Thank you very much for being with us today. The v. A. Is an important subject to talk about the area that people hear about but dont necessarily know details a lot of us dont understand of what the v. A. Does. So what brought you to the v. A. . You are very successful in a civilian career a lot of times making a transition from the civilian world into the government world can be daunting so what made you want to do that quick. During my twenties i had a chance to serve in medical institutions and in my medical training and thats always one of the real regrets that i had of this amazing country i could not give back so later in my career i was the ceo of a hospital and i had the opportunity to get a call from the white house in 2014 when it was a very public crisis of the allegations were veterans were actually dying waiting for care. So i was sitting there as a citizen that i feel terrible about this. If anybody deserves the best care possible it is our veterans they wish there was something i could do to help and then i got a call from the white house saying would you consider coming to help lead the v. A. Healthcare system were looking for somebody who understands how healthcare works from the private sector. I did what everybody tends to do is to make a list of pros and cons con was much larger but how can i say no quick this is my duty as an american citizen to give back so i didnt think much about it. Thats great but that was during the Obama Administration initially so i would love to read a brief quote from your book early on you right it is important to understand of the v. A. System how it works and why it exists. A lot of people dont understand understand the scope could you start off by giving an elevator pitch . Because as you know it goes beyond healthcare. One of the reasons i wrote the book is exactly that. Im not sure the American Public understands. But why it is a part of the National Security system. If we rely on voluntary militar military. But these amazing americans raise their hand to sacrifice themselves. There is a commitment the country has made to them and there is no other organization is focused on that the v. A. Provides healthcare for 9 million americans but there is more so they have a large effort directed toward education and the g. I. Bill and benefits if they should require assistance if they cannot work and it goes all the way through to make sure every veteran when the time comes is buried with dignity so the cemeteries around the country do an amazing job. This is the organizations secondlargest and employees 370,000 people it does an amazing job with the support and understanding of the american people. Thats what i often point out the v. A. Is the second Largest Department with the second largest budget even from a civics mind point should just be more informed. I think thats right into stephen on the healthcare aspect talking about the focus that when i came from the private sector i never worked in government before had a completely open mind reading this in the press and i would find the system was so broken and so dysfunctional that maybe my job is to close out shop this is the best i can do for veterans to eliminate the v. A. Healthcare system after i got there i put on my white coat and visited hospitals across the country to see places like where we bring paralyzed veterans in colorado i began to understand what it does is a Health Care System is different than the private sector and it cannot be replaced doesnt do what the v. A. Healthcare system does in all cases. For example behavioral healthcare is as extensive and as large as behavioral is struggling and trying to get access to put 5 million veterans and just dump them into the system we just know the veterans would not come out on the right side of that. I became a very strong advocate to make sure this is a system that works well but is sustainable. Owner make sure we come back to privatization for quite dont want you to think im skipping that. Be will get to that but what you mentioned was common within the veteran community if youve been to one youve been to all especially in the beginning doing a lot of programs. Why do you think that is even though we talk about an agency that has oversight you get so many different stories . So what you hear is our membership often tells us they would like to have access faster why is there such a variety of levels quick. It is under public scrutiny that no other Hospital System in the country has they can tell you those Little Things that happen in the v. A. That never come to the attention of private sector are now the subject of congressional hearings and major inquiries. So there are a lot of things that are happening in v. A. Hospitals that dont happen in private sector and then using that comparison what i would most frequently dig up what is the best hospital for me to go to . There are hospitals that are good and they may not be so good and other areas. And thats the same with the largest system in our country with over 1000 facilities there are excellent at some conditions and that you will find in healthcare. So that it needs to provide care to veterans. So therefore we have a large number and to find the specialist to work that challenges the v. A. And also the private sector as well. You have a tremendous variation between what works in the v. A. For another. And then to standardize these practices. This is a funny story from your first confirmation hearing that said with a unique set of circumstances and challenges you need to compare and understand that. People know more about that. Many dont understand the Senate Confirmation process and in order to go through that process it would require unanimous consent. And then you will be confirmed. And then senator sullivan needs to have a conversation with the nominee. And then im going to the floor to cast my vote but i want you to commit to me that if confirmed he will come to alaska with me and senator were going to alaska. [laughter] i assume that is your intention anyway geographically speaking. Alaska is one of the few states that dont have its own v. A. Hospital fragoso meeting the Health Care Needs is extraordinarily challenging and we have to partner. But i was absolutely delighted going to other rule states like maine with their senators as well because thats how you understand talking to veterans what they are experiencing. And then you continue to see patients that might