Recounts his time at the secretary of the Veterans Affairs department for the Trump Administration. Hes interviewed by jeremy butler. After words is a weekly interview program. They are also available to listen to as podcasts. Thank you for being with us today the v. A. Is an important subject to talk about one area of our government that dont necessarily know one of the details. Those that dont understand the breadth and the depth. Certainly about your book and your time of the administration. I would love to begin talking about the v. A. You are very successful with a civilian career making the transition from the civilian world into the government world can be jarring what would you to take up the mantle of work . During my twenties i didnt have a chance to serve in the way that you did. I spent my time in medical institutions building my medical training and one of the real regrets that i would have but later on in my career i was the ceo of the hospital and i had the opportunity to get a call from the white house. Ride at the time in 2014 when it was a very public wait time crisis in the v. A. Were there were allegations veterans were dying waiting for care. I remember sitting there is a citizen saying i feel terrible if anybody deserves the best care possible to veterans i wish there is something i could do to help and as itib happens i got a call from the white house to say would you consider coming to help lead the v. A. Healthcare system because we are looking people who understand how healthcare works from the private sector. So i made a list of the pro and cons the coin one the con side was much larger they on the pro but simply how could ii say no . This is my duty as an american citizen to give w back to the American People i didnt think too much about it i am prepared to come and help. Thats great. If you have read the book that was during the Obama Administration initially so you are one of the few who serve both and the obama and Trump Administration we look forward getting into that but i would love to read a brief quote from your book early on you write it iske important america understands with the v. A. System is and how it works and why it exist. A lot of people dont understand the scope of what the v. A. Has and what they are responsible for. Could you start off by giving and elevator pitch to everything the v. A. Does because theres so much more that the v. A. Does. One of the reasons i wrote the book is exactly what you talked about im not sure whatt if the American Public understands why it it exist and why it is an essential part of the National Security system that when we rely on a voluntary military that is now less than 1 percent of americans that are serving, these american razor hands and sacrifice themselves on behalf of all oflv us there is a commitment the country will make to them they will take care of them when they coment back and there is no other organization focused on that. So they provide healthcare for 9 million veterans but there really 12 million veterans so they have a large directive toward education, the g. I. Bill and should some of these require assistance and it also goes all the way through the time to make sure every veteran when the time comes is with dignity and respect that there are cemeteries around the country they do an amazing job supporting families during these tough times so this is the second largest in the Us Government 370,000 people and the veterans themselves it does an amazing job and does deserve the support and understanding of the American People. Thats great. I point out that it is the secondlargest department or agency the secondlargest budget and even from a civics mine point should be more informed. I think thats right and if i could even with the healthcare aspect to get more focus of the public attention on the v. A. But when i came from the private sector of government i never worked in government before i had a completely open mind reading all the Horror Stories in the press that i would go there and find the system was so broken and dysfunctional that my job would be to close up shop say the best i can do for the country is to eliminate the v. A. Healthcare system and move everybody into private hospital which is what i knew very well. After i got to the v. A. And i saw what it does, i put on my white coat and went out to visit hospitals acrossve the countrydo to see places like where we bring veterans and i began to understand what it does is very different than what the private sector does the private sector doesnt do the things the v. A. Healthcare does for example it is extensive and it is large for the private sector the Healthcare System is struggling trying to get access if they put 9 million veterans to the system that already is struggling. We know the veterans would not come out on the right side of that. So i became a very strong advocate to make sure this is a system that works well to modernize and improve that will be sustainable. Absolutely. And then go back to privatization very important topics are a large part of your book but i want to continue with the setting the scene because it reminds me of a common thing that even within the v. A. If you been to one youve been to one. So in the beginning you did a lot there were different so why is that even though we talk about an agency has so many different stories unfortunately its the Horror Stories that make it to the presske but and then the membership tells us they would like to get access to it faster but why is there such a variety of level of care one receives . The v. A. Is under public scrutiny that no other Hospital System in thede country finds with the hospital ceo in the private sector i can tell you Little Things that happen in the v. A. Would never come to the attention of private sector turn out to be the subject of congressional hearings and frontpage stories. But the public gets the sense there are a lot of things that are happeningheo in the v. A. Tt dont happen in the private sector but then even in the private sector comparison the question i get most frequently as a physician and ceo what is the best possible for me to go to . I would always say interestingly say there is no the best theres hospitals are areas maybe not another specialties. V. A. S the same in the system with over 1000 facilities you will have some that are excellent for certain conditions and those that need work w and thats what you will find in healthcare. So it needs to provide care to veterans