Impact Unfiltered

Welcome to another episode of Impact Unfiltered, where we dive deep into honest conversations with leaders creating real change in healthcare and beyond. This is Part 3, the finale of a special three-part conversation.Guest host Stuart Gilly interviews host Philippe Pucheu, who has spent nearly two decades on the front lines of rural healthcare, and the conversation pulls back from the mechanics of 340B to the bigger picture: the future of rural and tribal care.Together, they take on the perception that small rural care is somehow less than big-city care and make the case that the opposite is often true, weighing the $50 billion Rural Health Transformation Program, the vanishing supply of primary care providers, and Philippe's vision for putting primary care inside the pharmacy and making rural clinics the first touch point for patients. It builds to his rallying call for the healthcare underdogs, small entities taking control of their own care.

1. Introduction and Episode Overview

• A special format where the tables turn and guest host Stuart Gilly interviews host Philippe Pucheu

2. The Biggest Challenge: The Perception That Rural Care Is Less

• The greatest challenge is the perception that small rural care is lower quality than big-city care
• Philippe points back to the family-practice doctor who made house calls and knew your history, a continuity big systems broke up

3. Why Smaller Can Mean Better Care

• A rural provider can call another provider immediately, while a big system sends a chart referral and the patient waits weeks
• Patients often get about 15 minutes at a big facility versus up to an hour and a full history locally

4. The $50 Billion Rural Health Transformation Program

• The program targets workforce, technology, prevention, new care models, and local access as rural care slowly erodes
• The dollars should reinforce what a facility does well and fund what it does not, such as a provider on site once a month

5. Meeting Patients Where They Are: The First Touch Point

• Rural access points should be the first touch point, or tip of the spear, for a patient's care
• For homebound patients a local house call beats an ambulance ride, and driving 90 minutes for local-ready care is waste

6. Why Patients Drive Past Rural Hospitals

• Patients perceive rural care as less, and insurance may cover only one visit, so they drive to the big facility
• Insurers sometimes own parts of hospital systems and steer patients toward them

7. Collaboration Over Competition

• Funding lets each facility bolster what it does well and get help where it is weak
• A facility 30 miles down the road can pick up what another cannot, building a network of rural systems supporting one another

8. Primary Care Inside the Pharmacy

• The core shortage is in primary care, as new doctors specialize for higher pay
• He proposes primary care within the pharmacy, with revenue funding local labs, an MRI, and extended ER hours

9. Building Local Trust and a Local Benefits Idea

• Rural centers earn community trust by asking what people actually need
• His magic-wand idea is a local benefits program covering primary care and labs alongside a catastrophic premium

10. The Healthcare Underdogs

• The need of a community of organizations running telehealth, workforce, remote monitoring, and collaborative care, alongside those just beginning
• Healthcare needs every lens, like legs on a table, and Philippe's rallying call is for the underdogs producing better outcomes from the inside out

Welcome to another episode of Impact Unfiltered, where we dive deep into honest conversations with leaders creating real change in healthcare and beyond. This is Part 2 of a special three-part conversation. Guest host Stuart Gilly continues his interview with the show's own host, Philippe Pucheu, and it gets practical, opening with a story that sounds almost impossible: a tribe in the South with no pharmacy, no pharmacist, and no way to fill a single prescription that still cut its drug spend by more than half.Together, they walk through how it happened, from the mail-order contract pharmacy that passed savings straight to tribal members, to the myths about who qualifies for 340B, the HRSA application that shrinks from 120-plus pages to a streamlined tribal path, and the manufacturer restrictions now being fought in some 23 states. Philippe lays out the crawl, walk, run path from contract pharmacy to an in-house operation, and his advice to any tribal health leader who feels unready.

