Recounts his time as secretary of the Veterinary Affairs department. Ceo and afghanistan veterans of america, and after words has relevant hosts interviewing top authors about their work and after words are also available to listen to as podcasts. Dr. Shulkin, thank you for being with us today. Its an honor to have you here. I think the va is an important subject to talk about and i think its one of the areas of our government that a lot of people hear about, but dont necessarily know many of the details, frankly in the veteran community, i think a lot of us that dont understand the breadth and the depth of what the va does. Im excite today talk about the va in general and certainly about your book and about your time in the administration. If youd like, id love to begin by sort of what brought you to the va. You were successful in the civilian career and a lot of times making a transition from the civilian world into the government world can be a bit jarring. What drove you to want to take up the mantle of working within the government, especially within the va . Well, during my 20s, i didnt have a chance to serve the way that you did. I spent my time in medical institutions and doing my medical training and sort of a busy 20s and thats always one of the real regrets that i had, with in amazing country that we have that i wasnt able to give back and so later on in my career, i was the ceo of a hospital and i had the tonight to get a call from the white house, this was right at the time in 2014 when was a very public wait time crisis in the va where there were allegations the veterans were actually dying waiting for care. And i remember sitting there as a citizen saying, oh, i feel terrible about this. If anybody deserves the best care possible its our veterans and i wished there were something i could do to help. And as sometimes happens in strange ways, i got a call from the white house saying, would you consider coming to help lead the Va Health Care system because were looking for somebody who understands how Health Care Works and from the private sector. And you know, i did what everybody tends to do when they have the choices to make, i made a list of the bros and the cons and the con side as much, much larger than the pro side, but on the pro side, it was simply how could i say no . This is my duty as an american citizen to give back to people who have given up so much and so, i really didnt think much about it. I said yes, im prepared to come and help. Thats great. And that was as nos of you who have read the book know, that was the Obama Administration initially. So youre one of the few people who serve under the Obama Administration and trump administration, so look forward to getting into that. That said, i thought i would start, but id love to read a brief quote from your book, early on you write its important that americans understand what the va system is, how it works and why it exists. As i mentioned, i think a lot of people dont understand the scope of what the va has and what theyre responsible for. I wonder if you could start off by giving maybe you had an elevator pitch talking about everything that the va does, as you well know, it goes well beyond health care, but thats what they do know and how much more that the va does. One of the reasons i wrote the book is exactly what you talked about, jeremy. Im not sure the American Public understands why the va exists, but why its really an essential part of our National Security system that when we rely on a voluntary military, which now less than 1 of americans serve in, but niece amazing americans raise their hand and are willing to sacrifice themselves on behalf of all of us. When they go, theres a commitment that the country has made to them that they will take care of them if they need that help when they come back and there is no other organization thats focused on that. So as you said, the va provides health care for 9 million veterans, but there are really 20 million veterans in the country. So, the va has a large effort directed towards education, the gi bill. It has an effort towards benefits should somebody require assistance if theyre no longer able to work or if theyre disabled and it also goes all the way through the time of making sure that every veteran, when the time comes, is buried with dignity and respect. There are 114va cemeteries around the country and they do an amazing job supporting families during these tough times. So this is an organization second largest in the u. S. Government, employs 370,000 people who are there, many of them veterans themselves, continuing to give back. They do an amazing job and it deserves the support and understanding of the american people. Thats great and i often point to people, you know, the va is the second largest department. Second largest agency. Second largest budget and people, i think, really just from a civics mind think about everything it does. If i could, just about the health care aspect, because it gets so much focus of the public attention on the va, when i came from the private sector and the government, i had never worked in government before. I actually had a completely open mind when i was reading all of these Horror Stories in the press that i would go there and i would find that the system was so broken and so dysfunctional that maybe my job was just to sort of close up shop and say, you know what . The best thing i can do for veterans is eliminate the Va Health Care system and move everybody into private hospitals, something that i knew very well. And after i got to the v amount va and got to see what the va does. When i put on the white coat and went out and visited hospitals across country and went to see places like, where we bring paralyzed veterans skiing down the slopes in aspen, colorado. I really began to understand that what the va does in the Health Care System is very different than what the private sector does. And in fact, cant be replaced. And the private sector doesnt do the things that the Va Health Care