, assuming he’s confirmed by Congress, as he prepares to follow in the footsteps of a battle-tested U.S. Army General, the savvy CEO of a multinational corporation, and an accomplished healthcare executive whose tenures as secretary had fallen short of expectation, largely for reasons out of their control.

In their wake still lies a healthcare system that’s suffering an identity crisis as career bureaucrats, veterans, veteran advocates, and ideologues vie for its fate. Even as Dr. Shulkin claimed tremendous progress on his watch, which President Trump has acknowledged, there’s no doubt that the VA needed to continue to improve. But there are different flavors of bad, and America will soon find out whether this is as bad as it gets for the VA — or whether the latest changes will lead the situation to something far less palatable.