1. Introduction and Episode Overview

• A special format where the tables turn and guest host Stuart Gilly interviews host Philippe Pucheu

2. The Challenge: A Tribe With No Pharmacy

• A tribe in the South with no pharmacy, no pharmacist, and no way to fill a prescription
• It wanted to advance its clinic and keep care on the reservation, but volume did not yet justify building one

3. The Solution: A Mail-Order Contract Pharmacy

• Philippe's team created a mail-order touchpoint from a local pharmacy they own
• Medications were provided near actual acquisition cost, with the savings passed to the tribal member

4. The Win-Win-Win

• The tribe pays less, and the patient pays zero or less at the counter, which makes them want to participate
• The pharmacy gains the patient and the access to carve care back to a local clinic or FQHC

5. Clearing Up 340B Myths: Who Qualifies

• 340B is not only for uninsured care, and a tribal program is not limited to enrolled Native American members
• Anyone who chooses the clinic can become a patient, which opened the room to grow and scale

6. The Three Basis Points: Patient, Provider, Pharmacy

• 340B is patient-driven: as long as the patient chooses a qualifying clinic, they can participate
• A patient, a provider, and a pharmacy must line up, letting it serve tribal and non-tribal members

7. The HRSA Application: 120 Pages vs. a Streamlined Path

• Registration runs through HRSA, and a full FQHC or grant application can be 120-plus pages
• Tribes get a much smaller one cut to a couple of pages, and with the right expert it can be done in as little as 15 minutes

8. Contract Pharmacy, Agreements, and Audits

• Entities can run an on-site pharmacy or use a contract pharmacy set up through a pharmacy services agreement
• Audits track the patient list, prescriptions, and policies, and HRSA-certified 340B experts keep it compliant

9. Where 340B Goes Wrong: One-Sided Contracts and Manufacturer Limits

• Without oversight, a contract pharmacy chasing profit can take advantage of a tribe chasing savings, so an experienced middleman levels the field
• Manufacturers have sued in roughly 23 states to limit how many contract pharmacies an entity can use

10. Crawl, Walk, Run, and Advice for Leaders

• Volume and population dictate whether to start contracted or build in-house, and many tribes start contracted, then build their own as volume grows
• To any leader who feels unready: ask the questions this month, since fear will drive you or faith will, and no tribe is too small

Welcome to another episode of Impact Unfiltered, where we dive deep into honest conversations with leaders creating real change in healthcare and beyond. This is Part 1 of a special three-part series. The tables turn as guest host Stuart Gilly interviews the show's own host, Philippe Pucheu, a doctor of pharmacy and founder and CEO of PBM Solutions. Stuart opens with the question that anchors the whole series: what exactly is 340B, and why does it matter?Together, they trace 340B from its 1992 origins to today's spotlight: how the program works, the bad actors who divert its savings into new hospital wings instead of lowering patient costs, and why most purchases flow through big hospital systems rather than the FQHCs, clinics, and Tribes it was built to help.

1. Introduction and Episode Overview

• A special format where the tables turn and guest host Stuart Gilly interviews host Philippe Pucheu

2. What Is 340B and Why It Matters

• A federal drug pricing program established in 1992 to help certain providers lower prescription costs
• The core purpose is to lower the cost passed on to the patient
• Now under the spotlight as a hot topic tied to the federal budget and pending changes

3. The Origins of 340B: Rural Access in 1992

• Built to protect rural access through FQHCs, critical access hospitals, and disproportionate share (DSH) hospitals
• It targeted uninsured patients who still needed care under the old system, offsetting the cost of no-pay care

4. Disease States and How Pricing Works

• Diabetes and HIV/AIDS treatments helped catapult the program in the early 1990s
• The government sets a federally matched, upper-limit price on medications
• After rebates net out, some medications come down to about a dollar for an entire dispensation

5. Bad Actors and Misdirected Savings

• Attention centers on bad actors spending 340B savings on things other than patient care
• Hospital wings, clinics, and surgery centers get funded, but the patient's cost at the door does not drop
• The dollars were meant to help people, not pad pockets or buy provider groups

6. Who Really Uses 340B

• Roughly 85 percent of 340B purchases come from large hospital systems
• Only a small share reaches FQHCs, Ryan White clinics, Tribes, and black lung programs
• A 340B rebate program is set to begin in 2027, which many hospital systems oppose

