Preventing Veteran Suicides: VA Under Secretary Dr. Shereef Elnahal Outlines Plan

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Mark Masselli ( 00:04 ):
Our guest says the US Department of Veterans Affairs has one of the most important missions in the
country, to care for people who risk their lives for us. As we approach Veterans Day, it's important to
talk about that mission, and how the VA is trying to reach its goal for America's 9 million enrolled
veterans.
Dr. Shereef Elnahal ( 00:23 ):
We released a systematic review earlier this year, which is a summary of over 40 studies that compared
VA to non - VA care. And the good news from that is that we perform just as good, most often better as
the civilian sector in surgical and nonsurgical care.
Margaret Flinter ( 00:39 ):
Dr. Shereef Elnahal is the undersecretary for health in the Department of Veteran Affairs, where he is
responsible for the country's largest integrated healthcare system.
Dr. Shereef Elnahal ( 00:49 ):
Our hypothesis when we started the innovation ecosystem was that these are the folks who know what
the solution should be. A lot of our employees are veterans themselves. If not, they have a veteran in
their lives. And so they often go above and beyond their job descriptions to try new things, to invent
new technologies even, to meet veteran needs. And now we have a way to lift up those things that are
working and say, what should we do to scale that across the system?
Margaret Flinter ( 01:17 ):
This is Conversations on Healthcare.
Mark Masselli ( 01:27 ):
Welcome, Dr. Elnahal to Conversations on Healthcare.
Dr. Shereef Elnahal ( 01:30 ):
Thanks so much for having me.
Mark Masselli ( 01:31 ):
You direct the healthcare system with an enormous annual budget, approximately $102 billion. I
wondered if you could tell our listeners, what are the metrics and data telling you right now about how
that care is being delivered, and what do the outcomes look like?
Dr. Shereef Elnahal ( 01:48 ):
Well, I really appreciate having the opportunity to serve veterans across the country. You mentioned 9
million enrolled veterans, over 6 million of them regularly get most of their care within VA.
( 01:59 ):
And the good news is, we're held to the same standard as private sector and civilian sector institutions
on quality and patient safety ratings. And so 67% of VA medical centers, as just one example, get either
four or five stars out of five in the Center for Medicare and Medicaid services overall hospital quality
rating.

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( 02:21 ):
They also have a star rating that they release on patient experience, and 72% of our medical centers get
either four or five stars on that rating alone. And so that compares to less than half of civilian sector
hospitals in both of those metrics.
( 02:36 ):
On top of that, we released a systematic review earlier this year, which is a summary of over 40 studies
that compared VA to non - VA care. And the good news from that is that we performed just as good,
most often better, as the civilian sector in surgical and nonsurgical care. And so we have the same
benchmarks that the rest of the American healthcare system uses to assess quality of care. And we're so
proud to know that our medical centers stack up and do even better than the civilian sector.

Margaret Flinter ( 03:07 ):
Well, that is very impressive, and thank you for sharing those results with us. And you have also just
announced that the VA and 13 community health systems have pledged to share data to improve
veteran healthcare. Tell us how this will work, what brought about the initiative, and what do you think
this will do in terms of being a model for the rest of the healthcare sector?

Dr. Shereef Elnahal ( 03:31 ):
Well, a lot of folks don't necessarily know that about a third of the care that we offer to veterans, we
actually purchase from private sector and civilian sector partners. Our academic affiliate institutions,
higher - volume institutions that see a lot of our veterans and take care of a good scope of our veterans
care.
( 03:52 ):
And so because of that, the need to coordinate that care and share information seamlessly back and
forth is just absolutely critical. Right now, we still use some of the archaic technologies like eFax and
snail mail. We really need to move into the next generation of technology here. And these 13 health
systems are going to tell us, and work with us on building that seamless exchange of information.
( 04:16 ):
On top of that, we want to build a system that they can query to understand whether they're in front of
a veteran or not, whether their clinicians are caring for one of the veterans in our system. And for those
veterans to get information about our programming. Programming about the PACT Act, the new law
that the president signed last year that allows us to be there for veterans exposed to toxic substances,
our programming on suicide prevention, and so much more.
( 04:40 ):
So I want to thank those 13 health systems for working with us on this pledge.

