Department for the Trump Administration but hes interviewed by jeremy butler, ceo of veterans of america. After words is a weekly Interview Program with relevant guest hosts interviewing top nonfiction authors about their latest work. All after words are availablee through podcasts. Doctor shulkin, thank you for being with us. Its an honor to have you here. I think the va is important to subject to talk about in one of the areas of our government that a lot of people hear about but dont necessarily know many of the details. Frankly, even in the veteran community a lot of us dont understand the breadth and depth of what the va does. Im excited to talk to you about the ba in general and certainly about your book and about your time in the administration. Id love to begin by hearing about what brought you to the va. Youre very successful in the civilian career and times making that transition from the civilian world into the government world can be a bit jarring but what drove you to want to take up the mantle of working with the government especially within the va . During my 20s i did not have a chance to serve the way you did. I spent my time medical institutions and doing my medical training and it was a busy 20s. That is always one of the real regrets i had that with this amazing country that we have i wasnt able to get back. Later on in my career i was the ceo of a hospital and i had the opportunity to get a call from the white house and this was right at the time in 2014 when it was a very public way to time crisis in the va where there was allegations of the veterans were dying waiting for care and i remember sitting there as a citizen saying i feel terrible about this. If anybody deserves the best care possible it is our veterans and i wish there was something i could do to help. As sometimes happens in a strange way i i got a call from the white house saying would you consider coming to help lead the va Healthcare System because we aree looking for somebody who understands how healthcare works from the private sector. You know, i did what everybody tends to do when they have these choices. I made a list of the pros and cons and the cons side was much, much larger then the pro side but on the pro side it was simply how good i say no. This is my duty as an american citizen to get back the people who had given us so much and so i did not think much about it but said yes, im prepared to come and help. That is great. As those of you who have read the book know that was during the Obama Administration initially so you are one of the few people who served under both the obama and Trump Administration and look forward to getting into that. That said i would start and i love to read a brief quote from your book, early on the right it is important that americans understand what the va system is. How it works and why it exists. As i mentioned a lot of people dont understand the scope of what the va has and what responsible for. If you could start off by giving maybe you had an elevator pitch to those that you gave or talked about everything the va does because, as you well no, it goes well beyond healthcare but there is so much more that the va does. Right. One reasonable book was exact me what you talked about. Im not sure the America Public understands why the va exists but why it really is an essential part of our National Security system thatan when we relyic on voluntary military whh now is less than 1 of americans serving but these amazing americans raise their hands and are willing to sacrifice themselves on behalf off allll f us and when they go there is a commitment that the country has made it to them that they will take care of them if they need that help when they come back. H there is no other organization that is focused on that. As you said, the ba provides healthcare for 9 million veterans. There really are 20 million veterans in the country so the va has a large effort directed towards education and the g. I. Billdi in the house and effort towards benefits should somebody require assistance that they are no longer able to work or if they are disabled and it goes all the way through the time of making sure every veteran, when the time comes, is buried with dignity and respect and so there are 114 va cemeteries around the country and they do an amazing job supporting families during these tough times. This is a organization, second largest in the u. S. Government, employs 370,000 people who are there, many are veterans themselves looking to give back. It does an amazing job and really does deserve the support and understanding of the american people. Host thats great but i appreciate that. I often point out to people that the va is the secondlargest ofdepartment and second largest agency, second largest budget and people just from a civics mind point should be more informed about everything. Guest i think that is right. If i could, just about the health care aspect because he gets so much focus of the public attention on the va. When i came from the private sector into government i had never worked in government before and i had a completely open mind when i was reading all these Horror Stories in the press that i would go there and find that the system was so broken and so dysfunctional that maybe my job was going to be just to close up shop and say you know what, the best thing i can do for veterans is eliminate the va Healthcare System and move everybody into hospitals, something i knew well. After i got to the va began to see what the va does and when i say got to see i put on my white coat as a doctor and took care of veterans and went out and visited hospitals across the country and went to see places like where we bring paralyzed veterans skiing down the slopes in aspen, colorado and i really began to understand that what the va does is Healthcare System is very different than what the private sector does and in fact, cant be replaced with the private sector doesnt do the things that the bl Healthcare System does. For example, our behavioral Healthcare System is extensive and large and where the private sector behavioral Healthcare System is really struggling and trying to get access if we were to put these 9 million veterans just dump them into the private sector system on the system that already is struggling to meet its needs we just note that the veterans would not come out on the right