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Rural Health Information Hub
Rural Health Information Hub

Rural Tribal Health

The 574 federally recognized American Indian and Alaska Native (AI/AN) communities are sovereign nations that share a unique government-to-government relationship with the U.S. government. Due to the trust responsibility established by the U.S. Constitution, treaties, numerous Public Laws, and Presidential Executive Orders, the federal government is obligated to provide healthcare to American Indians and Alaska Natives (AI/ANs), either directly through Indian Health Service facilities, through tribally owned and operated services, or some combination of the two.

As sovereign nations, American Indian and Alaska Native tribes have authority to oversee and provide for the overall health and well-being of their members. Tribes are involved in public health activities and regulations, and deliver public health services on their own, in collaboration with other tribes and state governments, or through state/county health departments. These services may be funded directly by the tribes or through grants and other contracts.

According to a 2023 report, AI/AN people have long experienced poorer health status than other Americans with an average life expectancy in 2020 that was 9.9 years less than the national average for all races (67.1 years versus 77.0, respectively).

Resources in this guide provide specific information on tribal health, including disparities, healthcare, services, wellness, and workforce needs, as well as funding sources and tools that can be used to help improve healthcare for AI/AN people.

Frequently Asked Questions

What services does the Indian Health Service (IHS) provide?

The Indian Health Service (IHS) serves as the principal federal health service provider and advocate for American Indian and/or Alaska Native (AI/AN) people, including descendants, who belong to the American Indian community served by the local IHS. According to its 2024 fact sheet, the IHS provides a comprehensive health service delivery system for approximately 2.8 million AI/AN people from 574 federally recognized tribes in 37 states.

The IHS maintains health services directly at IHS owned/operated facilities and in compact or contract with tribes. The Indian Self-Determination and Education Assistance Act of 1975 (ISDEAA) authorized the Secretary of the Department of Health and Human Services (HHS) to enter into contracts and compacts with federally recognized tribes where the tribes may assume all or part of the federal responsibility and administration of healthcare programs, services, functions, or activities that HHS would otherwise provide. These are often referred to as "638" contracts/compacts in reference to the ISDEAA being public law PL93-638. The IHS A Quick Look brief provides an overview of the relationship between IHS and American Indian tribes and Alaska Native corporations. It also provides information and statistics about the IHS healthcare delivery system.

When an IHS or tribal facility is unable to offer a specific service, the service may be provided through the Purchased/Referred Care (PRC) program (formerly called Contract Health), as medical necessity dictates and funding allows. This is a priority-based system that grants approval based on the urgency of the patient's condition. First priority is given to patients who have life-threatening conditions. Through the PRC program, healthcare services can be purchased from non-IHS providers by IHS and tribal facilities in special situations where:

  • No IHS or tribal direct care facility exists;
  • Existing direct care component is incapable of providing required emergency and/or specialty care;
  • Utilization in the direct care component exceeds existing staffing; and
  • Supplementation of alternate resources such as Medicare, Medicaid, or private insurance is required to provide comprehensive healthcare to eligible AI/AN people.

For more information about the IHS mission and structure, see the IHS Agency Overview, Fact Sheets, and the Indian Health Manual.

What is the Tribal Self-Governance Program, and what are the eligibility requirements and funding opportunities associated with the program?

The Tribal Self-Governance Program (TSGP) is authorized by Title V of the Indian Self-Determination and Education Assistance Act (ISDEAA).

This program authorizes federally recognized tribes to negotiate a compact and funding agreement with IHS to transfer IHS programs, services, functions, and activities (or portions of them) with associated funds to be administered and operated by the tribe.

As tribes develop programs and solutions to address the needs of their members, they may choose one or a combination of the following options:

  • Continue to receive healthcare services directly from the IHS
  • Exercise the authority of the ISDEAA Title I Self-Determination Contracting or Title V Self-Governance Compacting, to take control over the healthcare programs the IHS would normally provide
  • Support the development of their own programs or the augmentation of ISDEAA programs

See Differences Between Title I Contracting and Title V Compacting Under the Indian Self-Determination Education Assistance Act (ISDEAA) for additional information.