Margaret Flinter ( 04:44 ):
Can you share a few of, what are those community health systems? Maybe a few to give our listeners a
sense around the country of where those systems are?

Dr. Shereef Elnahal ( 04:52 ):
Absolutely. We have Mass General Brigham up in Boston, Kaiser Permanente in California, Sanford
Health that serves the Dakotas and a lot of the rural areas in the middle of the country, and Inova Health

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right here in the DC area. A number of really important health systems, very large footprints, and very
advanced in the technology that they do. And so those are just some examples.

Mark Masselli ( 05:15 ):
That's a great partnership you have. The country's facing issues around Covid, as a wave sweeps across
the country and around the globe. And the VA is reporting that active covid cases among patients have
been up more than 200% in the last two months, roughly 4,000 cases in the system right now. Of course,
that's still below the numbers you saw during the pandemic, but I wonder if you could update us on
efforts to encourage vets to get vaccinated for covid and for the flu as well.

Dr. Shereef Elnahal ( 05:49 ):
Yeah, so I want veterans to know that we are never complacent when it comes to tracking the status of
where we are with Covid 19, but also the flu and so many other transmissible infectious diseases. We
have systems that we review literally every day to make sure we're not seeing significant trends upward.
And if we are, what we need to do to prevent further spread.
( 06:11 ):
You mentioned vaccination. It is one of the most important things veterans, family members, caregivers
can do to protect themselves against severe outcomes from this disease. And in fact, there's really
strong data that shows that if you're vaccinated and up to date with your vaccination, remember that
the latest booster was just released a few weeks ago for use across the country, and if you get infected
and start on a regimen of Pax Lovid, you are very, very unlikely to pass away or have a severe outcome
from Covid 19.
( 06:42 ):
So thankfully, we have a lot more tools now, and we want veterans know we offer all of them to you.

Margaret Flinter ( 06:47 ):
Well, Dr. Elnahal, A very sobering statistic to point out is that we're losing 17 vets a day on average to
suicide, according to the latest data. And you've announced that you're focused on improving suicide
prevention initiatives. We would welcome you commenting on some of those initiatives, both traditional
ones that you may be expanding.
( 07:09 ):
Also, are there any novel or innovative approaches that you're taking? I understand that you've
incorporated some complimentary and alternative strategies into your program. Share with us the range
of those initiatives.

Dr. Shereef Elnahal ( 07:23 ):
Thank you for asking about that. Because it is my most important clinical priority for veteran care, and
also our most important public health priority, to really reduce veteran suicides to the lowest extent
possible. Even one veteran dying by suicide is one too many. Every single veteran suicide is a tragedy
that we have to learn from, and we are doing that to the extent possible every single day. And we really
have three prongs to our approach in reducing veteran suicide.
( 07:51 ):
The first is to make sure that crisis care is available to any veteran who needs it, no matter where they
are. Our veteran's crisis line is on first with that. It's a much easier number to remember now. It's 988,

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and if you're a veteran, press one. You get connected to a professional on the other end who can help
you through that crisis, and help you understand that there's a reason to keep going, and the reason to
live. And then connect you to VA care that's needed after that.
( 08:18 ):
On top of that, our emergency rooms, our clinicians and medical centers across the country are there for
you. It is okay not to be okay. There's a stigma around mental health. For veterans, it could be lifesaving
to encourage a battle buddy. Or if you're a caregiver, loved one, to encourage that veteran to seek
healthcare.
( 08:36 ):
We also have really important community coalitions that we are funding across the country. We've now
given out more than $50 million in grants this year alone to community organizations that help fortify a
veteran's social and support network to be protective against the risk of suicide.
( 08:53 ):
And finally, and very importantly, the work we are doing on gun safety and lethal means safety. We
hand out gun locks with every opportunity we have. This isn't us wading into any type of political debate
on guns, it's just allowing for a few extra seconds to minutes to help save that veteran's life.
( 09:11 ):
If they need to reach out for something to unlock their gun, or if their gun lock is with their caregiver or
loved one, that could be a lifesaving situation where they would not use that firearm to die by suicide.
And so between all of those initiatives, we're working as hard as we can on this very important public
health priority.