system does in all cases. For example, our behavioral Health Care System, it is extensive, it is large, where the private sector behavioral Health Care System is really i struggling and trying to get access if we were to put these nine million veterans dump that into the private steck tore sector system, already struggling, we know that the veterans would not come out on the right side of that. So i became a very strong advocate making sure that this is a system that works well, that we need to modernize and approve and it will be a sustainable system. Absolutely. Youve touched on a couple of things there i want to make sure to come back to. You touched on things that i want to make sure we come back to privatization are important topics. A large part of your book. We will get to that. But i want to continue with this setting because you mentioned reminded me of a comment saying within the veteran community, if youve been to one being, youve been to one va. You mentioned how in the beginning you did a lot of going around to why do you think that is that even though were talking about an agency that has oversight of all these different areas you get so a different stories . The negative stories but the ones that make it to the press that you hear Horror Stories about one v. A. But in talking to somebody veterans our membership tells us they love the care they get at the v. A. They would like to get access to it faster and things like that. Why do you think there is such a variety of levels of care that one receives from the v. A. . Guest the v. A. Is under a public scrutiny that know the Hospital System in the country finds. As hospital ceo when private sector i can tell you Little Things that happen in the v. A. That would never come to the tension in the private sector turn out to be the subject of congressional hearings and major frontpage stories. The public gets a sense that there are lots of things that happened in the hospitals that dont happen in the private sector. Again using the private sector comparison the question of would get most frequently being a physician, ceo was whats the best b hospital for e to go to rex answer was interestingly there is no a suh thing as the best hospital. There are hospitals that are good at some things. Those same hospitals may not be so good in some other specialties and areas. Thats the same in the v. A. System. When youre the largest system in the country with over 1000 facilities you are going to have some that are excellent and certain conditions and others that frankly need work on them. Thats what youre going to find in healthcare. But the v. A. Has an additional complexity in that it needs to provide care to veterans whatever they live in this country. So, therefore, we have a large number of our better to live in areas and finding people especially specialists to be able to work in rural areas is a challenge for the v. A. Can also challenge for private sector as well. You have tremendous variation between what works in the v. A. From one place to another place and thats one of the things that i worked very hard to try to standardized some of these practices. Host reminded me of a funny story from your first confirmation hearing when i believe senator sullivan from alaska who basically said you need to come to alaska because we have unique set of circumstances here, unique challenges to veterans and you need to come and understand that before he was going to vote for you. Guest i think just to let people know all the bit more about that, jeremy, many people dont understand the Senate Confirmation process, and you actually in order to go quickly through a similar process and not require an entire gorbachev to have unanimous consent. This was when i was under secretary and white house said good news, you have unanimous consent, youre going to be confirmed at the next couple minutes. Right as that was happening senator sullivan said, not so quick. Conversatione a with the nominee. He called me upno and said im standing on the senate floor, im about to castng my vote buta want you to commit to me that in the first 30 days if you are confirmed that you will come to alaska with me because alaskas very different than other states and are veterans have different needs. I said were going to alaska, and then the went through. I sai to alaska. And the vote went through. [laughter] which i imagine was your intent anyway. You mentioned there was a lot of variability geographically speaking especially, in terms of making it difficult to get proper professionals to some of the rural areas. Alaska is one of the few states, New Hampshire and hawaii being the others that dont have its own va hospital. So meeting the healthcare needs of those states is extraordinarily challenging with the partner. In anchorage, we partner with the air force hospital. But i was delighted to travel with the senator. Because thats how you understand how to fix problems out there by talking to veterans about what theyre experiencing. Another thing you did issue continue to see patients during your time in the va. Which i think mightsurprise people. That you have the though ai would take the time to do it. But in fact, that was something you felt was necessary and vital to you understanding the needs of the veterans. Could you expand on that . 