surprise some people but then you work hard seven days a week for that is something you thought was necessary with the needs of the veterans. Every leader can do their job more effectively if they understand the impact of their decisions. If im making a decision on which electronic record the v. A. Would use how could i make that decision but ive never been working with patients to understand if i have to put on my white coat nobody knew i was secretary certainly. But it helped me to understand and at the ground level. And also with the Electronic Health records. And then with that anecdote and in your doctor capacity. I see patients to ways. Here in new york city and to a clinic and in telehealth and in person but when i saw a patient saying what can i do for you . He said i need a position one a position to fill out this form. He said i need certification because im sewing secretary scholl t. I asked what that was about. He was a homeless veteran and was trying to get additional benefits to get himself out of that situation and get himself back on track. And needed a physician certification of his issues. I said first of all i will help you and we will get you the form that you need but i dont think im the person and he said why cracks and i said because im the secretary. But we got him on his way in a position to help him. Teeseven early on you mentioned high priorities. Could you talk about those five priorities and how you get at achieving quick. And not only worked in government and that is such a Large Organization that if i had waited until i understood everything about it we would be waiting a long time. So waiting for care that this was a normal situation. So i studied from the outside as best i could. And if we change them later on thats okay. And then thats to address the crisis. There are thousands of veterans waiting 30 days for care but there were 57000 veterans waiting for Urgent Medical consultation. That was 30 days and totally unacceptable to me. So i immediately called for every Medical Center to be opened on the following weekend and during that weekend we contacted those 57000 veterans and by a monday morning it was down to less than 1000. Once we got that backlog taking care of i wanted to make sure we never got into that situation again. So first, as secretary one of my first decisions was to publicly post the weight hours today it publishes the wait times. And the second thing is i established Sameday Services so by 2016 i could tell secretary mcdonald and president obama so that we are never in a situation and then to publish an article the journal of American Medical Association studied and then now the v. A. Is better. We have made tremendous progress and with the employees and the staff. That was the top priority to focus on establishing and improving employee morale. And then recruiting to an organization that is a significant challenge. It was to re gain the trust of the veterans that we serve with all states and staff. We dont have a stock price we are a Government Organization and what we can do and to regain the cost of veterans so that began to decline as well. Which is very good news. So we established another priority of best practices and then to do it across the country fragoso with that variation of quality of care. That was successful to do that as well thats how we established our priorities. And then thats what well alluded to to provide the civilians and provide to veterans. And what we can learn from the private sector. As i mentioned before not only did we not have the time but also deliberately didnt want to start to think and those best practices and to government and what i ended up learning the government could benefit and then to learn there is more in the v. A. But this is a twoway bidirectional learning that could happen. Its interesting there is the ongoing continue debate about the future of healthcare. I dont think that is a perspective that is brought into that perspective and what we can learn from the government side. I dont think people understand if you look at the outcomes of care with the population it is very popular right now, the v. A. Outperforms almost every other major Healthcare System. Those that provide Terrific Care but if you look on average that is most than the private sector if you look at what we did like for example i made the declaration to eliminate hepatitis c from the entire veteran population. There was 163,000 veterans. Now we have a drug fortunately federally that can eliminate the virus at 95 percent or higher cure rate. So we went out and then to proactively and with those well on the way to eliminating hepatitis c. We need to do that in the general population and not Many Health Systems are looking at outreach this is what we can learn from the v. A. So they care that veterans get that show that there are things they want for improvement that we do too often hear those negative stories. You didnt mention it but you address it in the book in which the v. A. Gets around the military veterans. Its such a complicated issue for co Mental Health is complicated that we are struggling to understand and figure out how to talk about and how to solve. From your time at the v. A. How we can begin to address this issue within and without quick. Those priorities that i establish was to reduce veteran suicide. Twenty a day is a staggering figure that i used to sit there and say if we let another week go by there goes another 140 veterans. There was still so much work to do thats why im pleased that secretary wilkie has continued to make veteran suicide a priority. So looking at this of those 20 veterans, only six are getting care. There are 14 and then not getting any help at all. In one of those first initiatives was to send outreach to Community Partners those in churches and religious organizations for groups like the united way and others out there local governments and state governments all begin to identify veterans at risk every v. A. Medical center has a Suicide Prevention coordinator. And their job is to be out there looking for veterans at risk and identify ways to help them. Thats at the private sector should have. It with the Public Health issue not just veterans. But we need to do a lot more the underlying reason is not because they wake up one day and say i feel like doing this but it could be depression, pts depression, ptsd, substance abuse, other reasons. We have to look at the ways to get those