side of that. I became a very strong advocate for making sure that this was a system that works well and that we need to modernize and improve tt that it will be a sustainable system. Host absolutely. You touched on a few things i want to make sure we can come back on and privatization in things like that and very important topics with a large part of your book and i dont want you to think i will skip over that but i think we will get to that in a little time but i want to continue with [inaudible] youis mentioned a comment saying that within thehi veteran community i think even within the va that if you been to one va event 21 va and he mentioned especially in the beginning he did a lot of going around to visit different mbas and things like that but why do you think that is . Even though were talking about an agency that has oversight over all these areas you get so many different stories but unfortunately, i think, negative stories are the ones that gets e e press but you hear Horror Stories about one va but then talking to so many other veteransns our membership often tells us they love the carrot that they get at the va but they just owned or would like to get ask us to it faster and things like that but whyd you think there is that there such a variety of levels of care that one receives . In guest first of all, the va is under a public scrutiny that no other Hospital System and the country finds. As the hospitals ceo in the private sector i can tell you Little Things that happen in the va that never would come to the attention in the private sector turn out to be the subject of congressional hearings and major front page stories. I think the public gets a sense that there are lots of things are happening in the va hospitals dont happen in the private sector but again, using the private sector comparison the question i would get most frequently being a physician ceo was what is the best possible hospital for me to go to in my answer always was interestingly there is no such thing as the best hospital. There hospitals that are good at some things and those same hospitals may not be so good and other specialty areas so i think that is the same in the va system where he had the largest system of the country with over 1000 facilities you will have some that are excellent at certain conditions and others that frankly need work on them and that is what you will find in healthcare. The va has an additional complexity and that it needs to xiprovide care to veterans wherever they live in this country and so therefore we have a large number of her veterans who live in very rural areas and finding people, especially specialists, to be able to work in rural areas is a challenge for the va and the challenge for private sector as well. You have a tremendous variation between what works in the va from one place to another place and that is one of the things that of course, i worked very hard on the tried to standardize some of these practices. Host absolutely. That reminded meth of a funny story from your first confirmation hearing where the senator from alaska basically said you need to come to alaska because we have a unique set of circumstances here, unique challenges to veterans and you need to come here to understand that before he was going to vote for you. Guest yeah, i think a lot of people know more about that journey i and many people dont understand the Senate Confirmation process and you actually, in order to go quickly through assignment process and not require a entire floor vote you have to have unanimous consent and this was when i was under secretary and the white house said to me good news, you have unanimous consent and you will be confirmed in the next couple of minutes. Right is that vote was happening senator sullivan said not so quick, i need to have a conversation with the nominee te called me up and said listen, im standing on the senate floor and about to cast my vote but i wanted you to commit to me that in the first 30 days if you are confirmed that you will come to alaska with me because alaska is different than other states and our veterans have different needs. I said senator, we are going to alaska and then the vote went through. [laughter] host imagine that was your intention anyway because he mentioned there was a lot of variability, geographically speaking in terms of making it difficult to get proper professional to some of the rural areas. Guest alaska is one of the few states, New Hampshire and irwaii being the others that dont have its own va hospital and so meeting the healthcare needs of those h spaces is extraordinarily challenging with the partner in anchorage where we partner with the Air Force Hospital but i was delighted to travel with the senator as i was when we went to other states with the senators as well because that is the way you really get to understand how to fix problems that are out there by talking to veterans about what they are experiencing. Host absolutely. Another thing you did was you continue to see patients during your time in the va which might surprise some people that you had, i would not say the time to do it because you are working very hard seven days a week in there but in fact that was something you felt wasnt necessary and vital to understanding the needs of the veterans. Could you expand on that . Ou guest i think every leader can do their job more effectively if they understand what the impact of their decisions are. If i was going to be making a decision as i ultimately did on which electronic record va would use the big decision how could i make that decision if i never use the va electronic record and if i had never been working with patients and nurses and doctors to understand how they interact with the record. When i would put on my white coat and go and see people no one knew i was secretary in the veterans did not know that but it felt or helped me understand what was working and how they were experiencing the decisions i had to make from the ground level and i think that made me a better more m effective leader. Host absolutely. If you touched on the Electronic Health records which is something i also wanted to talk about in a little bit but you remind me theres a funny anecdote that when you are in your doctor capacity talking to veterans as you said you have your white coat on and they dont necessarily know who you are and you got