With introductions from the National Indian Health Board and Regenstrief, my team and I talked to 148 people from 37 facilities in all 12 IHS regions: 123 clinicians and admin staff, 8 Tribal leaders and 17 patients. While it was important to anchor the patient's voice, we had to be careful about interviewing them. Many of these communities have a long history with research and experimentation done without consent, and their distrust of outside researchers is well founded. Staff carried much of the patient perspective, as they were often both patients and workers in these small communities.

Most of what we heard was about care crossing from one organization to another. Specialty care is bought from outside through a process and budget called Purchased/Referred Care, with limited funds approved case by case, and the report notes that "it is not unusual for this process to take months." Many veterans can use both the VA and IHS, but the two systems don't share data. Eligibility depends on Tribal membership and descent, and each Tribal facility can set its own rules. Underneath all of it, most sites are rural, with slow connections and long downtimes.