underlying reasons with those conditions to make sure we are proactively identifying how there is so much more work to do. And these promising opportunities to do that looking at Predictive Analytics and therapies. But unfortunately what we see the situation is not improving coming out from the military that we are not getting at the problem. And with that Emergency Response needs to be much broader homelessness or Financial Issues and maybe even the government alone. And to be a whole of government and whole of society that but the Veterans Community but that is a challenge. Im proud of the work they are working hard to address those issues but like many tough problems americans face we have to push through the barriers that prevented us from making progress so it looks like a smaller number it is not in fact it went up a little bit its not about keeping a scorecard but making progress. And im not sure we are there yet. I completely agree. This is an area how the landscape has changed we have more serving in combat roles and if they dont feel welcome at the v. A. And that they feel it is assumed they are there for a spouse or a boyfriend or Something Like that. And maybe throughout the v. A. Or the country. The Fastest Growing demographic we now have 14 percent and they are playing extremely important roles that cannot be tolerated by the v. A. Or any other part of the society but what it has to do and something that i supported for the culture to change is to make sure we are providing care. So we created womens clinics that have separate entrances with a secure and comfortable environment to get their care there not working on those issues that we talk about where people get their care it is a shame we have to create a separate crisis for people that we were not willing but to change attitudes but while giving these Women Centers we do need to change that. At the washington dc v. A. Where a former veteran was harassed walking through the halls and who encourage to cannot talk about that experience and to support to say this is unacceptable and we need people like this brave woman to speak out on behalf of fellow veterans and start changing these attitudes. And we also need veterans to be leading the charge. Its not something that should be placed completely on Women Veterans but now to begin the process with the topdown understanding there should be a cultural change and we were pushing that legislation that is more embracing of the changing nature and frankly it has received some pushback and it did come up internally at the highest levels. Its one of the disappointments that i had the military is the place in society where differences and diversity have the opportunity to go away. Everybody shares the same goal and you rely on each other to survive republican or democrat for the v. A. Not to be inclusive with that diversity is a mistake and while i understand peoples deep attraction to Abraham Lincolns motto, that was at a different time. We need to recognize the new modern v. A. Is leading in this inclusion and that they feel excluded from its time to recognize that. I do not believe they would be upset with that. He stood to make sure we were one country together but then to talk about the issues a couple hundred years after its time to move to our modern. So the v. A. Has the ability as an act of congress. I did not envision with the Abraham Lincoln to take that off the building there is a layer to honor history and respect and not changing the dignity with a commitment towards veterans but his original quote talking about widows and orphans this is not language that we traditionally used in 2019 and i think there is a way to honor the original words of Abraham Lincoln talking about that is respect for history. Talking big picture within the administration we already talked about a couple of issues but it is safe to say if you talk about the part of your under secretary under President Trump those that drove so much of your time around the Electronic Health records. Privatization is a word that comes up all the time. I dont think most people fully understand. Can you give the audience and understanding to talk about privatization within the v. A. That would be the full concept to shut down the v. A. Medical center and the Healthcare System to give a voucher to a veteran to say you go and find your own health care. And we will pay the bill. And there is a strong belief that government should not be the light on be involved in it is an efficient but to talk about this earlier with the governments involvement v. A. Healthcare is the most effective way of honoring our nations commitment that does not mean they shouldnt have the in their best interest so we all believe that should be available. So now the complete privatization of the v. A. Would be a disaster and we look back when they are not getting the care that they deserve. I dont want to see us going that direction. 19 percent veterans were getting here care so i strongly in favor of waiting for care we got them to the private sector. I think this is an issue there are policies being pursued those that favor the dismantling of the v. A. If they say they are not in favor of modernization so they will not say that. And over the years it will come to a point there is that modernization and then what i argue in the book to say what will happen if we follow these policies or very closely monitor there is no unintended consequence and there is the appropriate role of oversight and then to look at what is happening and then trying to essentially raise the visibility. I am optimistic about where the v. A. Is going. But be the expert in healthcare bases some warning signs. To make sure there are these unintended consequences. You said Something Interesting because you mentioned how the percentage of private care goes from 19 percent through 36 percent. Some people would say werent you working toward privatizatio privatization. It can be confusing and now this is what happens in washington. If you are not one end of the political spectrum to say you want complete control of healthcare by the government, the end of the political spectrum is we dont want government involved at all the want to prioritize on dash privatize. If you are in the middle then it is very lonely place in washington and people tend not to understand that so i appreciate that. So i believe as a physician the right answer and healthcare is when you do the right thing for