The Office of Tribal Self-Governance (OTSG) is the primary liaison and advocate for tribes participating in the TSGP, and provides information and technical assistance to Self-Governance Tribes.

For tribes to be eligible for the TSGP, they must meet statutory requirements of the ISDEAA, including:

  1. Complete a planning phase that includes legal and budgetary research and an internal tribal government and organizational plan for the healthcare programs to be administered
  2. Submit a tribal resolution or other tribal official action for participation in the TSGP
  3. Show evidence of financial stability and management capacity for the prior year for Contracting and the prior 3 years for Title V Self-Governance Compacting

Contingent on the availability of federal funding, Title V of the ISDEAA authorizes the OTSG to offer Planning and Negotiation Cooperative Agreements (limited competitive) to assist tribes with planning and negotiation activities related to participation in the IHS TSGP. See OTSG Eligibility and Funding for additional information.

Is access to Indian Health Service (IHS) resources considered health insurance?

No. As stated in P.L. 94-437: Indian Health Care Improvement Act:

“The Indian Health Service is funded each year through appropriations by the U.S. Congress. The Indian Health Service is not an entitlement program, such as Medicare or Medicaid. The Indian Health Service is not an insurance program. The Indian Health Service is not an established benefits package.”

Besides the Indian Health Service, what federal agencies support AI/AN healthcare and services initiatives?

The Indian Health Care Improvement Act (IHCIA) sets forth the national policy on Indian health. This and other legislation identify specific authority, roles, and responsibility for AI/AN health and human services across the entire federal government in addition to vesting certain authorities in tribes as providers and programs and establishing specific provisions for IHS eligible patients. IHCIA ensures tribal rights to access, bill and be reimbursed by federal programs such as Medicare and Medicaid. A number of other programs housed within the federal government, particularly the Department of Health and Human Services, support AI/AN people and have programs that benefit tribal healthcare services.

To what extent is a lack of healthcare workforce a barrier for meeting the needs of rural AI/AN populations?

Health workforce shortages are a significant barrier to achieving desired health outcomes at Indian Health Service (IHS) and tribal facilities. According to a 2018 GAO report, recruitment and retention of healthcare professionals at these facilities continues to prove challenging due to:

  • Remote and rural locations
  • Lower pay
  • Lengthy hiring processes
  • Insufficient housing for providers

According to this same report, the overall vacancy rate for providers in IHS facilities was 25% in 2017. Turnover for IHS providers and the use of temporary staff creates difficulties in developing trusting relationships between patients and providers.

In fact, health workforce shortages are persistent enough that the Health Resources and Services Administration provides automatic Health Professional Shortage Area designations for Indian Health facilities, IHS and tribal hospitals, and dual-funded Community Health Centers and tribal clinics that provide medical services to federally recognized tribes and Alaska Natives. That designation allows participation in some federal programs, such as the National Health Service Corps.

Where can I find information on working as a healthcare provider in a tribal community, as well as loan repayment programs?

The Indian Health Service (IHS) provides a wealth of information about IHS, tribal and urban Indian organization facilities on its Find Health Care website. In addition, opportunities to work as a provider in a tribal community can be found on the Career Opportunities webpage. IHS helps match prospective clinicians with healthcare profession vacancies to improve the health status of AI/AN people across the country. For example, the Indian Health Service Loan Repayment Program provides student loan repayment in return for full-time clinical service in IHS programs. The program awards up to $40,000 in exchange for two years of service, so health professionals can pay off student debt while earning a competitive wage.

Information about loan repayment programs and scholarship opportunities focused on AI/AN populations can be found on the Funding & Opportunities section of this topic guide by selecting “Narrow by topic” to limit by type of program.