no matter where they live in theisis country so therefore we have a large number of veterans who live in very rural areas in finding people, especially a specialist to work in the areas it is a challenge for the v. A. And private sector as well. So you have a tremendous variation between what works in the v. A. And another place thats where i work very hard to standardize some of these practices. That reminds me of a funny story from your first confirmation hearing the senator from alaska said come to alaska because we have a unique set of circumstances here in unique challenges to veterans you have to come here to understand that before he would vote for you. So people know about tha that, many people dont understand the Senate Confirmation process. In order to go through a senate process to go through an entire floor vote you have to have unanimous consent in the white house a good news you have unanimous consent you will be confirmed in the next couplemo minutes and write is that what was happening senator sullivan said not so quick. I need to have a conversation with the nominee. So he called me up and said im standing on the senate floor and im about to cast my vote. But i want you to commit to me in the first 30 days of your confirmed that you will come to alaska with me because alaska is very different than other states and their veterans have different needs. I said senator, were going to alaska. Yo i imagine that was your intention anyway because there is variabilitye geographically to get proper professionals to the rural areas. Alaska is one of the few states New Hampshire and hawaii that doesnt have its own v. A. Hospital so meeting the Health Care Needs of those is extraordinarily challenging. We have to partner with the Air Force Hospital actually. But i was absolutely delighted to travel with the senator as i was to other role states and maine with those senators as well because that is the way you get to understand the problems that are out there. See you continue to see patients during your time the wouldnt say the time to do it but in fact that is something you felt was necessary and vital to your understanding. I think every leader can do the job more effectively to understand the impact of their decisions. What the record that he would use how could i never make that decision ifci i never was working with patients or nurses or doctors understanding how they interact with the record . So to put on my white coat nobody knew i was secretary certainly would help me to understand what was working down at the ground level. And touch on the Electronic Health record but you remind me of a funny anecdote in your doctorate capacity that they dont necessarily know who you are you god a startling response from the veterans. I would see patients to ways. In person in the exam room either in new york city at the manhattan v. A. In my office in washington which is a very rural part of the country. But i was in the new york manhattan v. A. When a politician came and i said what can i do for you is that i need a physician to fill out thefi form and he said i need a certification because im suing secretary show can use actually homeless veteran and was trying to get additional benefits so he could get himself out of that situation and get himself back on track and needed the certification of the issues he was dealing with. So it turns out i said first of all we willll help you but i think im the person to do it and i said because imt 14. Im secretary shulkin but we got him on his way and got another physician to help him. [laughter] we mentioned High Priorities and how you arrived and how you did to achieve those . When i first came to the v. A v. A. , i not only had not only worked in government if i had waited until i truly understand injured in a time of crisis and not to feel like i had the time like a normal situation to study from the outside the best i could but the single top priority to address the wait time crisis with hundreds of thousands of veterans but most critical to me was the 57000 veterans waiting for the urgent consultation. And that was totally unacceptable to me. And for every Medical Center to be open on the following weekend and during that weekend we contacted those 57000 veterans and then we had that less one the list down to less than 1000. Once we essentially got the backlog taking care of i wanted to make sure we never got into that situationn again. One of my first decisions was to publicly post wait times today we are the only system of the role that publishes the wait times so people canse see. And then establish same day services by december 2016 with secretary mcdonald and president obama every v. A. Medical center on the same day basis to never be in that situation we ended up publishing an article where we studied where we put all these things in place for what the American Public knows and the v. A. Turns out to be better now and really with the commitment and the other priorities to establish employee morale with the 43000 vacancies for the organization has low morale and probably one of the most important priorities and then to say to our staff we are a Government Organization to follow the progress that what we can do is regain the trust we lost in thewe veterans and then that began to climb as well with the v. A. Today. And then to create best practices from one v. A. To another across the country to decrease some of v that variation. And that was very successful. Thats how we establish priorities. Some of these things you brought from the private sector between the ways the country can provide care to our veterans but other things we can continue to learn from the private sector . Interestingly as we one as i mentioned before we did not have a the time to learn the ways of government because i felt there were urgent issues. But also i didnt want to as a Government Employee i wanted to deliberately bring industry best practices of the private sector to government. What i ended up learning was that government could benefit from any of the practices of the privateti sector if it needs to challenge itself but if i actually learned there is more that i learned in the v. A. That the private sector would benefit from its truly a bio directional learning between the private sector and government and in this case, v. A. Right now there is an ongoing continue debate with the future of healthcare and that is the perspective thats brought into the conversation about what we can learn from the