7. FQHCs Explained and Who They Serve

• FQHCs are the outpatient, independently owned side, unlike inpatient hospital care
• A grantee qualifies for grants; a look-alike is a non-grantee, both with strict reporting
• They serve rural areas as a stopgap where no family practice provider exists

8. The Headwinds and Compliance Burden

• Lower reimbursements and tough physician recruitment squeeze rural clinics
• Rising regulation adds a compliance load they need the right partner to manage
• Hospital systems try to absorb them, and closures are a real risk

9. The Opportunity: Independence and One-on-One Care

• The biggest opportunity belongs to FQHCs that stay independent and add services
• Patients want real, one-on-one care, not a rushed, volume-driven visit

10. Holistic Care and Better Patient Outcomes

• Outcomes should be settled on data, comparing hospital outpatient clinics with FQHCs
• FQHCs offer holistic care instead of fragmented referrals where no one talks
• The future of a well-run FQHC is better outcomes by bringing services in-house

Welcome to another episode of Impact Unfiltered, where we dive deep into honest conversations with leaders creating real change in healthcare and beyond. Host Stuart sits down with Jason M. Raidbard, Executive Administrator for the Department of Ophthalmology at the University of Chicago, who works in a dyad with the chair to lead the department's strategy, finance, and operations. A politics major who once planned to be an attorney, Jason came to healthcare through public administration and a chance clinic opportunity in 2003, and traces his why to a childhood spent tongue-tied and in speech therapy.

Together, they explore why wellness and engagement sit at the core of leadership, why your people already know how to fix the problems if the culture lets them speak up, and how a leader is defined by the worst moments rather than the best. Jason talks candidly about burnout, the KPIs healthcare got wrong, serving Chicago's most vulnerable communities, and governing AI in what he calls the Wild West. Tune in for an honest look at keeping people at the center of a complex system.

1. Introduction to Impact Unfiltered and Episode Overview

• Real conversations with leaders driving change in healthcare, business, and community
• Host Stuart welcomes Jason M. Raidbard, Executive Administrator for Ophthalmology at the University of Chicago
• Themes: culture, wellness and engagement, burnout, and the thoughtful adoption of AI

2. An Unlikely Path from Politics into Healthcare

• A politics major who assumed he would become an attorney
• Came to healthcare through public administration and a chance clinic role in 2003
• Nearly 24 years in, now a little over four years as Executive Administrator for Ophthalmology

3. His Why: A Childhood Speech Journey

• Was born tongue-tied and stayed quiet until it was surgically repaired at seven
• Two years of speech therapy showed him early how much it matters when people help

• The healthcare calling took root young but grew only after that 2003 opportunity

4. Defining Impact: Wellness, Engagement, and Connection

• Names wellness and engagement as his core focus as a leader
• Insists on genuine connection with everyone, from the C-suite to the EVS staff
• Pairs acknowledgment and thanks with real accountability for the team

5. Impact at the Macro Level: Culture That Walks the Walk

• Just completed enterprise-wide engagement surveys and is acting on the scores
• Credits new mission and values plus strong C-suite leaders for the culture
• Says the University of Chicago genuinely lives its mission every day

6. Serving the South Side of Chicago

• Aims to provide care second to none in the Hyde Park neighborhood
• Serves some of the most vulnerable, impoverished communities in the region
• Values groundbreaking research and exceptional training alongside patient care

7. Rethinking KPIs and Addressing Burnout

• Says healthcare focused on the wrong measures too long, with staff paying the price
• Sees burnout everywhere and stresses building a culture where people speak up
• Notes labor shortages and the rising cost of replacing staff who leave

8. Handling the Worst Moments

• Argues everyone hits a breaking point, even with the best resources
• Says a leader is defined by how they handle the worst moments, not the best
• Without genuine connection beforehand, it is hard to understand why someone struggles

9. Governing and Using AI Thoughtfully

• Calls the current AI market the Wild West and expects it to consolidate over time
• Credits the health system's AI governance committee for vetting what is safe
• Frames AI as a way to supplement work and expand access, not replace human connection

