White House physician Ronny L. Jackson, President Trump’s nominee to be veterans affairs secretary. (Manuel Balce Ceneta/AP)

With White House physician Ronny L. Jackson’s nomination to lead the Department of Veterans Affairs in serious doubt, here are five things that veterans advocates and experts say are the most urgent needs a new VA secretary must address to successfully run the $200 billion agency that serves 9 million.

1. Fill vacancies

The next VA secretary must fully staff the agency. That means hiring the still-unfilled key jobs of undersecretary for health, undersecretary for benefits and chief information officer, in control of medical records. “The VA secretary’s job is not to do everything. But it’s to build the best team that can get it all done. If that doesn’t happen, it creates a ripple that hurts veterans,” said Max Stier, president and chief executive of the nonprofit Partnership for Public Service.

Aside from vacancies at the top, the VA health-care system is short more than 30,000 clinical staff, said Phillip Carter, a senior social scientist at Rand Corporation. That includes thousands of unfilled positions for doctors, nurses and mental-health therapists on the front lines of helping lower the high rate of veteran suicides — 20 per day. The VA also is trying to fight opioid addiction and fatal overdoses after being accused of dispensing the drugs too often for chronic pain.

2. Update VA’s antiquated medical record-keeping system

There should be a seamless experience from military service to burial, Stier said. But currently, a veteran’s medical record is printed out and retyped into the VA system. “It’s expensive. It’s slow. It creates errors. And it’s the backbone of the veterans experience with the VA.”

Before Secretary David Shulkin was fired last month, the VA was about to adopt the Cerner electronic health records system. It’s the same system used by the Department of Defense for its health-care providers.  The medical records plan is expected to take more than a decade. It will cost an estimated $16 billion to be implemented.

“Forward momentum seems to have been stymied by the recent leadership upheaval,” said Carl Blake, executive director of Paralyzed Veterans of America. “But it’s something that really needs to happen.”

3. Take a stand on and fund VA Choice

The next VA secretary must work with Congress to update and fund the controversial VA Choice program, which allows veterans to use some degree of private care at taxpayer expense.

“Everyone wants VA reform. How best to do it is the issue that has divided many outside of the veterans service organizations,” said Paul Rieckhoff, CEO and founder of Iraq and Afghanistan Veterans of America (IAVA.) “IAVA and every VSO has stood firmly against expanded privatization.”

The White House has said it opposes closing down VA and says it favors a hybrid system of choice and improvement. One of President Trump’s key campaign promises was letting veterans use private health care. Shulkin claims to have been fired over the heated debate.

The new VA secretary will have to take a position on this issue while working with veterans groups and the White House, Rieckhoff said. “The VA’s contracted care programs are also burning funds more quickly than Congress can appropriate them, in large part because the VA’s projection and budgeting models appear to have underestimated demand from veterans for contracted care,” Carter said. Choice funds are about to run out in May, unless lawmakers extend funding.

4. Support and expand programs for female veterans

In 2017, IAVA launched the campaign, #SheWhoBorneTheBattle, focused on recognizing the service of female veterans and closing gaps in care VA provides to them. Women still regularly report being “eyeballed and catcalled” or that they are assumed to be “wives or daughters of male veterans” when entering a VA hospital or benefits office. VA only recently added women’s bathrooms.

“We fought hard for top-down culture change in the VA for the more than 345,000 women who have fought in our current wars — and for all Americans,” said Rieckhoff.

IAVA’s latest member survey showed that 35 percent of IAVA women were victims of military sexual assault. The new secretary needs to usher in a modern culture at VA, which includes making sexual harassment laws tougher inside the system’s 1,200 facilities and offering more women-only therapy groups along with expanding women’s health services.

IAVA, the largest organization representing post-9/11 veterans, is also championing an effort to use gender-neutral pronouns in the VA’s motto. An 1865 quote from Abraham Lincoln’s Second Inaugural Address, “To care for him who shall have borne the battle and for his widow, and his orphan,” has been the motto for 59 years. Other military groups have changed their mottos to include women.

In addition, the Service Women’s Action Network, along with IAVA, says it wants to increase the number of therapists who are trained to handle the unique needs of military women, specifically victims of sexual assault. The organizations also want to establish social support groups for all female veterans at Vet Centers.

5. Boost employee morale and make pay competitive with private sector

VA ranked at the bottom of the list of best places to work in government, second only to Homeland Security, according to a survey Stier’s organization conducted last year. Part of the reason may be pay for regional hospital directors, who can make over $1 million in the private sector. Their government pay is capped at around $200,000, leading to high turnover, Stier said. “This has a trickle-down impact on the staff. And it’s so important that the VA attracts the highest caliber staff possible to serve our veterans.”