government side we could use from the government. People dont understand when you look at the outcomes of care across the population which is very popular right now, the v. A. Outperforms almost every major Healthcare System. There are some great Healthcare Systems out there that this country provides terrific car care, but on average it performs better than the private sector. So if you look at the things we did for example, i made the declaration i wanted to eliminate hepatitis from the entire veteran population of all those veterans that have it now fortunately we have the drug that can eliminate the virus 95 percent or higher cucure rate. So we should not have any veteran that has hepatitis. I went out in Congress Gave us a billion and a half dollars to proactively contact those that had hepatitis c today it is well over 100,000 of those veterans. We need to do more of that in the general population and not Many Health Systems think that way proactively looking at outreach and Patient Health these are some of the lessons we can learn. So the care that the veterans get through the v. A. And then not the positive story. And then we addressed it in the book in which the v. A. Continues the problem that not only the veteran of the military states are struggling to understand how to talk about. Do you have any insights from your time how we can address this issue to move in and out of the v. A. . That is to reduce veteran suicide. It is a staggering figure that i used to sit there to say if we let another week go by there goes another 140 veterans. There is still so much work to do that secretary wilkie has continued so one of the things taking a look only six are getting care in the system and the biggest worry is there not getting any help at all. One of the first initiatives we did was to start outreach for Community Partners veterans serviceun Organizations Community groups and churches and religious organizations with groups like the united way and others out there and local governments and then to identify veterans at risk. Every v. A. Medical center has a Suicide Prevention coordinator. Their job is to be out there for veterans at risk and one of the practicesiv because this is an American Public health issue. And we need to do a lot more in the underlying reason is to wake up one day and say i feel like doing this it could be ptsd or chronic pain to get to the underlying reasons and to make sure we are proactively identifying and there so much more work to do that is promising with the Predictive Analytics and therapies but much work to be done. And i v. A. And they have this is their number one priority as well. With the military and the v. A. That were not the problem and you started to talk about that. We shouldnt be looking at it as a Emergency Response issue but the underlying issues with chronic pain and things like that and Financial Issues clearly there has to be a society that has the leader for the Veterans Community within the government should be spearheadingg that. Im proud of the work the v. A. Is doing to address issues but many tough problems americans face we have to push through some of those barriers that prevented us from making progress for Suicide Prevention it is not a smaller number it actually went up a little bit. But this is not about keeping a scorecard its about making progress and im not sure we are there yet. And that how much the landscape has changed. With the combat rules and then we certainly here that they dont feel welcome in the v. A. And then to feel it is spouse or boyfriend or Something Like that. And throughout the country. And to realize this is meal veterans. And now have 14 percent and they are playing extremely important roles not to recognizee their service for something that cannot be tolerated by any part of society with the inflection of issues the broader society. What the v. A. Has decided to do rather than waiting for the changefo and to provide care and to have separate entrances and then not have to worry about any of the issues that we talk about as centers of excellence in some ways though it is a shame we do have to have several places and not to change attitudes at theme same timee and that the recent public issue where one was just walking through the halls and have the courage to come out and talk about that experience and that that is unacceptable on behalf of fellow veterans and to start changing these attitudes is not something that the burden should be placed and then to begin the process to drive a topdown understanding and the v. A. To frankly change t the motto it is a quotation for he who goes to battle we have been pushing the legislation that is more embracing of the changing nature. And there is some pushback and it has come up to the highest levels. One of the disappointments that i had that the military is the place in our society where citizen diversity has the opportunity this is the ultimate melting pot. You rely upon each other. It doesnt matter if you are republican or democrat or black or white. This is a common mission. And for the v. A. Not to be inclusive and embrace that diversity is a mistake. While i understand the deep attraction to Abraham Lincolns motto, that was a different time that the modern v. A. Needs to be in this type of inclusion if people feel excluded it is time to recognize that and i do not believe Abraham Lincoln would that. Et with and to make sure we are one country to gather to supporting the people who fought for the country as many of us do. But talking about the issues and the importance of women a couple hundred years after of lincoln is time for us to move towards a more modern motto. And to change that the v. A. Has the ability to do it on its own. There is a way of honoring and respect but Abraham Lincolns original quote this lint language usually use in 2019 but to talk about the new v. A. With respect of our history. I completely agree and then we have already touched on these issues and it is safe to say if you look at v. A. Secretary the underlying policies that drove so much of the time there around Electronic Health records privatization comes up all the time i think most people fully understand. Could you give the audience an understanding . To its fullest extent and to give a voucher to a veteran to say go find your own health care in the private setting and we will pay the bill yet is the ultimate goal. That government is a strong belief that it should not be involved in services and is an efficient that