10. Looking Ahead, Advice, and Where to Connect

• Is most excited by improvements in care coordination and virtual care that expand access
• Advises staying true to yourself and letting go of perfectionism, wisdom from a mentor
• Invites people to connect on LinkedIn, where he shares knowledge freely

Welcome to another episode of Impact Unfiltered, where we dive deep into honest conversations with leaders creating real change in healthcare and beyond. Host Stuart sits down with Kayce Degenhardt, Vice President of Clinical Applications at Inova Health System, who oversees roughly 600 applications and a team of about 210 supporting five hospitals and around 300 clinics in the DC area. A former interventional radiology technologist turned health IT leader, Kayce traces her mission back to her mother's cancer journey and a three-week wait for an MRI stuck in a queue.

Together, they explore what it looks like when technology accelerates care instead of blocking it, from a waitlist tool that cut imaging waits by six days to ambient AI that saved physicians over 900 hours. Kayce shares how she led a turnaround by meeting all 210 team members first, why culture beats tools, and how the industry can adopt AI safely. Tune in for an honest look at healthcare technology built around the people who deliver care.

1. Introduction to Impact Unfiltered and Episode Overview

• Real conversations with leaders driving change in healthcare, business, and community
• Host Stuart welcomes Kayce Degenhardt, VP of Clinical Applications at Inova Health System
• Themes: patient access, clinician time, culture, and the safe adoption of AI

2. From Interventional Radiology to Health IT Leadership

• Started clinically in interventional radiology before moving into health IT
• Now oversees about 600 applications, including the Epic EMR, and a team of roughly 210
• Inova spans five hospitals and around 300 clinics across the greater DC area

3. Her Why: A Mother's Cancer Journey and Easier Patient Access

• Her mother's cancer diagnosis exposed gaps in how patients navigate the system
• An initial MRI sat in a queue, forcing a three-week wait
• Her mission became making patient access easier in an over-regulated industry

4. Defining Impact: Measuring Every Project's Outcome

• Quantifies the outcome of every project taking more than 20 hours
• A waitlist tool texts opted-in patients earlier slots when others cancel
• That tool cut advanced imaging waits by an average of six days

5. When Technology Helps Instead of Getting in the Way

• Tracks pajama time, the hours clinicians spend charting after their workday
• Ambient listening lets AI document the visit and place orders for sign-off
• The tool saved physicians over 900 hours in its first couple of months

6. Reducing Cognitive Load with Generative AI

• Uses generative AI mainly to reduce clinicians' cognitive load
• Targets administrative tasks so staff can focus on patients
• Aims to cut clicks, typing, and note length wherever possible

7. Leading a Turnaround: Assess the Team First

• Believes you cannot pour from an empty cup, so she started with her own team
• Met all 210 members individually to surface barriers and make quick fixes
• Spent year one strengthening the team, then turned to serving the organization

8. Finding Champions and Building Culture

• Identifies passionate change agents and empowers them with real support
• Argues culture, not tools, is the true differentiator for an organization
• Credits Inova's CEO for making culture and psychological safety a priority

9. Frontline Adoption and Designing for the Right Thing

• Comes with receipts: Inova's EHR was named second-best by its nurses
• Credits informatics partners as the liaisons between tech and clinical worlds
• Designs software to make it easy to do the right thing, not just add fields

10. Governing AI, Looking Ahead, and Where to Connect

• Says the industry must govern AI, manage hallucinations, and keep a human in the loop
• Sees telehealth and lighter administrative loads expanding access and speeding care
• Advises staying true to yourself and remembering healthcare is about people; connect with her on LinkedIn

Welcome to another episode of Impact Unfiltered, where we dive deep into honest conversations with leaders creating real change in healthcare and beyond. Host Philippe sits down with Victor Bycroft, a nurse of about 30 years and a longtime chief nursing officer and chief nurse executive in critical access and rural hospitals. Healthcare was never the plan: the Army offered him a medic role, and that carried him from EMT work into emergency and trauma nursing and on into leadership.