your patient. If you are a veteran you should want the very best care possible. Where the v. A. Can provide these things that i dont believe are readily available in the private sector is strong v. A. Focuses on areas that they do extraordinarily well that the private sector doesnt. Ptsd,tbi,rehabilitation. And toxic agents in combat. Frankly the v. A. Does extraordinarily well. But they cannot do everything well. So if you are a veteran and eating specialized care you should be able to get that in the private sector. I envision a hybrid system with a strong modern v. A. Focused on centers of excellence and the ability to seek the private sector when thats not available and i publish that as a model of care so everybody could see the plan that i had with the v. A. And one frankly that i think makes sense for veterans. Host and then you talk about this in the book with privatization, this debate comes up quite a bit with the recently passed mission act with choice care can you talk about what that bill does or did or will do when it was passed one year ago cracks . There is still a lot of confusion around it. You spent a lot of time on that bill. Can you explain that mission leading up to the passage of the act. When the crisis happened in 2014 Congress Responded obama signed veterans should go into the community if they need care that was called the choice act. It was temporary meant to last for three years and also hastily put into place. It was very complex and bureaucratic and difficult part of the mission act put the ability for veterans to go to the private sector into a permanent program. No longer temporary that is what i strongly supported and it simplified the way to use that systems care so would it be so difficult that veterans gave up. Something i worked very hard to get done. The mission act is now law because President Trump signed it is a very good thing and something that i supported. The danger is somewhat technical but i cannot overemphasize how important that the rules that govern how a veteran is able to go to the private sector is called access standards. At the time i was putting the bill through congress and working with the president , i knew that was so important we were not ready yet to have those rules in place. So i asked congress to allow that to be at the discretion of the secretary so the secretary could come forth with a well thought out plan because this is the engine that drives the whole act. Thinking i would be that secretary i felt i was confident in congress felt comfortable i would be doing that as well. Unfortunately i was not there the president had fired me. Now secretary wilkie had to produce the access standards. He made a decision that the access standards would continue to be based on administrative rules and those are how many minutes it takes you to drive to the v. A. And how many days you have to wait for an appointment. I would have chosen a different path and made them based on clinical rules. Everybody i know who gets their care at the v. A. When they use insurance or to the private sector, they get decisions based on the clinical situation. Im a doctor what is best from a patient. In the v. A. Now its based on how many minutes you have to drive. s now i say if you are a veteran who lives next door to the v. A. Hospital you should have the same ability to get high quality care as somebody live 65 minutes away. I think this is a mistake to use those standards that were picke picked. This is not such bad news because since this is at the discretion of the secretary and not loss of it could be changed. So there is flexibility so what i am suggesting im not saying there is a bad intent but this needs to be studied very carefully and monitor. Because if i am right, this will lead to bad consequences for veterans and then well make the adjustment we need to make. To tie that back into the book you also write how you had efforts to craft legislation and do other work within the v. A. That was often undermined what you referred to as the marl lago trio so talk about these groups and who they were and how they influenced your time. Many people do not realize the president comes into the administration and the group that supported the old president that were appointees leave on january 20th and 4000 new political appointees come into the administration and they are distributed all throughout government. So then they are put into leadership positions. These political appointees generally are there for the right reasons and are very effective at being able to help their agencies as are most at the v. A. But there were a number that were more politically ideologue than necessarily willing to focus on the mission. They believe differently than i did that these access standards and the mission act should move toward the direction of using administrative rules to open up the v. A. Very broadly which i believe would be leaning toward privatization. So to give a sense when the mission act in the bill that i proposed went to the senate to committee for a vote, the vote by the senators was 14 in favor of the bill that i proposed including the republican chairman isaacson. The political appointees align themselves with the one senator that opposed it and ultimately that minority bill was one that get it into the access standards. So instead of the v. A. Acting with one voice it was two voices the undersecretary and then a group of rogue political appointees who ultimately have the support of the white house and that was the issue i believe that led towards the differences between me and ultimately the president s decision to make a change in secretary teeseven thats interesting because as you wrote in the book, but the idea of privatization came up very early in your initial conversation with the president elect about potentially coming on as v. A. Secretary. Do you feel the president fully understands or has a desire to move the v. A. In the direction of privatization cracks or is this a situation of a lowerlevel appointee that has an agenda that is not fully communicated up the chain of command . Thats a fair question. I dont think im at the point i feel i can speak for what the president wants for his intentions every 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 hes trying to act in veterans interest are quite do believe the political appointees have a much Stronger Political ideology that is closer affiliated with the coke brother Organization