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 the va would use. A big decision. How could i make that decision if i had never used the vas electronic record. And if i had never been working with patients and nurses and doctors understanding how they interact with the record. When i would put on my white coat, no one knew i was secretary. It helped me understand what was working and how they were experiencing the decisions i had to make from the ground level. I think that made me a better and more effective leader. You touched on the Electronic Health record which is Something Else i want to talk about it a little bit. You remind me, theres a funny anecdote when you were in your doctor capacity talking to veterans. Youve got your white coat on and they dont necessarily know who you are. Youve got startling responses from a veteran. Could you tell that story . I would see patients to ways. In person in the exam room. Here in the city at the manhattan ba. Then i would see them using telehealth from my office in washington to a clinic in oregon. A very rural part of the country. I got to extend both urban and rural. But i was in the new york manhattan va. I saw a patient and what can i do for you, sir . He said i need a physician to fill out this form and i said id be happy to do that. He said im i need certification because i am suing secretary shulkin. He was homeless and was trying to get additional benefits to get himself out of that situation and get himself back on track. Needed a physician certification of his issues that he was dealing with. I said to him, well, sir. First of all, im going to help you. But i dont think im the person to do it. He said why, i said because i am secretary shulkin. We got him on his way and i got another physician to help them. You early on mentioned five priorities you had when you are coming into the va. Could you talk about those five priorities and how you arrived at what they would be . And maybe you can expand on how you feel you did in achieving those goals . When i first came to the va, i not only, never worked in government before. This was an organization that i was going to have to learn. It was such a Large Organization that if i had waited until i truly understood everything about it, wed be waiting a long time. As i mentioned, i entered at a time of crisis. There were veterans literally waiting for care that needed help and i didnt feel like i have the time that i normally would if this was a normal situation. So i came in having studied the va from the outside the best i could i came in and said we will have priorities right now. If we change them later thats 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 that there were 57,000 veterans waiting for an Urgent Medical consultation. That was just, waiting more than 30 days. That was totally unacceptable to me. And outside the bounds of what i call reasonable. I immediately called for every Medical Center to be open on the following weekend and during that weekend, we contacted those 57,000 veterans and by monday morning, we had that list down to less than 1000 veterans. So once we essentially got the backlog taken care of. I wanted to make sure we never got to that situation again. I did a couple things but the first is, as secretary, one of my first decisions was to publicly post our wait times. The va today is the only system im aware of. The second thing was, i established same day services. Throughout the entire country. By december 2016, i was able to tell secretary mcdonald and president obama every va Medical Center had the capability of seeing people on the same day basis. So wed never be in a situation where someone with an urgent issue couldnt be taken care of. We ended up publishing an article. We had made tremendous progress in addressing that issue really with the commitment of the employees and the staff that work there. The other priorities were focusing on establishing and improving employee morale. Because it had been terrible. There were 35,000 vacancies. Recruiting people to an organization that has low morale is a significant challenge. Probably one of the most important priorities was regaining the trust of the biggest veterans we serve. [indiscernible] we can track whether we are beginning the trust we had lost of our veterans. Fortunately, that began to climb as well. Which is very good news. We had established another priority of creating best practices. Learning from one va to another and doing it across the country so we could decrease some of that variation quality of care. That was very successful in being able to do that as well. Some of these things you brought from the private sector. I know there are vast differences as you either eluded to including the ways we as a country can provide care to civilians and how we can provide care to our veterans. Are the things we can continue to learn from . Max interestingly, not only did i not have at the time, to learn all the ways of the government. Because i felt there were urgent issues like the wait time issues. But i also deliberately didnt want to start to think as if i was a government employee. I wanted to deliberately bring the industry best practices, the way we thought about things to government. What i ended up learning was that the government could benefit from many of the practices that the private sectors does. Needed to modernize some of the ways it was thinking. I actually learned there was more i learned in the va that the private sector could benefit from. This is a twoway bidirectional way of learning between the private sector and the government and in this case, the va. Theres an ongoing debate about the future of healthcare. Thats not usually something that people can usually say, we can learn from the government. When you look at the outcomes of care across a population which is very popular right now. Called population health. The va outperforms almost every other major healthcare system. Not saying its the very best. When you look on average, the va performs better than most private sectors. If you look at what we did for example, i made the declaration that i wanted to eliminate hepatitis c from the entire veteran population. We have a drug, several drugs, that can eliminate the virus. At a 95 percent or higher cure rate. I didnt see any reason why we should have any veteran who had hepatitis. I went out. Congress gave us 1,000,000,000 and a half dollars to do this. [indiscernible] we need to do more of that in the general population. Proactively looking at outreach and population health. But these are lessons we can learn from the va. Here that veterans get through the va often is there are studies that show. Our membership generally likes the care they get from