some sort of startling response from a veteran but could you tell that story . Guest i would work or keep patients i would see them in person, in the exam room, here in new york city at the manhattan va and then i would see themem using telehealth from my office in washington to a clinic in oregon a rural part of the country so i got to experience both urban and rural using telehealth and in person but i was in the new york manhattan va when i saw a patient who came in and i said what can i do for you, sir and he said i need a position to fill out this form and i said id be glad to help you with that, can you tell me what the form is for and he says yeah, i need a certification because im assuming secretary a show can and i asked them what that was about and he was a homeless veteran and was trying to get additional benefits so that he could get himself out of that situation and get himself back on track and needed a position of certification of his issues that he was dealing with and so i said to him sir, first of all, i will help you. We will get you the form you need but i dont think im the person to do it. He looked atin me and said why d i said because im secretary shulkin and he said no, no, this cant be true. [laughter] but we got him on his way and i got another position to help them. Host you also early on mentioned five priorities that you had when you were coming into the va because you talk about those five priorities and how you arrived at what they would be and maybe you can expand on some of how you feel you did in achieving those goalt during your term. Guest when i first came to the va i not only never worked in government before but this was an organization that i was going to have to learn and it was such a Large Organization that if i had waited until i truly understood everything about it we would be waiting a long time but as i mentioned, i entered in a time of crisis and there were veterans literally waiting for care that needed helpti and i did not feel like i had theat time that i normally would if this was a normal situation so i came in having studied the va and i came in and said we will have priorities right now and if we change them later on that is okay but our single top priority was going to be to address the wait time crisis. There were hundreds of thousands of veterans waiting more than 30 days for care but most critical to me was there were 57000 veterans waiting for an Urgent Medical consultation. That was just way more than 30 days and that wasnt totally unacceptable to me and outside the bounds of what i thought was reasonable. I immediately called for every Medical Center to be open on the following weekend and during that weekend we contacted those 57000 veterans and by monday morning we had that list down to less than 1000 veterans. Once we essentially got the backlog taken care of i wanted to make sure that we never got to that situation again so i did a couple of things. First is at secretary one of my first decisions was to publicly post the wait times. The va today is the only system that i am aware of that t publishes its wait times so that people can see. The second thing that i did wasl i established Sameday Services throughout the entire country. By december 2016 i was able to tell secretary mcdonald and president obama that every va Medical Center had the capability of seeing people the same day basis so we would never be in a situation so that someone with an urgent issue cannot be taken care of. We ended up publishing a article in the journal of the American Medical Association where we studied after we put all these things in place how the bas wait time compared to the private sector and what people and the American Public thought and the va turned out it to be better and that we made tremendous progress in addressing that issue really with the commitment ntof the employees and the staff that worked there. The other priorities but that was our top priority were focusing on establishing, improving employee morale because morale had been terrible and there were 45000 agencies in the va and recording people to an organization that had low morale is a significant challenge. Probably one of our most important priorities was regaining the trust of the veterans that we served and as i always say to her staff in the va we dont have a stock price. We are a Government Organization so we cant follow our progress by looking whether we are doing better with stock price but what we can do is we can track whether we are regaining the trust that we had lost of our veterans and fortunately that again began to climb as well and it was very good news. We had established another priority of creating best practices and learning from one ba to the other and learning what works and then doing it across the country so we could decrease some of that variation in quality of care that you had talked about and that was very successful and be able to do that as well. That is how we established that. Host that is great. Some of the things they brought from the private sector i know there are vast differences as you already alluded to between the ways in which we as a country can provide care to secivilians and the way in which we can provide care to our veterans but were there things or are the things that we can continue to learn from the private sector to improve the way we deliver care . Guest interestingly as i mentioned before not only did i not have the time to wait to learn all the ways of government because i felt there were urgent issues like the wait time issues but also the liberally did not want to start to think as if i were as a government. I wanted to deliberately bring the industry best practices in the way we thought about things in the private sector to government and what i ended up learning was that the government could benefit from many of the practices that the private sector does. And needs to challenge itself and it needed to modernize the ways it was thinking but i actually learned there was more that i learned in the va that the private sector could benefit from so this was a two way bidirectional learning that needs to happen between the private sector and government and in this case, the va. That is interesting because right now theres this ongoing continue debate about the future of healthcare within [inaudible] and i dont think thats a perspective that is often