Health System Transformation Under Tribal Self-Governance

Since the passage of the Indian Self-Determination and Education Assistance Act (ISDEAA) in 1975, Tribes have had the option to assume operation of health programs that the Indian Health Service (IHS) would otherwise deliver directly, either through self-determination contracts under Title I or, following the Tribal Self-Governance Amendments of 2000, or through self-governance compacts under Title V, which afford broader authority to redesign services and reallocate funds. Currently, Tribes and Tribal organizations administer approximately 65% of the IHS budget through Title I contracts or Title V compacts combined, with the remaining share supporting IHS-operated health service delivery. Documenting how Tribes have used self-governance to expand services and tailor care can support Tribal-to-Tribal learning and inform IHS partnership, federal policy, and strategies to strengthen rural health care delivery. This project will address the following questions:

1. Which Tribes and Tribal organizations administer health programs through Title I contracts, Title V compacts, or combinations of these authorities; where are they located; and what pathways have they used to assume responsibility for IHS-funded health programs?
2. How do Tribal health leaders describe changes in access to care and the mix of health services associated with the adoption of self-governance?
3. What models, practices, and innovations do Tribal health leaders identify as expanding services, improving access, or strengthening quality of care, and what organizational, financial, or policy conditions do they perceive as supporting their implementation?