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The IHS: A Blog Series, Part 4: Tribal Sovereignty in Healthcare Delivery 

As discussed in previous blogs, the IHS is responsible for providing care to AI/AN individuals. However, there are systems in place to allow for Tribal sovereignty when providing healthcare. Tribes can establish self-determination contracts with the federal government to be supported in providing healthcare services themselves. They can also compact with the government through The Indian Health Service (IHS) Tribal Self-Governance Program (TSGP), which allows Tribes to assume control over health systems with funding from the IHS. In recognition that Tribal authorities would have better insight into the needs of their communities, the TSGP allows decision-making to rest in the hands of community leadership while still maintaining a nation-to-nation partnership with the federal government. (1) Read more about the difference between contracting and compacting with the IHS here.  

Jonathan Nez, the Leader of the Navajo Nation, and other tribal leaders (Navajo Nation courtesy photo, Source

Each fiscal year the Office of Tribal Self-Governance awards Tribal Self-Governance Planning and Negotiation Cooperative Agreements to tribal organizations to help them take over responsibility of administering healthcare services. Planning Agreements support tribal organizational and planning initiatives for healthcare administration while Negotiation Agreements fund the costs of self-governance negotiations with federal entities. Learn more about these services here. (2)  

The foundation of these self-governance capabilities is in the Indian Self-Determination and Education Assistance Act (ISDEAA). The ISDEAA was enacted in 1975 (and amended thereafter) as crucial legislation as it authorized demonstrations for tribes to assume the management of the BIA and IHS programs in their communities, including hospitals and clinics. It importantly also allowed tribes to keep third-party revenue (public and private insurance), gave them access to federal grants, and provided additional funding for the management of these facilities and contracts.(3 and 4). 

The shortcomings of the IHS discussed in the previous post have encouraged many tribes to take advantage of this provision. However, this transfer of responsibility is expensive and accumulating capital to make it a reality can be difficult. The Cherokee Indian Hospital in North Carolina is self-governed, with 50% of funds coming from the IHS. Other funds are sourced from institutions like Medicaid and Casino revenue, which are not under IHS control. Construction of the hospital was deliberate in incorporating cultural history and creating a reduced stressed environment for patients. However, not all communities have other significant sources of revenue such as a casino (5).  

Cherokee Indian Hospital in North Carolina, KATJA RIDDERBUSCH/KAISER HEALTH NEWS 

The Alaska Native Tribal Health Consortium is another Tribal health organization that is considered one of the most successful tribal-run initiatives. It receives funds through Medicare and Medicaid billing, a partnership with the Department of Veteran Affairs, and through other federal grants. (6

The diversity in the culture, economy, health, and social aspects of tribes in the US indicates that their healthcare issues vary as well. Transferring more authority to tribal leadership can address the unique nature of these communities instead of approaching care through one system (the IHS) (7).  

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