brought into that conversation about what we can learn from the government side, frankly, does not used to that we can learn from the government to improve healthcare. Guest when you look at the outcomes of care across the population which is very popular right now in healthcare called Population Health the va outperforms almost every other major Healthcare System. Not saying its at the very in our great Healthcare Systems out there that this country provides atrophic care but when you look on average the va performs better than most of the private sector and so if you look at some of the things we did like, for example, i made the declaration that i wanted to illuminate hepatitis c from the entire veterans population, 163,000 veterans cared for in the va system that had hepatitis c and now fortunately we have a drug, several drugs, that can eliminate the virus, cure at 95 cure rate or higher so i dont understand why we should have any veteran who had hepatitis. And so, i went out and Congress Gave us a billion and a half dollarsco to do this and we went out and proactively began to contact every veteran who had hepatitis c and today the va has treated well over 100,000 of those veterans and well on the way to eliminating hepatitis c we need to do more in the general population and not Many Health Systems are thinking that way proactively looking at outreach and Population Health but these are some of the lessons we can learn from the va. Host absolutely. This gets back to it as you mentioned, here that veterans get through the va often use studies that you mention that show that as i mentioned our membership generally likes the care they get from the va and there are some things they want for improvement that said we do it too often for the negative stories in the press and on the positive stories. He did not mention is one of your priorities but you just sit in the book in another area in which the va continues to get slammed around is the problem military and veteran suicide. Its such a completed issue with Mental Health that not only in the veteran and military states certainly we as a country are struggling to understand and figure out how to talk about certainly struggling to figure out how to solve and do you have insights from your time at the va and your time as to how we can begin to address this issue and how we can both within and without of the va . Guest the single highest clinical priority that i established was to reduce veteran suicide, 20 veterans a day taking their life. Its a staggering figure that i used to sit there and say if we let another week go by there goes another 140 of our veterans. There is still so much work to do on this and it is why i am pleased that secretary wilkie has continued to makee veteran suicide a priority for the va. One of the things when we take a look at this is of those 20 veterans a day that take their life only six are getting care in the va system so there are 14 that are out in the community and my biggest worry is they are not getting any help at all. One of the first initiatives that we did at the va was to start outreach to Community Partners and veteran Service Organizations led by the va and others, Community Groups and churches and religious organizations about groups like the united way and others out there with local governments and state governments and all to begin to start working together to identify veterans at risk and finding them treatment. Every va Medical Center has something called a Suicide Prevention coordinator and many of them have multiple Suicide Prevention coordinators and their job is to be out there looking for veterans at risk and identifying ways to help them. That is one of the practices that i think the va has that the private sector should have Suicide Prevention coordinators because this is an American Public health issue not just in veterans. But, we need to do a lot more and the underlying reason why people take their lives is not because they wake up one day and say hey, i feel like doing this. They are suffering from something and could be depression and it could be ptsd or chronic pain or Substance Abuse and other reasons but we have to look at the ways of getting to those underlying reasons and finding more effective diagnosis and treatment of those conditions and beginning to make sure that we are proactively identifying how we can intervene and help and there is so much more work to do lots of promising, opportunities to do that. We are looking at Predictive Analytics and looking more effective therapies but much work could be done in this area. Guest absolutely,. Host unfortunately what we are seeing is the situation is not improving. Recent reports continue to come out from both the military, va and civilian world showing that we are not getting at the problem and i think he started to talk about and we should not be looking at it as an Emergency Response issue but a much broader thing and we need to look at the underlying issues, as you mention, chronic, things like that, Financial Issues and so much can be reaching into that which the va alone cant solve and maybe even the government alone cant solve but clearly there has to be a whole of government approach to this and that said, the va as the leader for the Veterans Committee within the government should be spearheading that, i think, but thats a challenge. Guest and i am proud of the work the va is doing. They are working hard to address issues but like many, tough problems that americans faceto e have to even do more and we have to push through some of the rerriers that prevented us from making progress. I think youre right that the recent Suicide Prevention report, although the va has decided to report the data differently so it looks like a smaller number but it is not a smaller number but in fact it went up a little bit. This is not about keeping a scorecard. This is about i making progress and im not sure that we are there yet. Host i completely agree. Another area id like to touch on is Women Veterans but this is an area in which again, i think a lot of the country doesnt realize how much the landscape has changed but we are more Women Joining in the military and certainly more women serving in combat roles and more women coming back from the deployments needing va care but i think we certainly hear from it first hand that women oftentimes dont feel