Mark Masselli ( 09:29 ):
Well, those initiatives are really so important. Congratulations to you and the VA for that work. And
certainly, the public service announcement around 988, so important in addressing the issues of stigma.
( 09:43 ):
Undersecretary, you mentioned earlier about the PACT Act. Veterans are still being urged to apply for
the promise to address comprehensive toxis. As you've mentioned, PACT Act signed by the president
last year. I'm wondering if you could talk a little bit about it. This is called perhaps the largest healthcare
and benefit expansion in the VA history. And not sure it's on everybody's radar, it should be. Such an
important program.
( 10:12 ):
Should vets apply even if they don't have any symptoms?

Dr. Shereef Elnahal ( 10:17 ):
Well, I'll tell you, there are so many more doors to get into the VA than we had before because of this
law. The bulk of the law addresses both Vietnam veterans and Persian Gulf and post - 9/11 conflict era
veterans vis - a - vis the latter's exposure to burn pits in central command, that's Iraq, Afghanistan, and
many other surrounding countries.
( 10:39 ):
And for Vietnam vets, of course, it's Agent Orange, the law expands the number of deployment areas
that make someone eligible to be considered presumptively exposed to Agent Orange. And then tracks
back on conditions that they may have and says, "This could be related to your Agent Orange exposure."

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( 10:57 ):
Meaning, the burden of proof is no longer on veterans to say that their condition is connected to their
service, as long as they were deployed to particular locations at particular times.
( 11:07 ):
However, even if you don't have a chronic condition or symptoms, you can still enroll directly into VA
healthcare with various different pathways under the law. And so I encourage everybody to go to
va.gov/pact and click apply for healthcare. You can see all of the new opportunities to get VA healthcare
if you are a veteran. It is not necessarily required that you've been exposed to these substances to
benefit as a result of the PACT Act.

Margaret Flinter ( 11:36 ):
Well, maybe along those same lines, you've been speaking out about how the VA and the Cancer
Moonshot initiatives are aligned to support the PACT Act and veterans with environmental exposures.
How do these interact?

Dr. Shereef Elnahal ( 11:51 ):
Well, Cancer Moonshot is a really key part of what we're doing. It's the president's agenda on reducing
cancer mortality by 50% in the next few decades. And that's a pretty significant goal, but it's a goal that
we think is achievable. And VA can really contribute to that goal.
( 12:07 ):
The first thing is that we have researchers who are doing incredibly innovative and important work,
expanding all clinicians' pie of knowledge across the country. We're affiliated with almost every single
academic medical center and medical school in the country with the faculty needed to find more
answers and develop new therapies.
( 12:25 ):
On top of that, the PACT Act, especially folks who are exposed to burn pits in Iraq, Afghanistan, and
Central Command, adds many, many cancer conditions as related to that burn pit exposure. So if you
were deployed to anywhere in Central Command, either in the first Gulf War or in the post 9/11
conflicts, and you have one of the many cancers added as presumptive conditions, we will assume that
you've been exposed to burn pits and therefore that your cancer is related to your service if you apply
for VA benefits.
( 12:58 ):
And so, really want folks to know that part of the cancer moonshot is allowing so many more of these
vets with cancer to get VA benefits and healthcare.

Mark Masselli ( 13:10 ):
Well, that again is another important resource for veterans, and we're glad you're leading the way on
that.
( 13:21 ):
You're facing a lot of challenges. Another one of them is the federal government shutdown and less than
a month, and we realize that you and your colleagues must be ready for whatever happens. I'm
wondering, for a veteran who's listening, what should they know about what will and will not be

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affected if there is a shutdown? We hope there's no shutdown, but hope for the best and fear the worst,
I know. So you're always planning. What can you tell a veteran?

