Improving health access and outcomes: What states and tribes are doing

The Indian Self-Determination and Educational Assistance Act of 1975 (P.L. 93-638) allows federally recognized Indian tribes to contract with the federal government to assume management of part or all of their health care programs. Concerned by the continuing health problems of their communities, many American Indian nations and Alaska Native villages have exercised their rights under this law and taken a proactive role in health care. They have been expanding their management role in health programs, affirming their own priorities, and based on these priorities, developing innovative programming to improve access to high quality, culturally competent health care. These efforts by Indian nations to play a larger and more assertive role in health care decisions and operations are the most striking change in Indian health care services over the last thirty years. Tribes’ successes are intriguing, but they are poorly understood.

With funding from the Nathan Cummings Foundation. the Native Nations Institute for Leadership, Management, and Policy at The University of Arizona conducted a research effort in 2007-2008 to assemble, review, and summarize existing information on tribal initiatives and the effects they are having on access to culturally competent health care services. Activities consist of a review of current research on tribally managed health care services and interviews with a range of informants capable of describing the dimensions and dynamics of Native nation health care management decisions. Individuals with a health care orientation working for supra-tribal organizations, nontribal government agencies, and academic institutions are one target group for interviews. Another is tribal leaders, tribal government employees, and traditional healers. In an effort to survey the diversities in Indian Country, members of this second target group were specifically selected to represent the cultural, economic, and geographic range of tribes (including two in Minnesota). All interviews address tribal initiatives that are already in progress and how they impact health care delivery and outcomes.

Interviews revealed that reoccurring challenges to tribal management of health services include limited data, limited funding, and of the difficulty of reorienting service delivery for cultural competency. For many tribes, there is much to gain by assuming control over health care, such as the ability to promote community priorities through the management and organization of local health care services or the entire local system. Native nations already managing health care services and the Indian Health Service itself are valuable resources for tribes wishing to follow this course. Knowledge sharing, resource sharing, and mentoring could be vital to the success of tribal control of health care. For other tribes, it appears that there is something to lose through self-management. While they acknowledge that direct service by the Indian Health Service diminishes the opportunities for culturally competent care and the ability to respond to local needs, fears about issues such as funding and local government capacity overwhelm those advantages.

A subsequent, larger research effort intends to identify policy initiatives and practices available as resources to Indigenous nations in order to increase their citizens’ access to quality, culturally competent health care.