well welcome at the va and often are harassed on the way in, and sometimes they feel that when they are walking up people assume they are there for spouse or boyfriend or Something Like that. What needs to be done to begin to change this culture . It seems its throughout the va and may be from the country, friendly, the doesnt quite recognize the service the Women Veterans the same way we recognize the service of the male veterans. The Fastest Growing demographic the military is women in the military grade we now have about 14 of our military service by women and as you said, the airplane extremely important roles and not to recognize and respect their service but it is simply wrong and something that can be tolerated by the va or any other part of our society but i do think youre right that this is a reflection of issues that we see in the broader society. What the va has decided to do and something that i supported rather than waiting for culture to change in attitudes to change but to make sure that we are providing care with the respect that everyone deserves, especially women and so we created womens clinics and womens centers. They are now over 120 Medical Centers that often have separate entrances but create a secure and comfortable environment for women to get their care there where they dont have to worry about any of the issues that weve talked about. These are often really centers of excellence where people love getting their care there. N some ways its a shame that we have to create separate places for people but we werent willing to just wait and say we will try to change attitudes but at the same time that we are providing these Women Centers and we do need to begin the change in attitudes and not accept it. There was a recent public issue at the washington dc va, less than one month ago where a woman veteran was harassed just walking through the halls and had the courage to come out and talk about that experience and i know that i certainly went out publicly and supported her as Many Organizations did to be able to say this is unacceptable. We need people like this brave woman to be able to speak out on behalf of her fellow veterans and we need to begin the start to change these attitudes. Host as you mentioned we need male veterans to be leading the charge and speaking up for them as well. S s it should not be something that the burden should be placed really on the Women Veterans. One of the ways we are trying to begin this process and to drive a topdown understanding that there really does need to be and should be a cultural change within the va is to frankly, change the model. Its an Abraham Lincoln quote for he who has borne the battle and for his widow and for his orphan we have been pushing legislation into change the modern that is more embracing of the changing nature of our military and of our veteran unity. Its something that received pushback in a lot of quarters to just come up internally at the highest levels when you were within the va . Guest yeah, one of the disappointments that i had. You know, the military is probably the place in our society where differences and diversity have the opportunity to go away and this is the ultimate melting pot. Everyone shares the same goal any reliable each other just in some cases [inaudible] it doesnt matter if youre republican, democrat, black, white, woman, male this is a Common Mission and for the va not to be inclusive and to embrace that type of diversity is a mistake. While i understand the deep attraction to Abraham Lincolns motto that was in a different time. We need to recognize the new modern va needs to be leading in this type of inclusion and i think that if there is a motto that people feel excluded from it is time for us to recognize that and i do not believe that Abraham Lincoln would be upset with that he was a guy who stood for making sure that we were one country together and he believed strongly in supporting the people who fought for the country as many of us do what you know, talking about the issues and importance of women a couple hundred years after Abraham Lincoln is time for us to move towards a more modern model. Host absolutely. There is legislation to change that motto but correct me if im wrong, the va has the ability to do it on its own and would not tod an act of Congress Change that, is that correct . Guest no, it would not. I dont think as secretary i do not envision fizzling off the Abraham Lincoln quote off the concrete of the building. There is a way of honoring history and respect and not changing the dignity of what Abraham Lincoln gave to us as a country with thisli commitment towards our veterans. But Abraham Lincoln original quote as talked about widows and orphans this is not language that we traditionally w use in 2019 and i think there is a way of honoring the original words that Abraham Lincoln by talking about the new va in a way that can be done with respect for our history. Host absolutely. Completely agree. I like to ship now that we are talking big picture about the va and id like to move into your time specifically within the administration and as secretary weve already touched on a couple of these issues but i think it is safe to say that if you look at especially the parts in your book about the service as va secretary under President Trump two of the underlying policy debates that drove so much every time there were on privatization and around the Electronic Health that we discussed here. Privatization is a word that comes up all the time and i dont think most people fully understand what is meant when we talk about that and could you give the audience and understanding of what we mean when we talk about privatization within the va . Guest privatization was both would be the simple concept of shutting down the va Medical Centers in the va Healthcare System, giving a voucher to a veteran and saying, you go and find your own healthcare in the private setting and we will pay the bill. That would be the ultimate goal of privatization. There is a strong belief that government should not be involved in the delivery of services and that government is inherently inefficient and i think we have talked about this earlier where i believe that the governments involvement in va healthcare is the most effective way of honoring our nations commitment to our veterans. That does not mean that veterans