Indian Health Service's past director on the agency's unique challenges for providing care

MARK BRODIE: The U.S. Senate last month confirmed Mark Cruz as the new director of the Indian Health Service; he’s previously worked in the federal Department of Health and Human Services and Interior Department, as well as for two Republican members of Congress.

My next guest was the last permanent director of IHS; Roselyn Tso resigned from the position in January 2025.

The agency is responsible for providing health care to Native Americans and Alaska Natives.

And when I spoke with Tso earlier, I asked if there are challenges to running a department like IHS that are unique to it, compared to other health care operations.

Full conversation

ROSELYN TSO: Well, um, generally speaking, probably not because there’s, you know, our whole, our entire healthcare system is challenged from time to time, whether you look at resources, or workforce, or those kinds of things to keep to keep an operation going. I think what probably distinguishes Indian Country’s healthcare system from other healthcare systems is probably some of the remotenesses that that our facilities are at, or where our people live.

And so trying to make sure that we’re connecting people to the healthcare that they need, Number 1, and the healthcare system that works for them, I think is really important. And certainly we’re we’re learning a lot more about rural healthcare, and as we do that, you know, as as I said earlier, some of the things that that tribal organizations and tribal governments have done to improve healthcare system for their people in their tribal communities is something we could probably all take something away from.

MARK BRODIE: What are some of the best ways to try to do that? You mentioned, you know, a lot of a lot of tribal members live in places that are not necessarily close to healthcare providers, and they also don’t necessarily have reliable internet service. So like telehealth, I would imagine, could also be a challenge in some cases. How do you how do you try to make those distances a little smaller and maybe make access to care more available?

ROSELYN TSO: One of the things that I’ve really been thinking about, and this has really been since you noted the time that I’ve been out of Indian Health, the federal government arena anyway, with regards to healthcare, is really looking at how can we uh utilize technology, how can we utilize um the what is around us maybe that we haven’t quite all explored to improve healthcare for people.

Some of our social drivers of health continue to be transportation. So even if we could get people to where they need to be in terms of referrals or in terms of being able to see a provider, we have to look beyond that. We have to look at just what is that uh patient also dealing with, as you alluded to, transportation for example. How do we address that? And so I think that there are ways that we can continue to look at using technology that might be available to us.

The other part I think is the more we can invest in encouraging our tribal communities to to look at ways that our tribal people better understand their healthcare, uh to take those small steps that need to be taken to really uh understand, for example, blood pressure.

And do you understand, do our people really understand, what does that mean? What do those numbers mean, and how do we Number 1, if they are high, um what is it that we’re doing, as opposed to, you know, your provider coming in and just saying, “OK, Roselyn, your your blood pressure’s high, so we need to do A, B and C.” Are there other steps, there are other steps, that we can take before that maybe before a medication is is uh recommended, or things like that, that we can start to take care of ourselves.

And so that really gets into the preventive care. If we can, as a healthcare system for our tribal people, start to look at prevention, and there’s lots of good programs out there that do that. How can we do that? And some of that can be u- utilizing technology in remote locations, whether it might be a smartwatch, whether it might be a pedometer, whether it might be a place where people can walk and and exercise. Maybe looking at those kinds of things a little bit different.

And that takes, those are just all things that are great ideas, but it takes time and it takes change in tribal communities to be able to do that. So what I have seen work the best is when tribal communities determine what are the needs in their tribal communities and then they take it and address for themselves.

MARK BRODIE: Well, so which do you think is the bigger challenge then: getting individuals to sort of do the things that you’re talking about and maybe taking a little more ownership over their own health, or some of the systems changes in terms of figuring out and deploying technology and maybe recruiting more providers, that kind of thing?

ROSELYN TSO: Well, it’s going to be on both sides. You know, there are things that we can help the system maybe have better outcomes if we are better understand our own healthcare needs. And then there’s the other component where maybe we have people that that absolutely need to make sure that they get into their healthcare provider and get the medication that they need and to be able to address that, because they they do both connect and they they’re going to work hand-in-hand if we’re able to do it.

But I, going back though, I would say that that my experience has been that those communities, again, whether it be American Indian and Alaska Natives or any other community, that take that community need, because just because there’s 575 federally recognized tribes, we should not assume that every tribe has the same challenges and every tribe can solve the same challenges the same way. That’s, that’s not it.

MARK BRODIE: To the point you were making about the number of federally recognized tribes, did you find that the needs are similar across that wide swath of of people across this country?

ROSELYN TSO: I think generally speaking, you can say that there’s probably not enough resources. Because, you know, tribes would argue that, you know, the federal government has a a responsibility to provide healthcare to American Indians and Alaska Natives. And these are established through treaties that have been in place for years, executive orders and things that have been in place to support healthcare for American Indians and Alaska Natives in exchange for land and other resources that were taken from from the people. And these are documented.

So when you look at it just strictly from that perspective, and you look at a tribal community and and the funding that comes to Indian Health Service through Congress, you’re probably looking at 50, if we’re lucky, 50 to 55% need of funding that’s needed to support the healthcare for people. So you’re already out the door trying to provide healthcare for half of the resources that you that you need to address the needs of that community, without even looking at the data and the healthcare needs that are out there.

So you start with sort of a deficit, and then you’re constantly trying to make up those additional resources to to try to make sure that we best, we provide the best care possible to our to our tribal uh community members and our relatives. But then you look at all the other things like, you know, you you really, it’s it’s nearly impossible if you have a small community to bring in a physician. You you can’t support a physician in that community. So what else can you do? How else can you look at providing the care that you need?

And some of these there’s some great examples out there in Indian Country where care is being provided, and maybe it’s through telehealth, maybe it’s using other technologies that allow us to to address the needs of the people that we have.

MARK BRODIE: All right. Roselyn, thanks so much. I really appreciate it.

ROSELYN TSO: Thank you as well.

MARK BRODIE: Roselyn Tso is a former director of the Federal Indian Health Service.