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The federal Indian Health Service is one step closer to having a permanent leader as it tries to improve the service it provides to Indigenous people amid frequent criticism of inadequate care and a COVID-19 pandemic.

The U.S. Senate Committee on Indian Affairs held a nomination hearing for Roselyn Tso, a citizen of the Navajo Nation, on May 25, pressing her on how she would ensure the health agency, which has faced numerous challenges throughout its history and has been chronically underfunded, meets its trust responsibility to those it serves.

President Joe Biden announced Tso’s nomination to lead IHS on March 9. The agency has had only one permanent, Senate-confirmed director — who held the job for less than one year — since 2013.

The committee didn’t take any action on the nomination during the hearing. But committee members didn’t question Tso’s qualifications and focused on asking how she’d address the many challenges the agency faces, like serving a population with high rates of chronic health conditions, a lower life expectancy compared to the rest of the U.S. population and struggles to recruit and retain qualified providers. The COVID-19 pandemic, which disproportionately affected Indigenous people in the country, further highlighted some of the agency's problems and vulnerabilities.

After introducing herself in Navajo and thanking her friends and family for supporting her, Tso said her personal experiences as a Navajo woman and work as a tribal health administrator have given her an understanding of what IHS patients need, how they experience the system and what improvements are needed with the agency to improve the health of Indigenous people.

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“I will work to maximize the agency’s resources to improve the physical, mental, social, and spiritual health and well-being of all American Indians and Alaskan Natives served by the agency,” she said. “This is particularly important as we are more than two years into a pandemic that has disproportionately affected Indian Country.”

It’s unclear if the committee has set a date to vote on the nomination, but the committee’s chairman, Sen. Brian Schatz, a Democrat from Hawai’i, said he planned to move the nomination “expeditiously” through the committee.

If confirmed, Tso would oversee 26 hospitals and nearly 90 health centers and other facilities employing more than 15,000 healthcare professionals across 37 states. About 2.6 million Indigenous people rely on IHS for their healthcare needs.

Tso has worked for the agency for nearly 40 years, spending much of that time in the Portland area. She most recently served as the director of the agency’s Phoenix Area, which includes Arizona, New Mexico and Nevada. Tso earned a Bachelor of Arts in interdisciplinary studies from the now-closed Marylhurst University in Portland and a master’s degree in organizational management from the University of Phoenix in Portland.

“Tso’s administrative and operational experience as a longtime career IHS employee has the potential to benefit Indian Country for years to come,” Schatz said, adding that the committee has received “numerous” letters from tribes and tribal organizations supporting the nomination.

If confirmed, she would inherit an agency that has never had enough money to meet more than 50 percent of its needs since it was formed in 1955, according to the National Indian Health Board (NIHB). And the agency spends less per person — about $4,000 in 2019 — than the rest of the federal government does per person, which is nearly $11,600, according to the Affiliated Tribes of Northwest Indians (ATNI).

But Tso would take over as the Biden administration has proposed increasing the IHS budget to about $9 billion, an increase of roughly $3 billion compared to the 2021 budget.

Still, the agency would need more than $12.7 billion to fully meet its basic needs, according to the NIHB. And a nearly $50 billion budget would be needed to fully meet its treaty and trust obligations, the NIHB said.

Tso would also be guiding an agency that has faced a barrage of criticism in recent years for problems like providing poor services, high turnover rates among providers, a lack of leadership and inadequate oversight of its providers and facilities.

“The agency must continue to address its shortcomings and improve upon its ability to deliver quality healthcare to American Indians and Alaska Natives,” said Sen. John Hoeven, a North Dakota Republican, during the hearing.

Among her priorities, which Tso listed in opening testimony and as responses to questions, are revamping recruiting efforts and improving provider retention; maintaining or expanding access to telehealth services that have been more widely used amid the COVID-19 pandemic; and working to support tribes who contract with the agency to provide their own healthcare services and ensure speedy payments to those facilities.

If confirmed, Tso said she’d also develop new accountability and transparency policies, while improving oversight, to ensure patient safety. That, she said, would partially come from increasing centralization of facility governance, which she said she did while leading the IHS Phoenix region. While that would reduce the autonomy of some facilities, it would increase system uniformity and allow IHS to guarantee that facilities are providing proper care and all following the same guidelines and policies, Tso said.

To accomplish her goals, Tso said she’d rely on consultation with, and partnership with, tribal nations because “each tribe has unique needs, and those needs cannot be met if you do not understand them.”

The nomination also came after some tribes and tribal organizations, like the NIHB and ATNI, had pressed Biden to nominate someone to fill the position.

“The absence of a Director impedes the ability of both the Tribes, the Administration as well as Congress to carry out a bold vision for the … system,” the NIHB wrote in a March 7 letter to the Senate committee informing it of an earlier resolution calling on the White House to nominate an IHS leader. “The agency must have a permanent, competent leader who is capable and willing to advocate and act with diplomacy and tenacity, to respect Tribal nations and their voice, and to transform and reform institutional operations through innovative, effective, and sustainable systems-wide changes.”

Navajo Nation President Jonathan Nez spoke in support of Tso’s nomination on May 25, adding that he was “pleased” that the Biden administration responded to requests from tribal leaders to nominate someone, like Tso, who understands the challenges many Indigenous people in the U.S. face. He said her leadership was vital in combating COVID-19 on the Navajo Nation and credited her for being instrumental in helping the Navajo Nation achieve one of the highest vaccination rates in the world.

“Tso’s work ethic, value system and approach to problem solving demonstrates the resilience of Indigenous peoples and the commitment to combat the systemic inequities that have impacted tribal nations,” he said. “It is because of her extensive experience working with federal and tribal governments that we are confident that she will continue to promote federal trust responsibilities and enhance our nation-to-nation relationship to improve the Indian Health Service care service delivery throughout Indian Country.”

Tso said she could be counted on to improve the care IHS provides and how it operates because she has more at stake than just a job.

“The healthcare at the IHS is critical for those we serve,” she said. “I understand this not just because I work there, [but] because my family relies on IHS. My friends rely on IHS and I rely on IHS.”

Lead image: A screenshot from Roselyn Tso's May 25 hearing before the U.S. Senate Committee on Indian Affairs.

This story is co-published by Underscore.news and Indian Country Today, a news partnership that covers Indigenous communities in the Pacific Northwest. Funding is provided in part by Meyer Memorial Trust.

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ContributorChris previously covered tribal affairs in the Pacific Northwest for Underscore and ICT. He is an enrolled member of the Red Lake Band of Chippewa Indians and descendant of the Leech Lake Band...