Called veterans for america that has a political focus to move government out of services. I think every american who cares about veterans has the right to put forth their ideas and should be putting them forth not saying all ideas are bad. Them certainly in the middle on this issue but there were two camps of decisionmakers. They were pushing very hard brick in many ways they got the president to see them on their issues. And continuing to bribe the v. A. I believe that was in the veterans best interest and now we have seen a different movement more towards the approach they wanted. But i think the president , i dont know how much he has put himself into the details of these policies teeseven time has gone incredibly quickly. Theres more want to talk about. So now i want to do a speed round. So two things is medical cannabis. That is something that many veteran organizations are actively fighting to get the v. A. To be involved in at a minimum to do research there is a bill to do research for the v. A. To drive research around medical cannabis with untold numbers of anecdotal accounts how much it has helped them overcome so many wounds from more so also may be the leadership around that and then topic two is the additional issues of exposure to toxic hazards. Everybody knows agent orange is the big openair pits overseas and the combat zones just to dump everything in there and dump it in there and light it on fire and then the servicemembers breathe in these talk just fumes their entire deployment now they have very Serious Health issues related to that. So what is the v. A. Doing or not and how we can move forward the cannabinoid system is a system that has extreme potential to help improve health and wellness im strongly in favor of any effort to give us more evidence and research into ways to help veterans. So the v. A. I believe should be involved in open to research for anything that will help veterans improve their lives including medical cannabis. But to ignore the benefits is that the peril of veterans especially with the crisis of suicide that we talked about. Its time to change that. And the legislative help in that would be greatly beneficial. Next the way the system works today is to get benefits is we wait until there is Scientific Evidence to make policy changes that has resulted in veterans waiting decades to get the help they need. Talk about agent orange. Fifty years ago people were exposed to agent orange and today in 2019 they are still fighting for their benefits. For some which are scientifically shown to be with agent orange have not been approved for veterans are still waiting to get the help that they deserve go for veterans are not getting help them benefits when they clearly have exposure to toxic elements and that is not recognized because science has not shown it. We need to turn that around. When somebody sacrifices the way our veterans have they should be given the benefit of the doubt and if evidence comes to shows there is not the association or they were not at the location they said they were, then we change the policy for them. The burn pits is not just learning from the mistakes that we made from Vietnam Veterans and we are making them wait and suffer with 165,000 veterans in the registry and we study it but in the meantime there are people that really need our help. We need to start having government to be responsive. I appreciate that because those are two issues incredibly important. Im sorry we dont have more time. And to let the listeners know there is legislation pushing forward for the Government Entity to change so we can take real action on this. That being said you write about this that the v. A. Does have the authority to do research on cannabis. Is there just a stalling tactic or they generally dont feel they could until there is legislative guidance quick. I think researchers want to do this research. That has been made so incredibly difficult to get these protocols approved because it is a very restricted drug at this point so the researchers in Charleston South Carolina want to do the research and then were dropped from the bureaucratic barriers so thats what legislation would be helpful. Early in and your tenure you convened a meeting of former v. A. Secretaries. How did that go over cracks did you learn something . Do you stay in touch with them problems light government is the constant turnover at the top work almost every two years theres been a new v. A. Secretary the undersecretary position that i held is still open to this day. There is not a Senate Confirmed a person there. So when you have this turnover and it takes time to fill it there is a consistency. I believe it was incumbent upon me to learn from my fellow secretaries who had dealt with everything that i am dealing with and that it would be very helpful to move things along and that knew more than i did. So they were so kind and generous they appreciated to be tapped into in one of the reasons i wrote the book is because i have all this knowledge that i identified a formula to make great progress to fix things and do important things were veterans that nobody ever invites you and say what works and what doesnt . That is a travesty and a failure of leadership. I wanted to write this books of future leaders of the v. A. Could say this has been tried before and is working for quite think thats a duty or responsibility that i have i will continue to speak out and advocate what i believe is right for veterans. It is an Incredible Opportunity to talk with you. I certainly appreciate your service to the v. A. Is incredibly challenging and with those circumstances you were in working with the v. A. Is challenging its under the spotlight but often held up to very high standards. Its an honor. Thank you a fantastic organization advocates for iraq and afghanistan veterans. Hard work always to stand up to make sure were doing the right thing so of course your community is an important part of helping us reach the right decisions. Excellent. I appreciate your time. A maybe forever stand and the recently published breath a letter to my sons. Host professor imani perry, what is the structure of your newest book, breath . Guest there are three sections, fear, fly and fortune. It is a letter, a series of letters to my sons but of course to the larger world both about a the reality of the terror and anxiety and worry that comes along b
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