Many IHS and tribal health facilities are eligible as National Health Service Corps (NHSC) service sites. NHSC service sites may award scholarships and loan repayment to primary care providers in eligible disciplines. HRSA Loans & Scholarships describes this program and others, such as the HRSA Nurse Corps scholarship and loan repayment programs.

What health disparities exist for American Indian and Alaska Native populations?

American Indian and Alaska Native (AI/AN) people experience significant differences in health status compared to Americans as a whole. A September 2023 CDC report, National Vital Statistics Reports - Deaths: Final Data for 2020, provides death rates of AI/AN people by cause in relation to the entire U.S. population:

Comparison of 2020 AI/AN Age-Adjusted Death Rates to All Races per 100,000 Population
Cause of Death AI/AN Rate All Races Rate
Chronic liver disease and cirrhosis 60.5 13.3
Diabetes mellitus 52.1 24.8
Unintentional injuries 103.4 57.6
Homicide 14.4 7.8
Drug-induced 45.1 29.5
Influenza and pneumonia 18.5 13.0
COVID-19 175.9 85.0
Suicide 23.9 13.5
Septicemia 12.1 9.7
Kidney disease (nephritis, nephrotic syndrome and nephrosis) 14.7 12.7
Chronic lower respiratory diseases 30.6 36.4
Essential hypertension diseases and hypertensive renal disease 10.4 10.1
Major cardiovascular disease 198.2 223.0
Cerebrovascular diseases 34.0 38.8
Malignant neoplasms 122.1 144.1
Alzheimer's disease 19.1 32.4
Parkinson disease 5.1 9.9
Pregnancy, childbirth and the puerperium (females) 1.6 0.9
All causes 1036.2 835.4
Source: National Vital Statistics Reports - Deaths: Final Data for 2020, September 2023

Health disparities for AI/AN people extend beyond just mortality rates. The Centers for Disease Control and Prevention's Health of American Indian or Alaska Native Population page highlights data including leading causes of death, health status, smoking, infant deaths, and health insurance coverage.

How have environmental factors contributed to health disparities in tribal communities?

Many tribal lands across the Western U.S. are in close proximity to abandoned hard rock mines. According to a 2017 study, approximately 600,000 Native Americans live within 10 kilometers of an abandoned mine and 1 in 5 uranium mines are within 10 kilometers of a reservation. Proximity to abandoned mines can lead to contaminated drinking water and, according to the study above, living near uranium mines correlates with increased rates of kidney disease, hypertension, cardiovascular disease, neurocognitive disorders, various cancers, and developing multiple chronic diseases.

For more information on environmental health concerns for American Indian and Alaska Native communities, the NIH-funded Center for Native Environmental Health Equity Research conducts environmental health research and promotes culturally-informed practices to build community engagement in environmental health research.

There are also several resources for tribal communities looking to address environment health concerns:

Where can I find examples of best practices and/or model programs that address the specific health disparities responsible for the poorer health status of AI/AN populations?

The Rural Health Models and Innovations section features examples of programs and interventions that have shown to be successful in addressing specific health disparities affecting rural American Indians and Alaska Natives.

Additional examples of best practices and model programs for achieving health equity can be found by searching the Rural Health Models and Innovations for a specific health topic such as cancer, obesity, diabetes, tobacco use, and prenatal care and obstetrics.

For additional examples, see Other Case Studies & Collections of Program Examples: American Indian or Alaska Native.

What are the social determinants of health responsible for the avoidable differences in health status that affect tribal communities?

