Standing between the United States and the U.S. Health and Human Services flags, Mark Cruz wore a bright red tie and a tribal medallion. He raised his right hand in the air, placed the other on a copy of the Constitution and the Bible held by health secretary Robert F. Kennedy Jr., and swore his oath of office. With that, Cruz joined Kennedy’s team as a senior adviser to the secretary on American Indian health.
“It was very important to me to have a Native American in my direct inner circle, so that every decision we make at HHS takes into consideration the impacts and potential opportunities for Native Americans,” Kennedy said in a video taken at the June 18 ceremony.
Cruz, who is a member of the Klamath Tribes from Oregon, is the first person to hold this position. The job entails being a liaison between tribes and the HHS secretary, and working across different HHS agencies to provide a unified strategy on American Indian health, Cruz told STAT. The job is also being closely watched, as clinicians who work in American Indian health told STAT they were curious to see how Cruz’s tenure will play out.
Cruz has worked for several years in government at the federal and state levels. That includes working as chief of staff for Congressman Todd Rokita (R-Ind.), now Indiana’s attorney general, and time at the Department of the Interior on policy and economic development on Indian affairs during Trump’s first term.
In particular, Cruz said that he’s strongly in support of more tribes taking over health care services from IHS and running their own tribal health facilities, a process known as 638 contracting. He said he believed that was a core part of the administration’s policy on Indian health. He also said that he plans to focus on issues that have been central to Kennedy’s Make America Healthy Again initiative, including chronic disease and nutrition.
He also acknowledged that there are things he’s still learning about health and health care, and that there are multiple challenges facing the IHS. STAT spoke with Cruz about criticisms of the Trump administration’s approach to health, and his plans as a senior adviser on Indian health. This interview has been edited for length and clarity.
Clinicians at IHS told STAT about a new Trump administration policy called Departmental Efficiency Review or PAA-DER. They said it creates inefficiencies and is leading to delays and negative impacts on patient care. Is this something that you plan to address?
The secretary and I are committed to finding efficiencies to improve the delivery of health care services to tribes and tribal communities. The challenge, I’m observing, is IHS is the only operating division within the department that actually provides health care: hospitals, clinics, dental. [The NIH hospital also directly provides health care.] It presents a unique set of challenges. So, I definitely want to take a hard look at what governmental bureaucratic processes exist that other health care systems don’t have to face.
Because, look, the governmental system is very incompatible with operating hospitals. So, what are success stories, operating procedures, that we can integrate into IHS? Those are things we’ll take a hard look at and see what makes sense.
The Trump administration has been described as “moving fast and breaking things” in its changes to the federal government. Since IHS directly provides critical health services, do you think IHS should get exemptions from immediate changes to the federal government’s processes because of the risk of “breaking” a health care service?
In theory, that makes a whole lot of sense. But challenges didn’t start when President Trump took over. These have been longstanding, well-documented challenges, and have been the failure of leadership from Congress underfunding the health care system. It’s not just a Trump administration issue, and anyone who wants to paint that picture is not understanding the facts and history.
A piece of what I’ll do is identify solutions that try and address some of these longstanding matters. Without identifying specific recommendations, in general, I’m all for efficiencies and hearing out what career officials have to say, what recommendations they make, thinking through those, and making sure they align with the administration’s priorities. I have a guess that there are a lot of good practices from the 638s.
Oftentimes, they don’t have the same challenges. They do have procedures to modernize equipment and replacement programs. It just speaks to long-standing inefficient government practice.
Do you see supporting more tribes to take over managing their own health care facilities, known as 638s, as a way to improve health care in American Indian communities?
People have complained about IHS since 1955, and its predecessor under the Bureau of Indian Affairs — and years of reports showing it’s underfunded. Until there are additional conversations for additional funding mechanisms, that won’t change overnight.
What we’ve seen across the board, when tribes take over these services, programs, functions, or activities that the federal government should otherwise provide, tribes just do it better. We did this at Indian education, feeding programs, law enforcement, or health care at HHS. These offices are better able to be held accountable because they are living and working in their community. We talk about local control as a general policy of this administration. There’s nothing better than Indian self-determination in support of that. I’m very supportive of this.
I think that’s one of the things that I’ve seen and observed. I used to get dental health at IHS when I was a kid in Chiloquin, Oregon. It was done out of a double-wide trailer with two or three operating chairs. Now, we have a beautiful clinic. In my lifetime, I’ve seen massive improvement in quality and consistency and care. I know that has happened in other tribal areas. I try not to be in a deficit mindset all the time. There has been a lot of good.
IHS only provides tribally run facilities with a fraction of the dollars they need to operate. Many do rely on dollars from Medicaid reimbursements in order to run, and Medicaid is facing a major cut in the One Big Beautiful Bill Act. Does this mean you would support increasing funding that goes to the 638s?
My goal is to do what I can within the existing authorities and existing budget. We’re not able to provide any more than what Congress gives us in appropriations. We’re in this speculative stage. That bill just passed. I know tribes are asking a lot of questions. I’m looking forward to working with my colleagues at CMS to better understand the impacts. My understanding of the bill is that tribes are exempt from the work requirement [for Medicaid enrollees].
What about making reimbursements more straightforward for 638s? For example, allowing tribal facilities to get Medicaid reimbursements directly from CMS rather than through states?
That’s a policy discussion I want to have. How can we get there, what implementation would look like, having conversations with state leaders — those are all things that haven’t been done yet. I don’t have specifics for that, but it is a conversation worth having.
What other areas of Native health are priorities for you?
There are remaining challenges the secretary wants to focus on. That includes nutrition, access to healthy foods. A lot of tribal communities are in food deserts. I’ve seen it. I’ve lived it personally. We look forward as an administration to working with federal agency partners on how we fix that. We want to focus on chronic illnesses and the high rate of diabetes, heart disease, addiction, and mental health.
What does it mean to you to be in this position, as the first senior adviser to the secretary on Indian health?
Being in the room on budget conversations and saying, ‘How are we thinking about how this interacts with tribal communities?’ There’s been little experience in the room to flag those kinds of questions. It’s an honor to be asked to come on board. I’m very inspired by the leadership of Secretary Kennedy and his vision for making America healthy again.
The challenge the secretary has put on me is how we look at this system for the next 50 years. That’s a fun project to work for and one of the reasons why I wanted to come serve the secretary and the Trump administration for a second time.
STAT spoke with clinicians, tribal leaders, and Native community members who say Kennedy’s administration of HHS and IHS is making America unhealthier. They worry about changes they see to vaccine policy, preventive health, cuts to research, cuts to Medicaid, and more. What do you say to those individuals?
We can get into this tit for tat, and everyone has their own views. Look, I’m going to do the best I can while I have the time to do it here, under this political appointment. I’m going to engage. I’m not going to be shy about asking hard questions of the agency, and I’m going to provide the secretary with the best advice I possibly can.