Dr. Shereef Elnahal ( 13:53 ):
Well, thankfully Congress anticipated that a shutdown, if we were beholden to it in the healthcare
system, could be really crippling to VA healthcare. And because of that, we have something called an
Advanced Appropriation. Essentially, that is money that carries over into the next fiscal year that allows
our hospitals, clinics, and healthcare delivery mission to continue, even if there is a shutdown.
( 14:16 ):
And so the basics of your healthcare as a veteran will not be disrupted if a shutdown ends up happening.
So that's the first and most important good news there.
( 14:25 ):
However, there are other components of the VA that might be affected. Certain elements of our Office
of Information and Technology cannot start new deployments of technology that can be particularly
helpful for veteran care. We also have other components related to outreach, and making veterans
aware of all of the care options that they have in the VA. A lot of that outreach has to stop during a
shutdown.
( 14:49 ):
And all of that indirectly leads to more and better healthcare when we're able to do it. So if we're not
able to do it, we get concerned. And so especially on an extended shutdown, we might start to see some
of those impacts on veterans. And so I really do hope that Congress passes a budget. The President and
Congress are really trying to work on this. And when a speaker is elected, hopefully we'll be able to get
those conversations started again.

Margaret Flinter ( 15:17 ):
Dr. Elnahal, I know another area that you're highlighting is that the VA has reduced the number of
veterans who are prescribed opioids by 67% since 2012, which we've looked back at as kind of the
height of the opioid prescribing crisis. Yet, more than a third of veterans who use the VA say they live
with chronic pain. How have you accomplished the reduction while also adhering to the very important
principle of treating the pain?

Dr. Shereef Elnahal ( 15:45 ):
Yeah, we're really proud of our opioid safety initiative. We know that a large number of veterans and
people more generally in the United States start their journey into opioid addiction with a prescription
with a bottle they get of these opioids for their care conditions.
( 16:01 ):
And if that initial prescription ends up being longer than a patient or a veteran needs, or higher doses
than what a patient or veteran needs, that could lead to dependence, which could end up leading to
addiction. And so stopping prescriptions when they are not needed for things like chronic pain, or at
least limiting their duration, is a major way to prevent addiction to the extent that we can across the
country.
[NEW_PARAGRAPH]A really important part of our opioid safety initiative though, isn't just saying, hey,
we're not going to give you opioids. It's offering all of the other alternatives that can be, and often are
effective in relieving pain. So there is procedural care you can get to relieve pain from specialists.

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( 16:43 ):
There is what we call our whole health portfolio, so acupuncture and other methods that have worked
for veterans significantly in the past. And there are other medications that you can try first, before
resorting to opioids that are not addictive and can relieve your pain. And so essentially we exhaust all
options before having to move to opioids in the first instance. And when we do have to use opioids,
tapering them off and limiting their duration to the extent possible.

Mark Masselli ( 17:12 ):
Undersecretary, Margaret and I have been watching for years the innovations that come out of the
Veterans Administration. And you're the co - founder of the Veterans Health Administration Innovation
Ecosystem, which is a program designed to foster the spread of innovation and best practices to
improve veterans care. I'm wondering if you might share with us some of the latest advancements that
have been promulgated from this important work.

Dr. Shereef Elnahal ( 17:40 ):
Yeah, I think the innovation ecosystem is one of the major ways that we lift up the frontline, the
clinicians, the doctors, the nurses, the pharmacists, the social workers, everybody who is right there in
front of the veteran, serving them. They often know what the most important pain points for veterans
are as they navigate through the VA. And our hypothesis when we started the innovation ecosystem was
that these are the folks who know what the solution should be.
( 18:07 ):
A lot of our employees are veterans themselves. If not, they have a veteran in their lives. And so they
often go above and beyond their job descriptions to try new things, to invent new technologies even, to
meet veteran needs. And now we have a way to lift up those things that are working and say, what
should we do to scale that across the system? So that's what the innovation ecosystem does.
( 18:30 ):
We've done a lot with it even since the pandemic. So the 3D printing outfit that our innovation
ecosystem has allowed for many more masks to be distributed across the country when they were in
shortage. On top of that, we've invented novel medical devices like new types of hearing aids that more
effectively fit into someone's anatomy after using imaging and other methods to determine what that
hearing aid and assisted device should look like.
( 18:58 ):
And every year, new innovations and new inventions are coming through. And this isn't a new
phenomenon, by the way. The VA has really changed the standard of care throughout many decades.
First Pacemaker was invented and inserted in the VA. Many different types of surgical procedures
started at the VA. And so really this is continuing on the tradition that we've had for so long.