improvement in healthcare is the nations commitment that does mean that veterans should not have to go into the private sector when it is in their best interest and not in the v. A. And to believe that is available. With that complete privatization of the v. A. Would be a disaster. And to look back when veterans are getting the care that they deserve. I want to see us going in that direction. When i first came to the v. A. 19 percent of veterans were getting care so i was strongly in favor of not having veterans wait for care if the v. A. Could not do it to get them to the private sector i think this is an issue of policies being pursued by those who favor the dismantling of the v. A. If they do not raise their han hand, that would be politically unpopular. But if you watch the impact of policies over the years , i believe they will lead to a point there will be a complete privatization of the v. A. And what i am trying to say and what i argue in the booksa is that we either need to come out and say what will happen if we file these policies or very closely monitor and make sure its not an unintended consequence of these policies. But there is the appropriate role of congress of oversight and the role of the press to look at what is happening and i am trying to essentially waive the sensibility i am optimistic where the v. A. Is going. But being an expert or and healthcare i do see some warning signs and i want to make sure we are more vigilant with these unintended consequences that lead using. To privatization. You said Something Interesting because you mentioned how the percentage of private care visits rose from 19 percent up at 36 percent so some people would say where you working towardss privatization . So how that relates. It can be confusing if you are not one and of the political spectrum it says we want complete control of healthcare. And then to be completely privatized. And then with a compromise solution. And people not to understand it so i appreciate that. I believe as a physician that the right answer with healthcare is when you do the patienceng for your so if you are a veteran you should work for the very best care possible to say i believe they are readily available in the private sector there should be a strong v. A. Focusing on areas that they do extraordinarily well a mentioned chore made it on traumatic brain injuries and ptsd and environmental exposure this is what the v. A. Does extraordinarily well. But the v. A. Cant do everything well you should be able to get that in the private sector so i envision a hybrid system of modern those that are important and the ability to seek the private sector when they are not available. So everybody could see the plan and one that frankly just sense. You talk about this in the book with a privatization this term and debate comes up quite a bit with the choice care can you talk about what that bill does or will do . It was passed one year ago and implemented there is still a lot of confusion so you know it very well. I spent all three years of time in my government leading up to the passage of this act. And when this crisis happened in the bill that said to go into the community that was called the choice act it was meant to last for three years it was very difficult for veterans to navigate you put the ability for veterans to go into the private sector into a permanent program. No longer temporary. And it simplifies the system of care so would it be so difficult that veterans gave up again something i work very hard. So the missionwo act which is now law President Trump signed i it, is a very good thing and something i a support. The danger is somewhat technical but i cannot over emphasize that the role of the governed they can go into the teprivate sector are called access standards and at the time i was putting the bill through Congress Working with the president i knew that was so important that we were not ready yet to have the tools in place so i allowed congress to put that at the discretion of the secretary so good come forward with a well thought out plan because this is the engine that drives the mission act now thinking that i would be the secretary i was confident in congress was confident i would be doing that as well. Unfortunately i was not there. They fired me and now secretary will see one wilkie has the access standards and he made a decision they would continue to be based on administrative rules and how many minutes it takes you to drive to the v. A. And how long you wait for the import on appointment. Everybody that i know they may use their insurance or the private sector based on clinical situations. Im a doctor what is best for my patient but in the v. A. Its now based on you have to drive to the v. A. Or how many days you have to wait if you are a veteran if you live next door to the Medical Center you will have the same ability to get high quality care is somebody who lives 65 minutes away. I think this is a mistake to use the access standards that were picked by the v. A. E today. This is not bad news because since they are at the discretion of the secretary and not part of law, this can be changed and so there is flexibility. So what i am suggesting is the intent of picking the access standards but this needs to be studied very carefully. If i am right this will lead to dire consequences for veterans and then make the adjustments we need to make. You talk a lot about how your effort to craft legislation was often undermined with the maralago trio. Because you talk about these groups and who they were. Many people may not realize the group that the 12000 appointees that come into the administration so v. A. Gets 30 political appointees and they are generally there for the right reasons and to help their agencies. But i have a number of them that were more politically ideologue stand were willing to focus on the mission. And they believe differently that the ease access standards and the mission act should move toward the direction of administrative rules to open up the v. A. Very broadly which means toward privatization. And to give you a sense of all this the mission act and the bill that i proposed, it went to the senate v. A. Committee for a vote, the vote by the senators republicans and democrats was 14 in favor of the bill that i proposed including the republican chairman isaacson. And one soul senator opposed it. These political appointees align themselves with that senator and ultimately that minority bill was the one that got into