Rural Tribal Health
The 574 federally recognized American Indian and Alaska Native tribes are sovereign entities that share a unique government-to-government relationship with the U.S. government. This relationship, established in 1787, has developed through a combination of treaties, legislation, court decisions, and Executive Orders. Treaties served as contracts between federal and tribal governments in identifying the cession of lands in return for payment and services from the federal government. As a result, the federal government is obligated to provide healthcare to American Indians and Alaska Natives (AI/ANs). A system of Indian reservations was created in 1851 as a result of the Indian Appropriations Act. Today, Indian reservations still exist across the country, and are generally located in rural areas.
The 2010 Census identifies 5.2 million people in the United States as AI/AN. According to First Nations Development Institute, 54% of the AI/AN population live in rural areas and 68% live on or near their tribal homelands. Health disparities exist in American Indian populations, and the conditions in the poorest reservations often approach those of developing nations. According to the publication Indian Health Disparities, AI/ANs have long experienced poorer health status than other Americans. This same publication reports that AI/ANs born today have a life expectancy that is 5.5 years less than the national average for all races (73.0 years versus 78.5, 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/ANs.
Frequently Asked Questions
- What services does the Indian Health Service (IHS) provide?
- What is the Tribal Self-Governance Program, and what are the eligibility requirements and funding opportunities associated with the program?
- Is access to Indian Health Service (IHS) resources considered health insurance?
- Besides the Indian Health Service, what federal agencies support AI/AN healthcare and services initiatives?
- To what extent is a lack of healthcare workforce a barrier for meeting the needs of rural AI/AN populations?
- Where can I find information on working as a healthcare provider in a tribal community, as well as loan repayment programs?
- What health disparities exist for American Indian and Alaska Native populations?
- 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?
- What are the social determinants of health responsible for the avoidable differences in health status that affect tribal communities?
- Are there human services programs available to address the social determinants of health within the AI/AN population?
- What is tribal participatory research and how can it help ensure that health research contributes to the health of tribal members?
- What is a community health representative (CHR) and how can they assist in providing healthcare to AI/AN populations?
What services does the Indian Health Service (IHS) provide?
The Indian Health Service (IHS) serves as the principal federal healthcare provider and health advocate for American Indian and/or Alaska Native (AI/AN) people, including descendants, who belong to the Indian community served by the local IHS. The IHS provides a comprehensive health service delivery system for approximately 2.2 million AI/ANs who belong to 574 federally recognized tribes in 37 states.
The IHS maintains healthcare services directly at IHS facilities. In addition, the Indian Self-Determination and Education Assistance Act, enacted in 1975, authorized the Secretary of the Department of Health and Human Services (HHS) to enter into contracts, and make grants directly to, federally recognized Indian tribes to assume responsibility and administration of healthcare programs, services, functions, or activities that HHS would otherwise provide. 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.
In instances when an IHS or tribal facility is not able 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. 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.
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
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:
- 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
- Submit a tribal resolution or other tribal official action for participation in the TSGP
- Show evidence of financial stability and management capacity for prior 3 years (for Title V Self-Governance Compacting only)
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. According to IHS:
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 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. A number of other programs housed within the federal government, particularly the Department of Health and Human Services, support AI/ANs and have programs that benefit tribal healthcare services.
- CDC's Office of Minority Health & Health Equity (OMHHE) – Supports tribal public health initiatives
- CMS Division of Tribal Affairs – Works with AI/AN communities enabling access to culturally appropriate healthcare to CMS beneficiaries
- Federal Office of Rural Health Policy (FORHP) – Funds community-based programs that serve rural areas, including reservations and other tribal lands
- U.S. Department of Health and Human Services Office of Minority Health (OMH) – Works to improve the health of minority populations, including American Indians and Alaska Natives
- National Institute of Health, National Institute on Minority Health and Health Disparities (NIMHD) – Supports health disparities research, including work on disparities in American Indian and Alaska Native populations
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 Services (IHS) and tribal facilities. According to Testimony of the National Indian Health Board Oversight Hearing on Indian Country Priorities for the 114th Congress, recruitment and retention of healthcare professionals at these facilities continues to prove challenging due to:
- Remote and rural locations
- Lower pay
- Lengthy hiring processes
- Limited equipment
According to this same testimony, there is approximately 46% turnover for IHS physicians each year, creating difficulties in developing trusting relationships between patients and providers.
In fact, health workforce shortages are persistent enough that the Health Resources and Services Administration automatically designates groups of federally recognized Native American tribes as Health Professional Shortage Area population groups. 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/ANs 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?
The American Indian and Alaska Native (AI/AN) people experience significant differences in health status compared to Americans as a whole. An October 2019 IHS fact sheet, Indian Health Disparities, provides death rates of AI/ANs by cause in relation to the entire U.S. population:
|Cause of Death||Ratio: AI/AN to U.S. All Races|
|Chronic liver disease and cirrhosis||4.6|
|Unintentional injuries, including motor vehicle accidents||2.5|
|Influenza and pneumonia||1.8|
|Chronic lower respiratory diseases||1.1|
|Essential hypertension diseases||1.1|
|Source: Indian Health Disparities, October 2019|
Health disparities for AI/ANs 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.
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 Information Hub's Rural Health Models and Innovations features examples of programs and interventions that have shown to be successful in addressing specific health disparities responsible for the poor health status of rural American Indians and Alaska Natives. Some examples include:
- Mobile Women's Health Unit – A collaboration between the Indian Health Service (IHS) and Great Plains Area Indian Health Service to develop a mobile cancer screening unit - the Mobile Women's Health Unit. This unit traveled to remote American Indian reservations in Iowa, Nebraska, North Dakota and South Dakota to screen women for breast cancer. Services included free mammograms, rapid off-site digital radiological interpretation, and referrals to local, tribal, and regional healthcare facilities.
- 4P's Plus Pregnancy Support Project – A pregnancy support program for American Indian women in northern California who are pregnant and at risk for substance abuse. This program utilizes the 4P's Plus Screen – an evidence-based practice to evaluate and identify substance use risks. In addition to the screening services, this project also offers mental health counseling, substance use prevention counseling, prenatal care, domestic violence services, and classes in women's cultural wellness, parenting, and job skills.
More 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 Indians, Alaska Natives, and Native Hawaiians.
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:
- Availability of stable employment
- Educational attainment and literacy
- Safe housing
- Access to healthy food
- Quality healthcare
- Community infrastructure, such as safe roads and drinking water
- Environmental health
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/ANs. 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.
- 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, as discussed in Native Strong, 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/ANs 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 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/ANs, in addition to other populations. To read more on these topics, see the following topic guides:
- Social Determinants of Health for Rural People
- Human Services to Support Rural Health
- Rural Hunger and Access to Healthy Food
- Healthcare Access in Rural Communities
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 Assessment, and Program Evaluation.
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 Reviewed: 11/28/2018