Ałchíní Bi Bižzhóón–Diné First Laugh Ceremony
Baby’s first laugh is their transition from the spirit world to the human world
Healthcare within the Navajo Nation is a complex, highly fragmented network of public health systems. Because these systems lack a centralized oversight body, families and providers face significant structural hurdles when trying to secure continuous, high-quality care. Understanding the unique landscape requires looking closely at how services are structured—and where the systemic gaps lie.
This guide is a starting point for families and providers navigating the complex healthcare landscape on the Navajo Nation. It is not a complete map—the system is too fragmented, too under-resourced, and too cross-jurisdictional for that—but it will help you understand the territory, anticipate challenges, and find your way. It is grounded in the lived experience of families who have walked this path before you.
There are no private practitioners or private healthcare facilities operating within the boundaries of the Navajo Nation. All care—primary, urgent, and specialty—must flow through federal or tribal systems. This means you cannot “choose” a private doctor locally, and you cannot pay out-of-pocket for private care within the reservation.
Any private care outside IHS/tribal facilities requires travel off-reservation.
There are no state public health offices located physically on the Navajo Nation across the Arizona, New Mexico, or Utah portions of the reservation. Instead, public health infrastructure and healthcare services on the Navajo Nation are managed primarily by the Navajo Area Indian Health Service (NAIHS) (a federal agency under the U.S. Department of Health and Human Services), the Navajo Nation Department of Health (NNDOH) (a tribal entity) and alongside tribal health organizations. Please read the next section for more information.
Any public care outside IHS/tribal facilities requires travel off-reservation.
Non-Native Americans living on the Navajo Nation face a distinct challenge: local healthcare options on-reservation are both insufficient and limited strictly to IHS/tribal facilities which serve enrolled tribal members. As a result, those not enrolled as tribal members must travel off-reservation to border towns (such as Gallup, Farmington, Flagstaff, or Page) to access private or community-based commercial healthcare providers using their private insurance, Marketplace plans, or employer benefits.
NAIHS will stabilize non-Native patients in a true medical emergency. Under federal EMTALA (Emergency Medical Treatment and Labor Act) laws, emergency departments that receive federal funding must evaluate and stabilize anyone experiencing an emergency medical condition, regardless of race, tribal enrollment, or insurance status. Once the patient is stabilized and no longer in immediate critical danger, IHS facilities are not equipped or mandated to provide ongoing non-emergency or inpatient care to ineligible non-Natives. The care is not free. Non-Native patients are legally responsible for the cost of the emergency services provided and will be billed standard rates.
The federal government’s role in healthcare on the Navajo Nation originates from a solemn promise in the Treaty, which ended the Long Walk and “allowed” the Diné people to return to their homeland. The Treaty formally established the United States’ trust responsibility to the Nation. While this treaty and its 1849/1850 predecessor did not explicitly mention “healthcare,” they created a permanent framework of federal protection and obligation that the courts have consistently affirmed. This trust relationship has evolved into the modern legal duty to provide health services, a duty that is central to the mission of the IHS. The Snyder Act of 1921 and the Indian Health Care Improvement Act (IHCIA) codify the federal policy “to ensure the highest possible health status for Indians.”
Tribal sovereignty, federal resources, and community wisdom have a physical presence. However, state facilities are NOT present.
Indian Self-Determination and Education Assistance Act (ISDEAA). After more than 30 years of running stand-alone health and social service programs, in 2014 the Navajo Nation established an umbrella Department of Health. The Nation’s primary authority to operate its own medical and health programs comes from federal law — the Indian Self-Determination and Education Assistance Act (ISDEAA) or P.L. 93-638, enacted by Congress in 1075.
The ISDEAA provides tribes with primary authority to operate its own medical and health programs, or designate a tribal organization to do so. Depending on a tribe’s “financial stability and financial management capability,” the ISDEAA provides two pathways toward more control. Under Title I of the ISDEAA, a tribe runs a medical or community health program as a federal contractor under NAIHS oversight. Under Title V of the ISDEAA, a tribe would run that program under block “compact” grants as a sovereign partner to the federal government.
The Navajo Nation directly runs community health programs as a Title I contractor, and has designated tribal organizations to run some NAIHS medical facilities as both Title I contractors and Title V sovereign partner compacts.