should not have the ability to gofe into the private sector whn its in their best interest and when the care is better or. Specialized care is available and i think we all believe that it should be available but my belief is that the complete privatization of the va would be a disaster and we would look back whenld veterans arent getting the care they deserve and say how do we recreate a system that cares for them. I dont want to see us go in that direction. When i first came to the va 90 of veterans for getting here in the community but when i left it was 36 . I was strongly in favor of not having veterans get inferior care or waiting for care if the va could not do it but we got them to theva private sector. I think this is an issue of that there are policies being pursued by those who favor the dismantling of the va and where they do not raise their hand and say that they are in favor of privatization because there would be politically unpopular so they will not say that but if you watch the impacts of these policies over the years that will come i believe they will lead to a point where there is pleat privatization in the va. What i am trying to say and what i argue in the book is we either need to come out and say what will happen if we follow these policies or we need to very closely monitor and make sure that there is not an unintended consequence of these policies before it is too late and there is an appropriate role if congress has oversight over the va and those are role of the press to make sure that they are looking at what is happening and i am trying to essentially raise visibility. Lets just be cautious. Im optimistic about where the va is going and im supportive of where the va is going but being an expert in healthcare i see some warning signs and want to make sure that we are vigilant and that there arent these unintended consequences s. That lead us to privatization. Host you said Something Interesting that you said might confuse the audience because you mentioned how the percentagein f private care visits rose from 19 to 36 was the number and some people say were to then working to privatization and could you unpack that so people understand how that relates not wanting to privatize but wanting to improve quality of care. Guest it can be confusing for often this is what has not happened in washington. When you are not at one end of the political spectrum so the left very end of the spectrum says we want complete control of healthcare by the government v. The end of the political spectrum on the right is we dont want government involved at all and lets complete the privatize. If you happen to be in the middle with the compromise solution where i am its a very lonely place in washington and people tend not to understand it. I appreciate the opportunity to explain it. On i believe as a physician that the right answer in healthcare is when you do the right thing for your patient, in this case the veteran paid if you are a veteran what should you want . You should want the very best care possible and where the va can provide these things that i have said i do believe are readily available in the private sector the veterans should have a strong va that is focusing on areas that they do extraordinarily well with the private sector doesnt bring a mentioned behavioral healthcare. Ptsd, traumatic brain injury, rehabilitation, prosthetics and orthotics, environmental exposure to toxic agents when you get in combat. These are things that frankly the va does extraordinarily well. But the va cant do everything well and so if you are a veteran and you need specialized care or something that is not available in your community you should be able to get that in the private sector. I envision a hybrid system with a strong moderne va focus on centers of excellence and things that are important to veterans and the ability to seek the private sector when those arent available. I publish that as a model of care in the journal of medicine so everyone could see the plan that i had for the va and one that frankly, i think just makes sense for veterans. Host during your time you talk about this quite a bit in your book and going on with privatization this term, this debate we talk about the recently passed mission act before that the term was a choice and the choice care and things like that, can you talk that bill did, does, will do and it was past one year ago and implement it just in june of this year and there is still a lot of confusion around it so you worked a lot of your time on that bill and it was passed after you left so im sure you know it well but could explain about what the mission is . Guest i spent all three years overtime government leading up to the passage of the mission act. When the waste time crisis happen in 2014 Congress Quickly responded and president obama signed it and a bill that said veterans should not wait but should go into the community if they need care and that was called the choice act. The choice act was temporary and meant to last for three years. It was also hastily put into place so it was very complex, bureaucratic and different for veterans to navigate. With the mission act is it did two important things. But the ability for veterans to go into the private sector into a Permanent Program so it was no longer temporary. Something i strongly support. Secondly its a provide a way to use that system of care so it wouldnt be so difficult that veterans just gave up on it. Diagain, something i worked very hard to get done. And so, the mission act which is now law, President Trump assigned it, is a very good thing is something i support. The danger in the mission act something that is somewhat technical but i cant overemphasize how important it is. The rules that govern how a veteran is able to go into the private sector are calledis accs standards. The time i was putting the bill through congress in working with the president on this i knew that was so important that we were not ready yet to have all those rules in place and i had to be done carefully so i asked congress to allow that to be at the discretion of the secretary. Give a year so that the secretary could come forth with a really well thought out plan because this is the engine that drives the whole mission act. Thinking that i would be that secretaryar i felt that was competent and i thought congress felt confident i would