Together, they explore why a small rural hospital does not mean lesser care, why supporting the team has to be a leader's first priority, and what meaningful innovation looks like when electronic records and AI so often add work instead of removing it. Victor explains why change fails when staff are never told the why, and shares the culture practices that took his last hospital from a Band-Aid station reputation to the place patients and staff actively chose. Tune in for an honest look at rural healthcare leadership.

1. Introduction to Impact Unfiltered and Episode Overview

• Host Philippe welcomes guest Victor Bycroft
• Themes: rural healthcare, team support, innovation, and trust

2. Meet Victor Bycroft: From Army Medic to Nurse Executive

• Roughly 30 years as a nurse, with 20-plus years as a chief nursing officer and chief nurse executive
• Army medic and EMT first; emergency and trauma nursing was his first love
• 24 years in critical access hospitals; now advising and consulting between roles

3. Rural Healthcare: Smaller Does Not Mean Less

• The common misperception, even inside healthcare, is that a rural hospital means less
• Resources and volume are limited, but the work is still full-scope hospital care
• Rural clinicians cover every stage of care while big-system staff handle one piece

4. Setting Priorities: Support the Team First

• Supporting staff has to come before cost control, innovation, and outcomes
• Unsupported staff turn over, and turnover is expensive
• Innovation fails and outcomes suffer when staff do not believe in the plan

5. What Meaningful Innovation Actually Looks Like

• Innovation has to create efficiency and work for the staff using it
• Electronic medical records promised better lives but often added time at the desk
• Victor sees promise in AI but says it is aimed too heavily at providers, not nurses

6. Why Change Succeeds in Some Organizations and Stalls in Others

• Failure to implement change traces back to a failure of leadership
• Staff push back when change arrives with no explanation of the why
• With real buy-in, his last hospital finished 90 percent of its strategic plan in year one

7. Building a High-Trust Culture by Being Present

• Trust comes from sitting down in every department, not from routine rounding
• Listen to what people actually face, then fix something
• He helped wherever hands were needed, including maintenance, dietary, and housekeeping

8. Defining Impact and Changing Hospital Culture

• Impact means improving lives for staff, patients, and the surrounding community

• Simple practices: a 10/5 rule, eye contact, and a no-point policy that walks patients where they need to go
• In two years the hospital went from Band-Aid station to the place people chose

9. Advice for Emerging Leaders and the Lesson No Book Teaches

• Moving from a large system into rural healthcare is not a step down
• Expect the community to know your name and where you work
• Disciplinary action is the hardest leadership work; a leader serves the team, not one person

10. Hope for the Future and Where to Connect

• Despite the burnout headlines, Victor sees strong people coming up and worth mentoring
• Find him on LinkedIn under Victor Bycroft
• His top leadership book is Extreme Ownership by Jocko Willink and Leif Babin

Welcome to another episode of Impact Unfiltered, where host Philippe sits down with Dr. Lisa Birdsall Fort, emergency physician and Associate Chief Medical Information Officer (CMIO) at Ochsner Health. Dr. Fort shares her journey into clinical informatics and explains how she bridges clinical care, technology, and administration to improve patient outcomes.

The conversation explores Ochsner's virtual emergency department, the growing role of AI in healthcare, and innovations such as ambient listening, smart rooms, wearables, and agentic technology. Dr. Fort also discusses the future of remote care, particularly for rural and aging communities, and shares leadership lessons on adaptability, lifelong learning, and embracing innovation. Whether you're in healthcare or simply curious about its future, this episode offers valuable insights you won't want to miss.