Title I contracting requires each and every 638 Contractor to enter strictly construed scopes of work often limited to what the federal government interprets as its trust responsibility under the Navajo Treaty of 1868. The contracts are renewed annually subject to performance and audit. The annual performance and financial audits that each community health program were subject to for decades created time and resource consuming focus on compliance rather than services, until in 2014, the tribe established the Navajo Nation Department of Health (NNDOH), through passage of Navajo Nation Council Resolution CO-50-14 (Department of Health Act of 2014).
With the establishment of the NNDOH, community health programs that previously had to separately contract with NAIHS could now be grouped under NNDOH as subordinate programs and enter a single “master contract”
The 10-Year “Master Contract.” In November 2024, the Navajo Nation Council approved a ten-year Title I 638 contract through Naabik’ iyati’ Committee Resolution NABID-68-24, beginning January 1, 2025. While it is legally executed under the authority of Public Law 93-638 (Title I), it is a highly specialized, non-standard 10-year mature master contract that allows NNDOH to act as a massive umbrella encompassing a wide array of subordinate public health initiatives, including the Division of Behavioral and Mental Health Services (DBMS), Division of Public Health Services, the Community Health Representative (CHR) Program, the Navajo Nation Special Diabetes Project, and Emergency Medical Services (EMS).
Regulatory Authority Like a State, But With Challenging Differences. NNDOH community health programs focus on wellness, prevention, nutrition, and community-based care.
The Navajo Nation Council established NNDOH to resemble a state department of health, with regulatory authority similar to a state and a future goal to administer Medicaid. State health departments regulate, inspect, and enforce. They do not typically provide direct clinical care.
However, a state health department operates within a broader system that delivers Medicaid coverage and care through county and local public and private medical and community health providers in a coordinated and multi-layered delivery system, which the Navajo Nation lacks. There is no tribal Medicaid agency (though CO-50-14 authorizes study of one). There are no county health departments. There are no private providers. The NAIHS–the only clinical system–is beyond NNDOH regulatory authority. This means the NNDOH has no authority over the clinical care provided at IHS facilities, which is a major limitation on its ability to ensure quality. The authority is also limited over core programs controlled by 638 contractual terms.
Regulatory authority is also challenging in the checkerboard areas of the reservation in which tribal, state, private, and public federal lands exist in a “checkerboard” with competing boundaries.
Future Navajo Nation administration of Medicaid. New Mexico formally allowed the Navajo Nation to move toward managing its own Medicaid services in 2017. There are two technical routes for the Navajo Nation to administer Medicaid: as a full tribal Medicaid agency, or through an Indian Managed Care Entity (IMCE). A 2014 report to Congress found a full tribal Medicaid Agency could be feasible but would require significant planning and funds; this route remains stalled due to funding and federal law restrictions. The Nation sought to bypass these hurdles by pursuing the IMCE route, creating the Naat’áanii Development Corporation (NDC) to manage its own care plan in partnership with states like New Mexico. However, this path faced severe internal political delays, including a 2020 executive veto by Navajo Nation President Jonathan Nez over enrollment rules and sovereignty concerns. The full standalone IMCE insurance plan remains delayed by these disputes.
Traditional Healing. NNDOH is authorized to “establish a structure and system, in the form of assistance, for the practice and retention of traditional medicine” through consultation with organizations like the Diné Medicine Men’s Association. This is one of the few service-oriented provisions in the Act, and DBMS does provide traditional services at its treatment centers. However, traditional programming is framed as “assistance” and “structure”—not as direct programmatic support for families seeking traditional healing. An additional challenge is to have traditional healing interpreted as a necessary healthcare service, at least for provider coordination, under the federal trust responsibility. This is an ongoing area of advocacy, not a solved problem.
Funding Mechanisms for Other Programs. While a significant portion of the NNDOH’s core programming is funded through 638 contracts, specialized, time-limited, or community-based projects rely on a combination of federal grants, tribal revenue, and intergovernmental agreements (IGAs). E.g. federal grants fund Tribal Opioid Response (TOR), 988 Crisis Response, and Native Connections (youth suicide prevention). The Healthy Diné Nation Act (HDNA) uses a 2% tax on unhealthy foods to fund community-based wellness projects at the chapter level.
Because the Navajo Nation covers an immense geographic area spanning multiple Arizona counties, healthcare-specific Intergovernmental Agreements (IGAs) between the Navajo Nation and the State of Arizona are the primary mechanism used to coordinate funding, share jurisdictional authority, and deliver public services across tribal and state borders.
New Mexico has been building a different kind of collaboration with the tribe than Arizona—one based on tribally-led managed care, a foundational data agreement, and a strong network of community-based non-profits. This approach may eventually lead to a more integrated system without the need for the same number of administrative IGAs used in Arizona.