the va. We too often hear the negative stories and not the positive. You didnt mention as one of your priorities but you certainly addressed in the book, another area in which the va gets slammed is around the problem of military and veteran suicide. Its such a collocated issue. Mental health is a collocated issue not only in the veterans and military space but we as a country are struggling to understand. Do you have any insights from your time at the va in your time as to how we can address this issue both within and without of the va . The single highest clinical priority 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 thats why im pleased that secretary wilkie has continued to make veteran suicide a priority for the va. One of the things when you start to take a look at this. 20 veterans a day take their life, only six are getting care in the va system. So there are 14 out in the community. My biggest worry is there not getting help at all. So one of the first initiatives we did at the va was to start outreach to community partners. Veterans service organizations, Community Groups and churches and religious organizations. Groups like the united way. Got local governments and state governments. All to begin to Work Together to identify veterans at risk and finding them treatment. Every va Medical Center has something called a Suicide Prevention coordinator. Many of them have multiple. Their job is to be out there looking for veterans at risk and identify ways to help them. Thats one of the practices i think the va has that the private sector should have. But we need to do a lot more. The underlying reason why people take their lives is not because they wake up and say, i feel like doing this. Theyre suffering from something. Could be depression. Ptsd. It could be chronic pain or substance abuse. Other reasons. With a look at ways of getting to those underlying reasons. Finding more effective diagnosis and treatment. And really begin to make sure that we are proactively identifying how we can intervene and help. Theyre so much more work to do. Lots of promise and opportunities to do that. We are looking at predicted analytics and more effective therapies. But much work to be done in this area. As you said, many dsos have this as their priority as well. The does come out from both the military, va. Showing we are not getting at the problem. I think we should be looking at it as an Emergency Response issue but a much broader things to be to look at the underlying issue. Product pain, things like that. Financial issues. So much can be reaching into that. Which the va alone cant solve. There clearly has to be a whole of government and a whole Society Approach to this. The va as the leader for the Veterans Community within the government should be spearheading that. But i think im sure a challenge. Im proud of the work the va is doing for their working hard to address issues. Like many tough problems that americans face, we have to do even more and pushed through some of the barriers that prevented us from making progress. I think the recent Suicide Prevention report. Although the va decided to report to data differently. It is not a smaller number and in fact went up a little bit. This is not about keeping a scorecard. This is about making progress. Im not sure we are there yet. I completely agree. Another area id like to touch on is women veterans. An area which i think lot of the country doesnt realize how the landscape has changed. We certainly have more women serving in combat roles. While women coming back from these deployments needing care. I think we certainly hear from it firsthand that women often times dont feel welcome. They are sometimes harassed on the way in. Cat called. And its assumed there therefore a spouse or boyfriend or Something Like that. What needs to be done to begin to change this culture. It seems is throughout the va and maybe the country frankly that doesnt quite recognize the service of women veterans. The fastestgrowing demographic in the military is women. We now have about 14 percent and theyre playing extremely important rules. Not to recognize and respect of their service is simply wrong and something that cant be tolerated by the va or any other part of our society. I do think youre right that this is a reflection of issues we see in broader society. What the va has decided to do and something i supported, rather than waiting for culture to change in attitudes to change. We have to make sure we are providing care with the respect that everyone deserves. Especially women. And so we created womens clinics and womens centers. Now in over 120 Medical Centers. That often have separate entrances. But create a secure and comfortable environment when women get their care. Where there dont have to worry about any of the issues weve talked about and these are often really centers of excellence. Where people love getting their care. In some ways though, its a shame we have to create separate places for people. But, we werent willing to just wait and say, we will try to change attitudes. At the same time that we are providing these women centers, we do need to the ato change whats not accepted. There was a recent public issue at the washington d. C. Va less than a month ago. Where a woman veteran was harassed or just walking through the halls. And had the courage to come out and talk about that experience. I know i certainly went out publicly and supported her as Many Organizations did. To say this is unacceptable. We need people like this brave woman to speak out on behalf of her fellow veterans. And we need to begin to start changing these attitudes. And we need male veterans to lead this charge as well. To speak up for women as well. Not something that the burden should be placed completely on the women veterans. One of the ways we are trying to begin this process. That there should be a cultural change to frankly change the model. And Abraham Lincoln quote, for he who is born to battle for his willow and his orphan. We had been