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Rural Tribal Health

All federally recognized tribes are sovereign entities that share a unique government-to-government relationship with the U.S. government. Through a combination of numerous treaties, court cases, and legislative decisions, the federal government is obligated to provide healthcare to American Indians and Alaska Natives (AI/ANs). Treaties also provided for Indian reservations, lands reserved for the tribes, which are generally located in rural areas.

In recent years, there has been a decrease in the number of AI/AN residents in rural areas, due to a significant outmigration to urban areas. According to the most recent data available from the U.S. Census Bureau (2010), 20.5% of the 5.2 million people who identify as American Indians/Alaska Natives live in rural areas.

Health disparities exist in Native American populations. The conditions in the poorest reservations often approach those of developing nations. According to 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 4.2 years less than the national average for all races (73.5 years to 77.7, respectively).

Resources in this guide provide specific information on tribal health disparities, as well as funding sources and tools that can be used to help improve healthcare for AI/ANs.

Frequently Asked Questions

How many federally-recognized tribes are there?

There are 573 federally recognized tribes in the United States according to a July 23, 2018 Federal Register notice. For contact information for each of the tribal leaders, see the Bureau of Indian Affairs’ Tribal Leaders Directory.

How are health services to American Indians and Alaska Natives paid for and provided?

American Indians and Alaska Natives (AI/ANs) are citizens of the United States and are eligible to participate in all public, private, and state health programs.

Payment for American Indian health services, like those of many other groups, are covered by:

AI/ANs are eligible to participate in the Health Insurance Marketplace and receive targeted benefits and flexibility, as well as exemptions from penalties for not having insurance if they meet eligibility requirements. For more on what is required of AI/ANs the Affordable Care Act and what exemptions exist, see the Indian Health Service’s Three Things You Should Know.

In addition, Indian Health Service (IHS) is charged with meeting the U.S. Government's treaty obligation to American Indians and Alaska Natives to provide healthcare. IHS provides healthcare services and pays for healthcare services provided elsewhere as the payer of last resort, after applicable third-party payers.

What services does the Indian Health Service (IHS) provide and how are they provided?

The Indian Health Service is mandated to make healthcare services available to all members of federally-recognized tribes. Through a series of treaties, court decision, and executive orders over the past 200 years, a unique relationship has been formed between the sovereign Native American tribes and the United States federal government.

The Indian Self-Determination and Education Assistance Act of 1975 allows tribes to elect to assume responsibility and administration of their healthcare services or remain in the IHS system. 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.

IHS provides healthcare services directly at IHS facilities. When an IHS facility is not able to provide a specific service, the service may be provided through the Purchased/Referred Care (PRC) program, as medical necessity dictates and funding allows. For more information about the IHS mission, see the IHS’ Agency Overview and Fact Sheets.

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.”

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

Indian Health Service (IHS) provides a wealth of information on opportunities to work as a provider in a tribal community on its Career Opportunities web page. IHS helps match prospective clinicians with healthcare profession vacancies to improve the health status of American Indians and Alaska Natives across the country.

Information about loan repayment programs and scholarship opportunities can be found on the Funding & Opportunities section of the Rural Tribal Health and Human Services topic guide – choose “Narrow by topic” to limit by type of program. An example of such an opportunity is the Indian Health Service Loan Repayment Program, which provides student loan repayment in return for full-time clinical service in Indian health 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.

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 a Health Professional Shortage Area population group. That designation allows participation in some federal programs, such as the National Health Service Corps.

What grants are tribes eligible to apply for?

There is often confusion because some grants do not list tribes as eligible entities. However, most tribes are eligible for any federal grants with a rural focus, including all grants administered by the Federal Office of Rural Health Policy.

For a selection of programs targeted toward tribal needs, see the Funding & Opportunities section of this guide.

Besides the Indian Health Service, what federal agencies support Native American healthcare initiatives?

A number of other programs housed within the federal government, particularly the Department of Health and Human Services, support Native Americans and have programs that benefit tribal healthcare services.

Are there human services programs targeted to serve the needs of Native Americans?

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:

What disparities exist for American Indian and Alaska Native populations?

The American Indian and Alaska Native (AI/AN) people experience significant disparities in health status compared to Americans as a whole. According to Indian Health Disparities, life expectancy for AI/AN people is 4.2 years less than Americans of all races. Trends in Indian Health, 2014 Edition provides death rates of AI/ANs by cause in relation to the entire U.S. population:

Comparison of 2007-2009 AI/AN Death Rates to 2008 U.S. All Races Death Rates
Cause of Death Percentage Greater for AI/AN
Alcohol related 520%
Tuberculosis 450%
Chronic liver disease and cirrhosis 368%
Motor Vehicle Crashes 207%
Diabetes mellitus 177%
Poisoning 118%
Suicide 60%
Pneumonia and influenza 37%
Firearm injury 16%
Source: Trends in Indian Health, 2014

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 AI/AN disparities concerning:

  • Morbidity
  • Healthcare access and preventive health services
  • Behavioral risk factors
  • Environmental hazards
  • Social determinants of health

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.

Last Reviewed: 3/17/2016