be doing that as well but unfortunately i wasnt there and the president had fired me and now secretary wilkie had to produce the Access Centers but secretary wilkie made a decision that these access standards will continue to be based on what i call, and administrative rules and those rules are how many minutes it takes you to drive to a va and how many days you need to wait for an appointment. I would have chosen a different path but i wouldve made them based on clinical rules. Everybody that i know who gets their care out of the va when they use their insurance or go to the private sector they getet decisions based on their clinical situations. Im a doctor and i see my patient and what is best for my patient. In the v8 this is now based on how many minutes you have to drive to a va or how many days you have to wait so i say if you happen to be a veteran who lives next door to a va Medical Center you should have the same ability to get highquality care as someone who happens to live 65 and its a way. I think this is a mistake to use the access standards that were picked by the va today. Now, this is not such bad news because since the access standards are at the discretion of the secretary and not part of law this can be changed and so there isrn flexibility and whati am suggesting and im not trying to say that there was bad intent in making these access standards but what i am saying is this needs to be studied very carefully and we need to monitor it because if i am right this will lead to bad consequences for veterans and lets make the adjustments that we need to make. Ke host to tie this back into the book you talk about this but you also writes a lot about how you felt that your efforts to craft legislation and do other work within the va was often undermined by what you referred to and read about in the media from the maralago treaty and a separate group that you call the politicals in the book and could you talk about these groups and who they were and how they influenced your time at the va connect. Guest much many people may not realize is that when a president comes into the administration the group that supported the old president , 4000 political appointees leave on genera 20 and 4000 new political appointees eventually come into the administration ani there isja they are distributed all throughout government so the va gets about 30 political appointees who get put into leadership positions and these political appointees generally are there for the right reason and are very effective at being able to help their agencies as were most who were at the va but i had a number of them that were more politically ideologues then necessarily willing to focus on the mission. They believed differently than i did that these access standards in the mission act should moveov towards the direction of using administrative rules to open up the va very broadly which, i believe, would be leading towards privatization. To give you a sense about this when the mission act and the bill that i supposed went to the Senate Committee which is where bills go to their committee for a vote the vote by the senators both republicans and democrats was working in favor of the bill that i proposed, including the republican chairman, johnny isakson, and one soul senator who opposed him. These political appointees align themselves with that senator and ultimately that minority bill was the one that ended up getting into these accessto standards. So, there was, instead of the va acting with one voice there were really two voices and theree ws the secretary and then there were a group of rogue political ultimately had the support of the white house and that was really the issue, i believe, the lead towards the differences between me and ultimately the president s decision to make a change in secretary. Host it is interesting what you stated because, i believe, as you wrote in the book the idea and i wont say the word was used but the idea of privatization came up very early in your initial conversation with the president elect about you potentially coming on as va secretary and do you feel the President Trump fully understands or has a desire to move the va in the direction of privatization or is this a situation where maybe lower level political appointees have an agenda that isnt fully communicated all the way up to unit command for a full understanding connect. Guest its a very fair question, jeremy. I dont think im at the point that i feel like i can speak for what the president wants or what the president s intentions are for it every time i was with the president the president was focused on is what were doing good for veterans and so i will give him the benefit that he is trying to act in veterans interests. I do believe these political appointees have a much Stronger Political ideology and that is much closer affiliated with coke brother Organization Called concern veterans for america that has a political focus to move government out of the services. Look, i think every american who cares about veterans has the right to put forth their ideas and should be putting forth their ideas and im not saying that all their ideas are bad ideas. Ive already said im in the middle on this issue. But i do think there are two camps of decisionmakers and they were pushing very hard and i think that in many ways they found a way to get the president s ear on their issues and i think that continuing to drive the va with the study course the way that i was i can believe that was in the vet veterans best interest and nowbi we have seen a little bit of a different Movement Much more towards the approach that they wanted but you know, i think that the president , i dont know how much he is put himself into the details of these policies. Host time has gone incredibly quickly. Theres a lot more i want to talk about so i will jump into the speed around because i dont want to lose out but will try to get through them more quickly. Two things. Medical cannabis and burn kits. Medical cannabis is something that many veteran organizations are actively fighting to get the va to be involved in and at a minimum to minimum to do research and theres a bill in congress to do research for the va to drive research around the utility of medical cannabis. You have untold numbers of firsthand anecdotal accounts from veterans talking about how much cannabis has helped