pushing and theres legislation that something is more embracing of the changing nature of our military and veteran community. Something that received some pushback in a lot of quarters. Did this come up internally at the highest levels when you are within the va . One of the disappointments that i had. The military is probably the place in our society were differences in diversity have the opportunity to go away. This is the ultimate melting pot. Everybody shares the same goal that you rely upon each other to survive. Doesnt matter if youre republican, democrat, black, white, woman, male. This is a common mission. For the va not to be inclusive and to embrace that type of diversity, i think is a mistake. While i understand peoples deep attraction to Abraham Lincolns motto. That was in a different time. And we need to recognize that the new modern va needs to be leading in this type of and inclusion. If theres a lot of people feel excluded from, its time for us to recognize that but i do not believe Abraham Lincoln would be upset with that. He was a guy that stood for making sure we were one country together. He believed strongly in supporting the people who fought for the country as many of us do. But i think talking about the issues and importance of women. Now a couple hundred years after Abraham Lincoln. Its time for us to move toward a more modern motto. Theres legislation to change that model but correct me if im wrong, the va has the ability to do it on its own. It would need an active congress. Is that correct . It would not. I dont think as a secretary, i did not envision chiseling 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 this commitment towards our veterans. But, Abraham Lincolns original quote as it talks about widows and orphans, this is not language we traditionally used in 2019. I think theres a way of honoring the original words of Abraham Lincoln but talking about the new va in a way that could be done with respect for our history. Absolutely. Completely agree. Id like to shift a little bit. Talking big picture. Id like to move into your time specifically within the administration as secretary. Weve already touched on a couple of these issues. I think its safe to say if you look at, especially the parts of your book about your service as va secretary under President Trump. Two of the underlying policy the athat drove so much of your time were around privatization and around the Electronic Health record that we discussed. Privatization is a word that comes up all the time. I dont think most people fully understand what is meant. Could you give the audience an understanding of what we mean when we talk about privatization within the va . Privatization to its fullest extent would be the simple concept of shutting down the va Medical Centers and the va healthcare system. Giving a voucher to a veteran and say, you go find your own health care in the private setting. And we will pay the bill. That would be the ultimate goal of privatization. And there is a strong belief that government should not be involved in the delivery of services with that of a man is inherently an efficient. Weve 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 go into the private sector went ins in their best interest. When the care is better or specialized care is available thats not in the va. I think we all believe that should be available. But my belief is that the complete privatization of the va would be a disaster. And we would look back when 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, 19 percent of veterans were getting care in the community. I left it was 36 percent. I was strongly in favor of not having veterans get inferior care or waiting for care if the va couldnt do it. But we got them to the private sector. I think this is an issue of, that there are policies being pursued by those who favor the dismantling of the va. Where they do not raise their hand and say theyre in favor of privatization. Because that would be politically unpopular. Theyre not going to say that but if you want the impact of the policies over the years that will calm, i believe they will lead to a point where there is complete privatization in the va. And what i am trying to say and what i argue in the book is, is that we either need to come out and say what will happen if we follow these policies. Were we need to very closely monitor and make sure theres not an unintended consequence of these policies before its too late. And there is an appropriate role of congress to have oversight and there is a role of the press to make sure theyre looking at whats happening. And im trying to essentially raise the visibility. Lets just be cautious. Im optimistic about where the va is going. Supportive of where its going. But being an expert in healthcare, i see some warning signs. And i want to make sure we are vigilant that there arent these unintended consequences that lead us toward privatizing the va. You said Something Interesting that i think might confuse some of the audience. You said how the percentage of private care visits rose from 19 percent to 36 percent. Some people would say, then werent you working toward privatization . Can you unpack to the athat . It can be confusing. Often, this is what now happens in washington. When youre not at one end of the political spectrum. So the very end of the political spectrum says we want complete control by the government. The end of the political spectrum on the right is we dont want government involved at all. Lets completely privatize. If you happen to be in the middle with a compromise solution where i am, its a very lonely place in washington. People tend not to understand it so i appreciate the opportunity to explain it. I believe as a physician, that the right answer in healthcare is when you do the right thing foryour patient. In this case, the veteran if you are a veteran, what should you want . You should want the very best care possible thing. The veteran should have a strong va that focuses on areas that they do