Margaret Flinter ( 19:22 ):
Dr. Elnahal, looking back when you were in New Jersey's Health Commissioner, you significantly
expanded that state's medical marijuana program. VA healthcare providers I understand may not
recommend marijuana, or assist veterans in obtaining it because it's a Schedule one controlled
substance. And yet the US Department of Health and Human Services has formally recommended that
cannabis be moved from schedule one to a lower level.
( 19:48 ):

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What do you make of all these efforts and do you anticipate that the VA will be changing if those things
happen?

Dr. Shereef Elnahal ( 19:56 ):
Well, you mentioned the main barrier, which is that it is currently federally illegal, and currently
scheduled as a schedule one substance. Meaning that especially as a federal agency, we unfortunately
at this time are receiving guidance that we cannot recommend the therapy from our clinicians, or
engage in state programs.
( 20:14 ):
However, you also mentioned that the president has asked the DEA to look into rescheduling cannabis
for possible use, medically. There's also the possibility that research could be done increasingly if that
happens in our system. And we recently reached out to both the Attorney General and to the Secretary
of Health and Human Services indicating that we are already able to conduct clinical trials in this if and
when they make their regulatory decisions.
( 20:46 ):
And so we know that certain conditions have a lot of promise, things like chronic pain and even mental
health conditions like PTSD could possibly benefit from cannabis therapy. But we don't know the answer
to that unless we do rigorous clinical trials and build the evidence behind it. And the VA would be willing
to engage in that should those other agencies make those moves.

Mark Masselli ( 21:11 ):
Well, doing clinical trials is so important. We learn so much from them, and that will be a very
important. I want to keep you back in New Jersey, where you led the university hospital in New Jersey.
And you started a program, very exciting one, that deploys trusted chaplains as community health
workers. We just had CDC director Cohen on, who talked about the importance of someone you trust in
terms of decision - making.
( 21:39 ):
I'm wondering if you could just tell us more about this program. It sounds so interesting.

Dr. Shereef Elnahal ( 21:44 ):
Yeah. Well, we knew that chaplains in Newark were among the most trusted people, leaders of faith in
all denominations and and all faiths. Really were able to congregate communities, it was often one of
the most effective ways for us to spread the word on healthy habits, access to healthcare within our
institution.
( 22:05 ):
And the good news is that chaplains exist all over the country within the VA as well. In fact, our national
Chaplaincy service director reports directly to me. And she's definitely building an infrastructure, and
trying to support our chaplains across the country.
( 22:21 ):
That program at University Hospital combined a role with existing chaplains, and had them become
community health workers, which requires a certain degree of training and literacy and health issues.
And that was a really effective combination there. And so we're always looking at similar ways that our
chaplains within the VA can become a more and more important part of a veteran's care. Knowing that a

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lot of veterans' faith is so important to them, that could be a real effective avenue to increase their
healthy habits and improve their health.

Margaret Flinter ( 22:54 ):
And a very creative approach, congratulations on that one. A former undersecretary of the Navy once
said that she gets upset when everything focuses on the negative about military service, and others have
expressed that sentiment as well. They think it's wrong to assume every veteran is "broken." Are they
right? Do you think that we as a country are overlooking the positive aspects of service, even the
positive physical and mental parts of it?

Dr. Shereef Elnahal ( 23:21 ):
Well, what I'll tell you is that from the veteran standpoint, this narrative of the broken veteran is just so
wrong on so many levels. The fact that veterans serve our country, it's a selfless act in and of itself to put
yourself in the voluntary service to defend our country.
( 23:39 ):
On top of that, when they get through that service and they come home with trauma, and they come
home with conditions, they have to go through a really tough process in getting over those issues. And
that ultimately makes them stronger. That does not make them weaker.
( 23:56 ):
And so I reject the narrative of the broken veteran wholeheartedly, knowing that veterans end up being
stronger than the rest of us because of their journey, overcoming their trauma. And for the VA, and for
me to have at least a small part in helping veterans do that across the country is my life's professional
honor.
( 24:15 ):
But no, our veterans are not broken. When they need our assistance, it's actually our obligation,
because this is the care that they earned and deserve because they sacrificed so much for us. And they
end up coming out of that much stronger individuals.