1. Introduction to Impact Unfiltered and Episode Overview

• Introduction of guest: Dr. Lisa Birdsall Fort of Ochsner Health

• Setting the themes: clinical informatics, artificial intelligence, and virtual care transformation

2. Meet Dr. Lisa Birdsall Fort: Roles and Day-to-Day

• Emergency physician who still practices clinically, calling it “the best day of my week”

• Associate CMIO over inpatient care at Ochsner Health, spanning EDs, medical-surgical areas, ICUs, and procedural areas

• Medical director and leader over Ochsner’s virtual care center, providing centralized monitoring across 40-plus hospitals

3. What Is a CMIO?

• Chief Medical Information Officer, a relatively new title emerging over the past decade to decade and a half

• One of four associate CMIOs, each covering a domain such as inpatient, digital medicine, pediatrics, or ambulatory care

4. The Path from Provider to Technology Leader

• Started in operations as an ED medical director around 2011–2012

• Tasked with bringing electronic health records into the emergency department during the “meaningful use” era

• Joined Ochsner in 2017 and moved into quality work on sepsis, heart attack, and stroke care

5. Finding Her “Why”: Hurricane Katrina

• A third-year medical student who evacuated to Baton Rouge during Hurricane Katrina

• Volunteered at the Pete Maravich Assembly Center at LSU, caring for evacuees arriving from New Orleans

• Inspired by an emergency physician’s breadth of skill: “that’s what I wanna be”

6. Defining Impact: “Clin-gineering”

• The humanity of emergency medicine lies in being present with patients during acute injury or illness

• “Clin-gineering” pairs bedside insight with an understanding of the system needed to support it

7. Technology in Practice: The Virtual Emergency Department

• Stood up in roughly five weeks to help patients who don’t truly need the ED find the right care

• Navigates patients coming from nurse-on-call, urgent care, primary care, and specialty clinics

8. Staying Aligned with Community Need

• Observe the environment and talk to the people doing the work, not just the leader voice

• Consolidate, centralize, and standardize resources through the virtual care center and virtual nursing program

9. Artificial Intelligence in Healthcare: Augmentation, Not Replacement

• AI is not new to healthcare, but tools like ChatGPT opened an entirely new toolkit

• Ambient listening captures the conversation so clinicians focus on the patient, not the screen

• Smart rooms, wearables, and patches help monitor for fall risk, pressure injuries, and more

10. The Future of Healthcare: Remote Care and Agentic Technology

• Strategy horizons are shrinking, making it hard to project even seven months, let alone seven years

• Delivering care beyond “the four walls of the hospital,” including in patients’ homes

• “Faith or fear”: partnering with trusted digital companions to free people for the most complex work

11. Legacy, Leadership, and What’s Next

• Advice to her younger self: stay flexible and pivot when opportunities cross your path

• “Never give up on the next amazing thing”

In this episode of Impact Unfiltered, host Stuart sits down at the Self-Governance Conference with Sherylene Yazzie, Executive Director of the Navajo Department of Health. A companion to the conversation with Navajo Nation President Buu Nygren, this dialogue centers on Yazzie’s guiding phrase: “Navajo healing Navajo.”

She explains why sovereignty and healing are the same project, shares outcomes from the YHC detox facility in Phoenix — where more than 200 Navajo people have entered care — and lays out a vision for preventive health rooted in farming, agriculture, medicinal plants, running, and fasting. With strategies for reaching the next generation on the platforms they use, and a closing reflection on the traditional Navajo morning practice of asking the sun to burn away negativity, this episode is a master class in tradition-rooted leadership.

1. Background and Role

• Yazzie has served over 20 years in public service. As Executive Director, she leads health strategy for the Navajo Nation, spanning 27,000 square miles and nearly half a million members.

2. Navajo Healing Navajo

• Healing begins with individuals taking ownership. Decades of programming led people to believe solutions only come from hospitals, but Yazzie calls for a return to traditional and communal ways.

• “Our people have been programmed to think our solutions are at the hospital — and forgotten our medicinal ways, our traditional ways, our communal ways.”

3. Self-Governance and Healing

• Self-governance empowers sovereignty; Navajo healing Navajo empowers identity. The scale of the Nation demands monumental change.

4. Phoenix Detox Facility

• The YHC facility exists because of self-governance. Over 200 Navajo people have been healed. The goal is not just recovery but creating productive citizens whose example ripples to younger generations.