extremely well. Ptsd, traumatic brain injury, rehabilitation, prosthetics. Environmental exposure to toxic agents when you get in combat. These are things that frankly the va does extraordinarily well. But of the va cant do everything well. And so if youre a veteran and you need specialized care or something not available in your community, you should be able to get that in the private sector. I envision a hybrid system with a strong, modern va focused on centers of excellence and things important to veterans. And the ability to seek the private sector when those arent available. Ive published that as a model of care in the new england journal of medicine so everybody could see the plan that i had for the va. And when that frankly i think just makes sense for veterans. During your time, you talk about this quite a bit in the book. This debate comes up quite a bit talking about the recently passed mission act. Before that, the choice care. Can you talk about what that bill did, does, will do . It was passed a year ago, implemented in june of this year. Theres still a lot of confusion around it. You worked a lot of your time on that bill and it was passed after you left. I feel confident that you know it very well. Sure. I spent all three years leading up to the passage of the mission act. When the wait time crisis happened in 2014, Congress Quickly responded. President obama signed it. A bill that the debtor and shouldnt wait. They should be able to go into the community if they need care for that was called the choice act. It was temporary. Meant to last for three years. It was also hastily put into place so it was very complex bureaucratic and difficult for veterans to navigate what the mission act did is too 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 supported. Secondly, it simplified the way to use that system of care. So it wouldnt be so difficult that veterans gave up on it. Something i worked hard to get done. I think the mission act which is now law. President trump signed it. Is a very good thing and something i support. The danger is something that is somewhat technical. In that the rules that govern how a veteran is able to go into the private sector are call access standards. The time i was putting the bill through congress and working with the president. I knew that was so important that we werent ready to have those rules in place and have it be done carefully. So i asked congress to allow that to be at the discretion of the secretary. So the secretary could come forth with a wellthoughtout plan. Because this is the engine that drives the whole mission act. Thinking i would be that secretary, i felt it was confident. Unfortunately, i wasnt there. The president had fired me and now secretary will be how to produce the access standards. I think secretary will be made a decision that these access standards would continue to be based on what i call 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. I would have 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 get decisions based on their clinical situation. Im a doctor, whats best for my patient. In the va, this is based on how many minutes you have to drive or how many days you have to wait. I say, if you happen to be a veteran who lives next door to a Medical Center, you should have the same ability to get high quality care as somebody who happens to live 65 minutes away. So i think this is a mistake to use the access standards that were picked by the va today. This is not such bad news because since the access standards [indiscernible]. This can be changed. So theres flexibility. So what im suggesting. Im not trying to say there was bad intent. But what i am saying is this needs to be studied carefully. We have to monitor. But if i am right, this will lead to bad consequences for veterans and then lets make the adjustments we need to make. To tie this into the book, you talk a lot about this but you write a lot about how you felt your efforts to craft legislation or do other work was often undermined by what you refer to as a maralago trio and a second group. Could you talk about these groups, who they were and how they influence your time at the va . What many people may not realize is when a president comes in to the administration, the group that supported the old president and political appointees leave on january 20. And 4000 new political appointees come in through the administration. That gets distributed throughout the government. The va gets about 30 political appointees that get into leadership positions. 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 work in the va point but there are a number of them that were more politically ideologues are necessarily willing to focus on the mission. And they believe differently than i did that these acts of standards and mission act should move toward 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 feel i proposed went to the senate va committee. The vote by the senators, both republicans and democrats was 14 in favor of the bill i proposed. Including the republican chairman. And one soul senator who opposed it. These political appointees align themselves with that senator and ultimately that minority bill was the one that ended up getting into these access standards. So there was instead of the va acting with one voice. There were two voices. The secretary and then there were a group of rogue political appointees who ultimately had the support of the whitehouse. And that was really the issue, i believe, the differences between me and ultimately the president s decision to make a change in secretary. I believe as you wrote in the book, the idea, of privatization came up early in your initial conversation with the president elect about you potentially coming on as the secretary. Do you feel President Trump fully understands or has a desire to move the va in the direction of privatization or is it a situation where maybe lowerlevel political appointees have an agenda that isnt fully communicated up the chain of command . Its a very fair question. 