them overcome so many of the stigmas of war that weve talked about in were not saying a whole lot of movement around that or maybe leadership from the va on that. That is topic one for the speed on print topic two is you mentioned thehe foundational issues of the va is around exposure to toxic hazard but agentne knows about orange. Its a generation are the big openair kids that have served an overseas combat zones where we dump everything in there and fight it on fire and they burn to a 47 resulting in deployed Service Members reading in these tocsin fumes for their entire department and now theyre coming back and having very Serious Health issues. Can you touch on those topics and what the va is doing it when its not doing and how we can move forward to help . Guest tried to do these quickly because there important topics. Im a physician and have scientific training and i try to look at them scientifically. The system is a system that has extreme essential to help improve health and wellness and i am strongly in favor of any effort that will give us more evidence and research in ways that we can help veterans and the va, i believe, should be involved and should be open to research to help veterans improve their lives, including medical cannabis. Its different than Recreational Cannabis but the benefits of this is at the peril of veterans, especially with the crisis and soup suicides weve talked about. Its time to change that. Legislative health would be great great lead beneficial. On the issue of burn pits. This is an area that frankly, we have backwards. The way our system works today to be able to get benefits is that we wait until there is Scientific Evidence to be able to make our policy changes. That has resulted in our veterans waiting decades to get theg help they need. Talk about agent orange. Fifty years ago people were exposed to agent orange. Today in 2019 they are still fighting for their benefits. Presumptives which are scientifically shown the associated with toxicity agent orange have still not been approved. Blue water Navy Veterans still waiting for the health help they need and deserve. Gulf war veterans not gettingea help and benefits when they clearly have exposure to toxic elements and the science has not shown it and i think we need to turn that around. When somebody sacrifices the way they are a veteran they should be given the benefit of the doubt and then if evidence is they werent at the location that they were and there is evidence to show that then we need to change that policy. The burn pits are just awesome not learning from the mistakes that we made for our vietnam veterans. We are making these veterans wait and suffer and we are a registry of 100 is 5000 veterans in the burn registry and we are studying it but in the meantime theree are people that really need ourpe help and we need to start having government that is responsive to helping our veterans. Host thank you. I appreciate that. Those are two issues that are incredibly important to us. Im sorry we dont have more time because they are incredibly important. So the listeners know there is legislation pushing forward the government and the va to change that so we can take real action on that. The va actually does have ability and the authority to do research on cannabis in the utility of it and you think theres a stalling tactic they are or maybe they genuinely dont feel the kids could do anything until they get legislative guidance on gucannabis . Guest i think ba researchers want to do this research. I think that it has been made so incredibly difficult to get these Research Protocols approved through the processes because they are very restrictive drug at this point. The researchers in charleston, South Carolina want to do the research that got blocked from the bureaucratic barriers so that is where legislation will be helpful. Host one thing that was interesting early on in your tenure you convene a meeting of former va secretary so how does that go over and did you learn something from that and what do you thank you stay in touch and id be curious to know. One of the biggest problems of the big organizations like government is the constant turnover at the top. Almost every two years theres been a new va secretary and the under secretary position which i held which i vacated in februaro the state and theres not a Senate Confirmed person there. When you have this turnover and it takes a long time to fill it there is not a consistency of vision. I believe that it was incumbent upon me to learn from my fellow secretaries who dealt with all the issues i was dealing with and i thought would be very helpful in moving things along and knew more than i did in many cases. I brought them altogether and they were so kind and generous with their kind to come and spend and they appreciated being packed into print one of the reasons i wrote the book was because i have all this knowledge. I think i had to identify the formula for making great progress and for fixing things and doing important things for veterans but when you leave no one ever invites you to be able to say what did you learn and what was working and thats a travesty and a failure of leadership and so i wanted to write this book so that future leaders of the va could pick it up and say you know what, this has been tried before and this is working and that isnt working and there was a duty and response will you have and i will continue to speak out and to advocate for the things that i believe are right for vetera veterans. Host thank you, sir but its incredibly opportunity to talk with you. I appreciate your service at the va and i know its readily challenging and regardless of the circumstances that you are in working at the va is a challenge because its very much under the spotlight and its often held up in a very high standard. Guest its an honor and i want to thank you, jeremy. Its a fantastic organization that advocates for iraq and afghanistan veterans and hard work always standing up and making sure that we are doing the right thing and so the community ibo included was an important part in continuing to be in important part of helping us reach the right decisions. I appreciate your time. [applause] thank you, ladies and gentlemen. Please be seated. It is my distinct honor tonight to introduce a very special guest and a good friend. This is the second of our jack