Social determinants of health are the social, economic, and environmental conditions that people experience throughout their lives that can impact their health. For AI/AN populations, particularly those living in rural tribal regions, the social determinants of health are clearly evident and play a significant role in the health disparities experienced by AI/AN populations. Social determinants affecting many AI/AN populations in rural areas include:

  • Poverty
  • Availability of stable employment
  • Educational attainment and literacy
  • Safe housing
  • Access to, and affordability of, healthy food
  • Quality healthcare
  • Community infrastructure, such as reliable transportation, safe roads, and clean drinking water
  • Environmental health
  • Equitable access to technology

In addition, there are social determinants of health unique to the life and work of AI/AN populations. Native Strong and other papers discuss these social determinants, and how they affect the health of AI/AN people. These determinants include:

  • Self-determination (autonomy) – Self-Determination and Indigenous Health: Is There a Connection? suggests that when people have, or perceive to have, greater control over their lives, they are healthier.
  • Federal recognition and tribal sovereignty – Tribes that lost their sovereign status through disestablishment during the Termination Era, specifically the passage of HCR-108 in 1953, and are no longer considered "federally recognized" lack access to federal aid and legal protections.
  • Access and utilization of their traditional land – Culture as a Social Determinant of Health recognizes the relationship of AI/AN populations to their land has a strong influence on their health, particularly when their traditional economies and forms of government are weakened, and their patterns of individual, family, and community life become unstable.
  • Historical trauma – According to American Indian Social Determinants of Health, historical trauma is the collective emotional wounding across generations that results from massive cataclysmic events – historically traumatic events (HTE). The trauma is held personally and transmitted over generations.
  • Race-based discrimination and social exclusion – Along with historical trauma, race-based social exclusion can lead to mistrust of non-Native physicians and other health professionals, and is associated with high rates of suicide, homicide, domestic violence, child abuse, accidental death, and alcoholism. Discrimination in America: Experiences and Views of Native Americans reports the findings of a survey focused on the personal experiences of AI/AN people in regards to racial discrimination. A significant number of respondents indicated they avoided seeing a doctor or seeking health treatment for themselves or a family member out of concern they would be discriminated against or treated poorly.
  • Culture and cultural continuity – Culture as a Social Determinant of Health emphasizes that the disregard for the cultural beliefs of AI/AN communities and nations regarding health and healing contributes to their ill health.

See Social Determinants of Health for Rural People for information about social determinants in the rural context.

Are there human services programs available to address the social determinants of health within the AI/AN population?

American Indian/Alaska Natives (AI/ANs) experience health inequities due to a number of social determinants of health such as inadequate access to healthcare, substandard housing, and a lack of food security. A variety of agencies at the federal level cooperate to address the inequities experienced by AI/AN people, in addition to other populations. To read more on these topics, see the following topic guides:

What is tribal participatory research and how can it help ensure that health research contributes to the health of tribal members?

The Agency for Healthcare Research and Quality (AHRQ) defines community-based participatory research (CBPR) as:

“an approach to health and environmental research meant to increase the value of studies for both researchers and the communities participating in a study.”

Tribal communities have an interest in CBPR, particularly tribal participatory research (TPR), as a method of ensuring culturally appropriate research which aims to distribute power and the benefits of the research equally between the tribe and the researcher. To read more on TPR, see Conducting Rural Health Research, Needs Assessments, and Program Evaluations.

What is a community health representative (CHR) and how can they assist in providing healthcare to AI/AN populations?

The Community Health Representative Program is authorized by the Indian Health Care Improvement Act, to provide for the training of Indians as health paraprofessionals and to use such paraprofessionals in the provision of healthcare, health promotion, and disease prevention services to Indian communities. A community health representative (CHR) is a trained, community-based healthcare worker who delivers health promotion and disease prevention services within their tribal communities. CHRs are often from the communities they serve, share cultural beliefs, and are effective at assisting and connecting the community to the range of tribal community-oriented primary healthcare services. CHR efforts have also helped tribal communities improve and maintain their health, reduce hospital readmissions, and lower mortality rates. Community Health Workers Get Trained to Reduce Oral Health Disparities describes a CHR training program addressing the oral health disparities of Navajo Nation. For additional information regarding CHR education, training, program management, resources, and funding see IHS Community Health Representative and Indian Health Manual Part 3, Chapter 16: Community Health Representatives.

Last Updated: 12/11/2024
Last Reviewed: 12/11/2024