Mark Masselli ( 24:31 ):
We like that positive attitude. Undersecretary Elnahal, you have such a remarkable personal story and
career. I'm wondering how did you get interested in medicine? And then, how did you specifically get
interested in the work at the Veterans Affairs?

Dr. Shereef Elnahal ( 24:51 ):
So my story of getting into medicine actually was inspired by one kid that I mentored in Baltimore, who
had type one diabetes. I grew up with type one diabetes myself, and volunteered to teach a class on
self - management at a local, federally - qualified health center in Baltimore.
( 25:10 ):
And he worked with me over a matter of months, we really approved his blood sugars. And then I got a
really tragic call from his mother that he actually passed away. And I asked her, "Oh my God, was it from
his diabetes?" And her answer was no, he had actually fortunately joined a gang and ended up being
murdered.
( 25:27 ):

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And so it really taught me in a very, very emotional way that the social circumstances around folks can
be the thing that ultimately has much more bearing on their health and their outcomes, than the day - to -
day and managing their healthcare within our clinic walls. And so not only inspired me to go into
healthcare and become a physician, but also to look at other ways that I could serve in a broader way.
( 25:51 ):
And so to do this now for veterans is just my life's professional honor, and my journey into management
and policy stemmed from that direct experience. What levers can we pull as a society within
government, but also even at the institutional level, to make life better for people? And to be able to do
that for veterans is just an incredibly important opportunity to me.

Mark Masselli ( 26:14 ):
You mentioned federally - qualified health centers. One of the many hats we wear is a federally - qualified
health center. And one of the most important days of the year for so many of our staff, our work with
Stand Down. Which is so important here in our state, but I know other federally - qualified health centers
are privileged to serve our veterans. So thank you for the work that you've done, and also that work for
that young child.

Dr. Shereef Elnahal ( 26:45 ):
Thank you so much.

Margaret Flinter ( 26:47 ):
Dr. Elnahal, I think we might have time for just one more question. So if I may, I have always been
moved by the, I think it's part of statute, that part of the mission of Veteran Affairs is to care for, to
provide the healthcare for those who have served the country, and to train them. And to also train the
future healthcare providers for the people of the country.
( 27:10 ):
You have such a strong reputation as a health profession training system within the United States.
Anything new you'd like to share with us about innovation on that front? Changes in your training
programs or your strategy for addressing all the workforce shortages that we hear about, from primary
care, to nursing, to specialties? We'd love to give you a moment to comment on that.

Dr. Shereef Elnahal ( 27:34 ):
We're right to highlight our training mission is among our most important healthcare missions that we
have. I actually became exposed to VA as a physician because my first rotation on the wards was
actually at a VA medical center. And that's actually when I met a veteran who traveled more than an
hour with crushing chest pain just to get there. And we all knew he was having a heart attack, as did he
when he arrived, because it was his second one.
( 27:59 ):
And so of course when we asked him after he was stabilized why he drove that far to get to the West
Roxbury VA. He told us that he would not trust any other institution with his healthcare. And so that was
such a meaningful moment for me. It allowed me to understand how important the institution of the VA
was.
( 28:18 ):

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And it turns out that 70% of physicians have at least part of their training at one point in a VA. So many
more nurses do. So on the front of innovation, we've expanded many more slots in nursing residencies
to get and foster that same level of talent on that side. And it's just so critical to our overall staffing and
workforce mission to be a preeminent training institution.
Mark Masselli ( 28:44 ):
Undersecretary Elnahal, thank you for joining us today. And thanks to our audience, be sure to go online
to CHCradio.com to sign up for email updates. You can also share your thoughts and comments about
this program. Undersecretary, thank you so much.
Dr. Shereef Elnahal ( 28:58 ):
Thanks so much, Pat, for having me.
Margaret Flinter ( 29:05 ):
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