the access standards. So instead of the v. A. Acting with one voice there were two voices. It is the secretary and then a group of rogue political appointees that had the support of the white house and that was really the issue i believe that was the difference between me and ultimately the president s decision to make a change in secretaries. Thats interesting because you said the idea of privatization came upat very wearly with the president elec. Do you feel President Trump fully understands to move in privatization or is it a situation where lowerlevel political appointees have an agenda that is sent up the chain of command . I dont think im at the point i can speak for what the president once or his intentions. Time i was at the president he was focused on is what we are doing good for veterans . So i will give him the benefit he is trying to act in veterans interest. I do believe these political appointees have a much Stronger Political ideology that is much closer affiliatedli with the coke brother Organization Called concerned veterans of america that have a political focus to move government out of services. Every american who cares about americans that should put forth theirid ideas not saying they are all that ideas but i do think that there were two camps of decisionmakers pushing very hard. In many ways they got the presidency here and i think that with the study course in the veterans best interest and to see a different movement more toward the approach that they wanted. So the president , dont know how much he puts himself into the details of the policies. Time has gone incredibly quickly. So i will jump into a speed round. Two things. Medical cannabis is something that Many Organizations are actively fighting to get the v. A. To be involved in at a minimum research to drive research around the ability of canvas on cannabis you have untold accounts of how much it has help them overcome so many issues of for but yet we are not seeing a lot of movement on the ground around that. That is topic one, topic to the foundational issues around exposure. Agent orange burn pits open air where they serve in overseas combat zones a dump it and then burn it 24 7 four deploy age servicemembers are breathing in the talks this on toxic fumes now they come back having very Serious Health issues related to them. Can you touch on both of those topics with the v. A. Is doing or not24 doing and how we move forward . I will try to do it quickly but they are both important topics. I am ai physician and have scientific training and i try to look. The cannabinoid system is a system that has extreme potentialhe to help improve health and wellness. I am strongly in favor of any effort that will give more evidence and research into ways we can help veterans. So the v. A. I believe should be involved and should be open to research for anything that will help veterans improve lptheir lives, including medical cannabis. Thats different than recreationalal cannabis, but its at the payroll of veterans. So its time to change that. And that is greatly beneficial. So this is an area that frankly we have backwards so the way it works today to get benefits is that we wait until there is Scientific Evidence to make changes that has resulted in veterans waiting decades talk about agent orange. Fifty years ago people were exposed and now today in 2019 they are still fighting for their benefits. For some of those which are scientifically shown to be associated with agent orange have not yet been approved. And veterans are still waiting for the help that they need. Our goal found one of veterans to clearly have exposure to the toxic elements because the science hasnt shown it. We need to turn that around and they should be given the benefit of the doubt they are not at the location they said they would. And with those mistakes that they made and then to make them wait and suffer with 165,000 veterans and we study that but in the meantime people need our help. Thats a response to the veteran. Thank you those are issues that are important to us im sorry we dont have more time but so there is legislation pushing for the government and the v. A. To take action. So the v. A. Does have the ability to do research on cannabis and the utility is there just a stalling tactic and theyll until they get legislative guidance . I think v. A. Researchers want tot doo this research it has been made so incredibly difficult to get the Research Protocols approved throughcr the process because they are very restricted so the researchers in Charleston South Carolina from the bureaucratic barriers thats where legislation would be helpful. One thing that was interesting early in your tenure you convened a meeting of former v. A. Secretaries. How did that go over . Did you learn something from that . Do stay in touch with any of them . One of the biggest problems le a Big Organization the government is the constant turnover at the top. Almost every two years there is a new v. A. Secretary february 2017 is still open to this day. So when you have this turnover and then it takes a long time, theres not a consistency of vision. I believe it was incumbent upon me to learn from my fellow secretaries who dealt with the same issues i was dealing with. I thought it was be very helpful in moving things along and knew a lot more than i did in many cases. They were so kind and generous. They appreciated being tapped into. One of the reasons i wrote the book is because i have all this knowledge. I think i had to identify a formula for making great progress for fixing things. For doing important things for veterans. But when you leave, no one ever invites you to say what did you learn . Thats a travesty and a failure of leadership. I wanted to write this book so future leaders of the va could pick it up and say, this is working, that isnt working. I think that was a responsibility i had. Thank you, sir. Its an Incredible Opportunity to speak with you. Appreciate your time and certainly appreciate your service at the va. Its appropriate its under the spotlight but i think its often held up in a high standard. Its an honor. The va is a fantastic organization. Hard work always standing up making sure were doing the right thing. The were an important part of helping us make the right decisions. I appreciate your time. It is my distinct honor to introduce a very special guest and a dear friend. This is the second of our distinguished Leadership Series the first member was general james mattis who was