Specialty medical services are extremely limited. Local oncology specialty services are given by the Specialty Care Center, Tuba City, AZ (ISDEAA Title V facility of TRHHC) where patients and caregivers can access support and navigation services and obtain culturally sensitive support and counseling. Specialty Care Center is the first full-time cancer care program on any American Indian reservation. Unlike rotating or periodic traveling clinics that visit a region once or twice a month, this is a permanent, on-site cancer care program with full-time oncologists, hematologists, oncology-certified nurses, pharmacists, and dietitians—allowing patients to receive specialized treatments like chemotherapy, biotherapy, immunotherapy, and infusions locally instead of being forced to travel hundreds of miles off-reservation for every treatment.
An off-reservation clinic, Winslow Indian Health Care Center Winslow, AZ (ISDEAA Title I community hub run by Winslow Indian Health Care Corp.) has a rotational visiting specialist model for specialists (such as cardiologists, endocrinologists, podiatrists, or oncologists).
Neither the New Mexico Department of Health (NMDOH) nor the Arizona Department of Health Services (ADHS) have a physical presence on the Navajo Nation. State health departments handle specialty care access for reservation residents through specific administrative, financial, and collaborative pathways. State health and human services agencies manage state Medicaid programs. In Arizona, the Arizona Health Care Cost Containment System (AHCCCS) works closely with tribal health programs for specialized medical services off-reservation. NMDOH Children’s Medical Services provides visiting specialty/complex care services for reservation children at their border town offices.
When local IHS or tribal clinics lack the infrastructure for high-level specialty care (like advanced oncology), the federal-tribal system relies on Purchased/Referred Care (PRC) Coordination. State health departments coordinate with these networks to ensure patients who must travel off-reservation to major medical hubs (such as Albuquerque, Phoenix, or Flagstaff) have coverage.
The States of Arizona and New Mexico have entered intergovernmental agreements with NNDOH Epidemiology for specialized public health surveillance, funding, and resource-sharing for chronic disease tracking, cancer registries, and infectious disease control (such as tuberculosis or specialized screenings).
For those who are medically fragile or special needs, the Medicaid home and community-based waiver is routine for urban areas but in the remote, checkerboard expanses of the Navajo Nation presents massive logistical hurdles, leading to a system heavily reliant on workaround solutions. State-managed waivers are designed around the assumption that commercial home health agencies, private-duty nurses, and physical therapists operate locally and can travel easily to a patient’s home. On vast parts of the Navajo Nation, commercial home-care agencies are virtually non-existent. Families often struggle to find licensed nurses or aides willing or able to travel dozens of miles across unpaved roads to provide daily care.
To bypass the near-total lack of local agency-based providers, programs like New Mexico’s Medically Fragile Waiver (or self-directed alternatives like Mi Via) allow for Legally Responsible Individuals (LRIs), relatives, and family guardians to be formally certified and paid as home health aides or private-duty providers. For many remote Navajo families, this policy is a vital lifeline that keeps children at home, transforming family members into compensated frontline caregivers.
Oversight is typically managed through state-contracted nurse case management agencies (such as university-partnered programs) or state Medicaid managed care plans. However, case managers stationed off-reservation often face communication barriers, lack of reliable broadband or cellular service in rural chapters, and difficulties coordinating care that bridges state lines with federal IHS/tribal medical charts.
Delivering heavy or specialized medical hardware—such as hospital beds, ventilators, oxygen concentrators, or specialized nutritional formulas—to remote homes with substandard addresses or rough terrain is a persistent obstacle. Traditional medical supply companies based in off-reservation border cities frequently balk at delivery logistics, forcing families to travel long distances to pick up supplies themselves.
In October 2024, Arizona and New Mexico got permission from the federal government to let Medicaid pay for traditional healing services provided through IHS or Tribal 638 facilities and which do not need to be provided on IHS premises. These include ceremonies, sweat lodges, and other traditional wellness practices. Traditional practitioners need to enter contract with NAIHS facilities. However, it is very limited. Families can use this benefit for one ceremony per calendar year through their Medicaid plan, and reimbursement is capped at between $250–$350.
Hataali have said this is not enough for a full ceremony, which has a 4-day protocol and cost much more in time and materials than this benefit covers.
An additional issue is traditional healing is still treated as “extra,” not as core care. The medical system rarely understands or respects how ceremony works.