Medical Centers & Health Facilities

The ISDEAA provides the authority for a tribe to operate its own medical and health programs, either directly or through designated tribal organizations. The Navajo Nation uses both approaches, directly running its behavioral health (non-medical) programs, and designating tribal organizations to run medical centers. There are two kinds of ISDEAA agreements to run a medical facility.

In Title I “638 contracts,” tribals or tribal organization step into the shoes of the federal government, their duties often limited to what the federal government interprets as its trust responsibility in healthcare, providing services “that the IHS otherwise would have provided.” Such contracts are monitored closely by the NAIHS and come with rigid program design and spending constraints and are intended to be short-term. 

Title V Sovereign Partner. Once the tribal contractor shows financial capacity, usually after three years free of audit findings, they may leave behind their contractor status and become sovereign partners to the federal government through a Title IV compact. While still overseen by the NAIHS, they have high flexibility to redesign organizational structures, streamline hiring, tailor clinical services, bring in traditional healers, allocate and invest block grants, and adapt policies to local community needs. The central advantage of Title V is the authority to manage and tailor health programs to best fit the needs of your community, and flexibility in reallocating and investing 638 funds. 

ISDEAA facilities can pivot much faster than facilities run directly by the NAIHS when there are challenges e.g. federal hiring freezes, or regional vacancies. While ISDEAA facilities face many of the same systemic resource constraints, rural issues and high patient demand, they are able to handle operations and clinical scheduling with greater organizational flexibility. They establish their own human resources policies, salary scales, and administrative workflows tailored specifically to the cultural and geographic realities of the Navajo Nation rather than standardized procedures used by IHS across all reservations.

If a specialist is unavailable, ISDEAA facilities also rely heavily on emergency patient transfers or Purchased/Referred Care (PRC) pathways off-reservation. However, their relative autonomy frequently allows them to staff up more effectively or build specialized service lines (such as expanded youth residential care, local dialysis units, or integrated traditional medicine programs) faster than a direct NAIHS facility could under standard federal controls. They have more administrative freedom to experiment with alternative scheduling templates, expanded phone-triage systems, or mobile health clinics deployed directly to chapter houses to intercept crowds before they bottleneck the main hospital lobby.