5. Preventive Health

• Yazzie’s priority is preventive health: medicinal communities, farming, and traditional practices. She emphasizes reprogramming how people think and behave, returning to pre-contact self-reliance.

6. Why She Does This Work

• Driven by passion for elders, children, and all relatives, Yazzie says:

• “I make a difference in someone’s life, even if it’s just one person — that means so much to me.”

7. Expanding Behavioral Health

• The Nation has five agencies with facilities, but none accredited for detox. Yazzie’s plan is to elevate standards across all five, mirroring the YHC model closer to home.

8. Tradition as Preventive Health

• Healing through farming, agriculture, medicinal plants, running, and fasting. The Navajo Nation is a food desert; water and infrastructure are catalysts for change.

9. Reaching the Next Generation

• Youth live on phones and social media. Yazzie sees opportunity in podcasts, radio-style repetition, and cultural content. Language gaps are real — translating Navajo into English loses meaning.

• “How do we reach the younger generation who don’t understand our Navajo language?”

10. Empower Yourself First

• Her message: you can do anything you want, but empowerment begins with yourself.

11. The Sun as Medicine

• A traditional morning practice: bless yourself with the sun, asking it to burn away negativity.

• “Ask the sun. It has that much power. It will magically burn all of that negativity from you.”

12. Closing Remarks and Gratitude

• The episode closes with recognition of Sherylene Yazzie’s leadership, appreciation for her integration of tradition and health, and encouragement to continue scaling the YHC model across the Nation.

In this episode of Impact Unfiltered, host Stuart sits down at the Self-Governance Conference with Dr. Buu Nygren, President of the Navajo Nation, joined by Sherylene Yazzie, Director of Health. Together they explore the realities of running healthcare across 27,000 square miles for more than 200,000 residents — a hybrid landscape of 638 self-governance corporations and IHS-run hospitals.

Nygren shares his personal vision: he wants Navajo people to live long, healthy lives again, the way his great-grandmother lived to 109. He details how the Nation responded to a 2023 fraud crisis by purchasing its own three-story residential treatment facility in Phoenix, reflects on advanced appropriations, transportation infrastructure, and the Gila River model he hopes to scale tenfold. With candid insights into behavioral health recovery and sovereignty in action, this episode is a guide to what it would take to “shock the system” through full tribal self-governance.

1. Background and Role

• Nygren leads healthcare strategy for the Navajo Nation, joined by Health Director Sherylene Yazzie. Together they oversee services for 200,000+ residents across 17.5 million acres.

2. Federal Partnerships and Advanced Appropriations

• Strong ties with HHS Secretary Kennedy ensure reliable funding. Advocacy for advanced appropriations keeps facilities open even during budget uncertainty. The Navajo system blends corporations like Utah Navajo Health System, Sage Memorial, and Tuba City Healthcare with IHS facilities such as Chinle, Shiprock, Kayenta, and Gallup.

• “The relationships we’ve developed with Secretary Kennedy and his advocacy to make sure we continue to have advanced appropriations…”

3. The Scale Problem

• Covering 27,000 square miles, ambulance response is slowed by poor roads. Nygren met with DOT officials about washboard roads and potholes that delay emergency care. Healthcare must be thought of holistically alongside transportation.

4. The Vision: Long, Healthy Lives Again

• Centenarians were once common. Today, diabetes and hypertension cut lives short. Nygren’s goal is holistic wellness — traditional prayers, culture, and faith alongside modern care.

• “I want Navajo people to live long healthy lives again.”

5. Confronting Addiction

• Alcoholism and drug abuse remain the biggest behavioral health challenges. In 2023, fraudulent Phoenix “treatment” operations exploited Navajo people, warehousing them in tents and supplying alcohol. Arizona AG Kris Mayes prosecuted many of those firms.

• “Trying to make sure these people know that their lives are valuable.”

6. The Phoenix Residential Treatment Facility

• The Nation purchased a 30,000-square-foot facility downtown. About 200 people have entered care; 50 have graduated. Managed by Axiom, it impressed AG Mayes on her tour. Next steps include detox and transitional housing, with long-term plans to bring care home to Navajo.