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. Every time i was with the president he was focused on what we are doing good for veterans. So i will give him the benefit that hes trying to act in veterans interests. I believe these political appointees have a much Stronger Political ideology that is closer affiliated with the coke brother organization that has a political focus to move government out of services. And look, i think every american who cares about veterans has the right to put forth their ideas and should be putting forth their ideas. Im not saying all of their ideas are bad. Im sort of in the middle on this issue. But i do think there were two camps of decisionmakers. They were pushing hard. I think in many ways they found a way to get the president ear on their issues. And i think that continuing to drive the va with a steady course the way that i was bid i happen to believe that was in the veterans best interest. And now weve seen a different movement and much more toward the approach that they wanted. I think that the president , i dont know how much he has put himself into the details of these policies. Time has gone incredibly quickly. Theres a lot more i want to talk about so i will jump into a speed around. Wewill try to get through quickly. Two things i want to talk about the medical cannabis and. [indiscernible] Medical Campus is something Many Organizations are actively trying to get the va to get involved with. Theres a bill to get research around the utility of medical cannabis. Yet untold numbers of first hand anecdotal accounts from veterans talking about how much cannabis has helped them overcome signature wounds of war. But yet, were not seeing a lot of movementaround that. Thats topic one for the speed around the topic to is around what you mentioned some of the foundational issues of the va is around exposure to toxic hazards. Everyone knows about agent orange. These open air pits have been serving in combat zones where we dump everything on there and light it on fire. Sometimes they burn 247 resulting in servicemembers breathing in these toxic fumes and now theyre coming back and having very Serious Health issues related to them. Can you touch on those topics. What the va is doing or not doing . I will try to do quickly but both of these are important topics. Im a physician and have scientific training. I look at things scientifically. The cannabinoid system is a system that has extreme potential to help improve health and wellness. And i am strongly in favor of any effort that will give us more evidence and research into ways we can help veterans. So the va i believe, should be involved and should be open to Research Anything that will help veterans improve their lives, including medical cannabis. Thats different than recreational. But to ignore the benefits is i think at the peril of veterans. Especially with the crisis in suicide. Its time to change that legislative help would be great beneficial. On the issue of burn pits. We have backwards with the way our system works today, 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 the help they need. You talk about agent orange. 50 years ago, people were exposed. Today in 2019, they are still fighting for their benefits. Present shown to be linked to our agent orange. Still waiting for the help they need and deserve. Go for veterans, not getting Health Benefits when they clearly have exposure to toxic elements and that is being recognized. Because the science hasnt yet shown. I think we need to turn that around. When somebody sacrifices, they should be given the benefit of the doubt. Then if evidence comes to show theres not an association or they werent at the location they said they were. Then we need to change that policy for them. Burn pits are just us not learning from the mistakes we made for our vietnam veterans. We are making these veterans wait and suffer. The registry of 165,000 veterans in the burn pit registry and we are studying it. In the meantime, there are people that need our help. We need to start having government that is responsive to helping our veterans. I appreciate that because those are two issues incredibly important. Im sorry we dont have more time to spend on them. So the listeners know, there is legislation pushing forward for the government and the va to change so we can take real action. You write about this in your book. The va actually does have the authority to do research on cannabis and the utility of it. Do you think there is a stalling tactic there or maybe they generally feel they cant do anything until they get legislative guidance . I think researchers want to do this research. I think its been made so incredibly difficult to get these Research Protocols approved through the process because its a restricted drug at this point. So there are researchers in charleston. We have these bureaucratic barriers. I think thats where the distillation will be helpful. One thing i thought was interesting. Early on in your tenure as secretary, you convened the meeting of former secretaries. How did that go over and did you learn something from that and what do you think did you stay in touch with any of them . One of the biggest problems of an organization like government is the constant turnover at the top. Almost every two years theres new secretary. The under secretary position which i held and vacated in 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. This program is available as a podcast. All after words programs can be viewed on our website at booktv. Org. You are watching special edition of booktv, arrington al green week while members of congress are in their districts due to the pandemic. Tonight we look at foreign affairs. Enjoy cspan2 now on booktv and over the weekend. The president , released in paperback presents biographies of every president organized by the ranking and are much cited president ial historian survey. Visit our website cspan. 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