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Rural Health Information Hub
Rural Health Information Hub

Rural Tribal Health

The 575 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, either directly through Indian Health Service facilities, through tribally owned and operated services, or some combination of the two.

As sovereign nations, 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 2025 report, AI/AN people have long experienced poorer health status than other Americans. In 2023, the average life expectancy at birth for AI/AN people was 8.3 years less than the national average for all races (70.1 years versus 78.4, respectively).

Resources in this guide provide specific information on tribal health, including health status, 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. According to the IHS, it provides a comprehensive health service delivery system for approximately 2.8 million AI/AN people from 575 federally recognized tribes.

The IHS maintains health services directly at IHS-owned/operated facilities and through compacts or contracts 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 93-638. The Indian Health Service: 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
  • 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 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 under Title V, 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 the prior 3 years

Contingent on the availability of federal funding, Title V of the ISDEAA authorizes the OTSG to offer Planning and Negotiation Cooperative Agreements (limited competition) 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 by the Indian Health Service in For Patients: Frequently Asked Questions:

“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 American Indian and Alaska Native (AI/AN) 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 support AI/AN people and have programs that benefit tribal healthcare services.

  • Office of Minority Health, U.S. Department of Health and Human Services – Works to improve the health of minority populations, including American Indians and Alaska Natives
  • Office of Tribal Affairs and Strategic Alliances, Centers for Disease Control and Prevention (CDC) – Supports the federal-tribal government-to-government relationship and aims to improve the health of tribal communities
  • Division of Tribal Affairs, Centers for Medicare & Medicaid Services (CMS) – Works with AI/AN communities through the Tribal Technical Advisory Group to address Medicare and Medicaid policies and procedures that impact tribes and ensures access to culturally appropriate healthcare for CMS beneficiaries. CMS provides technical assistance through CMS Native American Contacts representing each IHS region
  • Federal Office of Rural Health Policy, Health Resources and Services Administration (HRSA) – Funds community-based programs that serve rural areas, including reservations and other tribal lands
  • Office of Tribal Affairs (OTA), Health Resources and Services Administration (HRSA) – Works with tribal governments and organizations to improve access to health services for American Indians and Alaska Natives by connecting tribal entities to HRSA programs
  • National Institute on Minority Health and Health Disparities, National Institutes of Health (NIH) – Supports health disparities research, including work related to American Indian and Alaska Native populations
  • Tribal Health Research Office, National Institutes of Health (NIH) – Works to build partnerships with tribal communities and enhance research capacity
  • Administration for Native Americans, Administration for Children & Families (ACF) – Supports tribal communities through financial assistance, data sharing, and working for improved policies throughout the federal government
  • Office for American Indian, Alaskan Native, and Native Hawaiian Programs, Administration for Community Living (ACL) – Administers Title VI of the Older Americans Act, including funding, provision of nutrition, supportive services, and caregiver support services for tribal communities
  • Community Facilities Programs, U.S. Department of Agriculture (USDA) – Offers direct loans, loan guarantees, and grants for federally recognized American Indian tribes to provide essential healthcare, education, public safety, and other civic services
  • Tribal Transit Program, U.S. Department of Transportation (DOT) – Provides funds for planning, public transportation capital projects, operating costs, job access reverse commute projects, and the acquisition of public transportation service to tribes located in rural areas

To what extent is a lack of healthcare workforce a barrier to 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 have proven 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 create 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.

A 2023 Rural Monitor article discusses the way the Oklahoma State University College of Osteopathic Medicine at the Cherokee Nation, the first tribally affiliated medical school in the U.S., is working to build an AI/AN physician workforce to tackle shortages on the Cherokee Nation and in other tribal communities.

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 $50,000 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 type" 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 conditions impact 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 June 2025 CDC report, National Vital Statistics Reports - Deaths: Final Data for 2022, provides death rates of AI/AN people by cause in relation to the entire U.S. population:

Comparison of 2022 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 64.7 13.8
Diabetes mellitus 47.7 24.1
Unintentional injuries 131.2 64.0
Homicide 16.5 7.7
Drug-induced 69.5 33.8
Influenza and pneumonia 15.8 11.3
COVID-19 65.9 44.5
Suicide 27.1 14.2
Septicemia 12.5 10.1
Kidney disease (nephritis, nephrotic syndrome and nephrosis) 17.1 13.8
Chronic lower respiratory diseases 29.2 34.3
Essential hypertension and hypertensive renal disease 9.0 10.3
Major cardiovascular disease 191.9 223.0
Cerebrovascular diseases 30.3 39.5
Malignant neoplasms 118.2 142.3
Alzheimer disease 15.1 28.9
Parkinson disease 4.8 9.5
Pregnancy, childbirth and the puerperium (females) 1.1 0.4
All causes 947.9 798.8
Source: National Vital Statistics Reports - Deaths: Final Data for 2022, June 2025

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 concerns 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.

A 2022 Rural Monitor article discusses how clinics operated by the Radiation Exposure Screening and Education Program (RESEP) are working to expand access to care and compensation for people exposed to radiation from uranium mining on the Navajo Nation.

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

Environmental conditions within homes, such as the presence of lead or other hazards, can also affect health. The Healthy Homes Grant Opportunities within the U.S. Department of Housing and Urban Development aim to increase family and community wellness by providing funding for lead remediation, radon testing and mitigation, and lead-based paint control, among other housing safety issues.

Where can I find examples of best practices and/or model programs that address the specific health issues of AI/AN populations?

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

Additional examples of best practices and model programs for addressing population health can be found by searching 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: Tribal Communities.

What are the upstream drivers of health that impact health status in tribal communities?

Upstream drivers 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 upstream drivers of health are clearly evident and play a significant role in the health issues they experience. Upstream drivers affecting many tribal communities 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
  • Access to technology

In addition, there are upstream drivers of health unique to the life and work of AI/AN populations living in tribal communities. These include:

  • Self-determination (autonomy) – Tribal communities tend to be healthier and better able to address community health issues when members have greater agency in the decision-making process.
  • 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 to and utilization of their traditional land – The relationship of tribal communities 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.
  • Culture and cultural continuity – Programs and services that are respectful of the culture and beliefs of the people they serve contribute to better health outcomes.

See Social Determinants of Health for Rural People for additional rural-focused information on the upstream drivers of health.

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

American Indians and Alaska Natives (AI/ANs) face health challenges due to a number of upstream drivers 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 these concerns. 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 that 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 American Indians and Alaska Natives (AI/AN) as health paraprofessionals and to use such paraprofessionals in the provision of healthcare, health promotion, and disease prevention services to tribal 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 of the 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: 10/30/2026