7. Scaling Self-Governance: Learning from Gila River

• Gila River is the model for true self-governance. Nygren’s challenge is scaling that model 10–20x for Navajo. Sovereignty means running programs directly and capturing federal dollars. Tribally built facilities should be funded through 105(l) leases.

• “If we did what Gila River or some of the other nations have done, I think we would shock the system.”

8. Closing Remarks and Gratitude

• The episode closes with recognition of President Nygren and his leadership team, appreciation for their commitment to bringing funding and control back to tribes, and encouragement for the Navajo Nation’s continued self-governance journey.

In this episode of Impact Unfiltered, host Stewart sits down at the Self-Governance Conference with Geoff Strommer, an Indian law attorney with 35 years representing tribes, tribal governments, and tribal organizations. His work spans legislation, litigation, and negotiation, with fingerprints on nearly every major stage of the self-governance arc.

Geoff explains what it takes — agency by agency, statute by statute, dollar by dollar — to move authority from the federal government to tribal governments. He details how Alaska’s 27 co-signers built the strongest model of tribal cohesion in the country, why 105(l) leases are a once-in-a-generation game changer for tribal infrastructure, and how a recent New York district court win could expand self-governance into water and sewer treatment facilities. With stories of tribes like Jamestown S’Klallam filling rural healthcare voids the private market can’t sustain, this episode is a working tour of how policy becomes lived reality.

1. Background and Role

• Geoff has spent 35 years representing tribes on self-governance, shaping legislation, litigation, and negotiation.

2. Why It’s a Fight Inch by Inch

• The original Indian Self-Determination Act faced resistance from IHS and BIA. Every step required litigation and amendments to force compliance.

3. The Eight-Generation View

• Tribal leaders plan far ahead. Long shots from decades ago have become today’s reality, proving persistence pays off.

4. Alignment Among Tribes

• Early friction gave way to cohesion. Since the late 1980s, tribes have worked together despite differences.
• “It’s working together that has made it work.”

5. The Alaska Model

• In 1992, Alaska tribes asked for one demonstration slot instead of competing. Today, 27 co-signers negotiate together, covering the entire state’s IHS system.

6. The National Picture

• Cohesion has strengthened. Tension between self-governance and Title I contracting tribes has narrowed. About 65–70% of tribes participate in some form.

7. The Two Biggest Wins

• 105(l) leases grew from $400K in 2016 to nearly $900M today. Contract support costs, after decades of litigation, are now fully funded. Together, they transformed tribal finances and facilities.

8. The Untapped 105(l) Opportunity

• Only 25–30% of tribes use 105(l). A recent court win could expand leases to water and sewer treatment — a breakthrough for infrastructure.

9. The Reality of Rural Infrastructure

• Some communities still lack water and sewage systems. Residents carry waste in buckets and melt snow for drinking water — in the U.S., in 2026.

10. Cutting Red Tape

• Self-governance aimed to eliminate meaningless reporting. Simplification remains a priority.

11. What’s Next

• Move contract support costs and 105(l) funds to mandatory appropriations. Expand self-governance into Fish and Wildlife, National Parks, and other agencies. Jamestown S’Klallam already manages the Dungeness National Wildlife Refuge.
• “They are more culturally connected to those lands than anybody else in this country, and they’re better stewards of them.”

12. What He Wants Everyone to Know

• Self-governance works. The more authority transferred, the better tribes perform.
• “Tribes are operating some of the largest, most sophisticated public health systems. Because they are truly the last public health system in this country.”

13. Tribes as Rural Healthcare Anchors

• Rural healthcare is collapsing. Tribes step in as anchors. Jamestown S’Klallam built a clinic serving four counties, cutting travel from two hours to 15 minutes.

14. Closing Remarks and Gratitude

• The episode closes with recognition of Geoff Strommer’s 35 years of work, appreciation for the legal infrastructure he helped build, and encouragement for tribes to keep fighting for every square inch.