A Law That Changed Everything

Fifty years ago, the Indian Self-Determination and Education Assistance Act (ISDEAA) marked a monumental turning point in federal Indian policy. Prior to its passage in 1975, U.S. policy was dominated by assimilation, relocation, and termination efforts that stripped Tribes of land, resources, and recognition. ISDEAA reversed this course, empowering Tribal Nations to reclaim authority over essential services and decision-making that directly affect their people

For the first time, Tribes could govern health, education, and social services in ways that reflected their values, priorities, and cultures—rather than relying on distant federal agencies.

The Power of 638 Contracts and Compacts

At the heart of ISDEAA are Public Law 93-638 contracts and self-governance compacts. These tools allow Tribes to take over the operation of federal programs, including Indian Health Service (IHS) clinics, schools, housing programs, and more. Under these agreements.

638 contracts transfer control of program management from federal agencies to Tribes.

105(l) lease agreements allow Tribes to lease their facilities to federal agencies (like IHS) and receive reimbursement for their use.

These mechanisms represent a powerful shift away from top-down control and toward Tribal sovereignty. Tribes became architects of their own futures—hiring providers, tailoring programs to local needs, and setting new standards for accountability and outcomes.

Healthcare Transformation Through Self-Determination

According to the Indian Health Service’s 2023 Self-Governance Annual Report, over 60% of the IHS budget is now managed by Tribes through ISDEAA contracts or compacts. These self-governance arrangements have not only expanded service access but also improved patient satisfaction and Tribal oversight.

Blue Stone Strategy Partners has supported dozens of Tribes in this transformation—developing strategic health plans, improving clinic efficiency, and maximizing third-party revenue through Medicaid, Medicare, and private insurance billing.

Some standout examples include:

Washington State: A Tribe developed a state-of-the-art family health clinic integrating primary care, dental, behavioral health, and an opioid treatment program. With support in strategic planning and revenue diversification, the clinic became financially self-sustaining—covering up to 85% of operational costs through billing and lease income.[1]

Oregon: The Coquille Indian Tribe established the Ko-Kwel Wellness Center, offering integrated, culturally grounded medical, dental, and behavioral health services. Their success is underpinned by robust 638 contracting and 105(l) lease strategies that ensure long-term sustainability.[2]

Oklahoma: Oklahoma tribes operate some of the largest and most comprehensive Tribal health systems in the U.S., encompassing hospitals, specialty care, and wellness initiatives. Their innovation in technology integration, workforce development, and policy advocacy has made them a national model for Tribal health governance.

Economic Empowerment and Infrastructure Development

ISDEAA has also been a catalyst for economic development. Through self-determination, Tribes have created jobs, trained local workers, and reinvested in critical infrastructure. A 2022 report by the National Indian Health Board found that some Tribes using 105(l) lease agreements offset 30–50% of clinic operating costs through reimbursements.[3]

With support from Blue Stone, many Tribes have leveraged these savings to expand services:

• One Tribe opened a behavioral health wing focused on trauma-informed care and traditional therapies.
• Another constructed a modern dental suite to tackle youth oral health disparities.

According to the U.S. Bureau of Labor Statistics, employment in Tribal establishments grew by 17,000 jobs between December 2022 and December 2023—with the majority in healthcare and hospitality sectors.[4] These gains are part of a broader pattern where Tribes are revitalizing local economies, especially in rural areas.

Challenges on the Path to Sovereignty

Despite decades of progress, self-determination is still constrained by inconsistent funding, regulatory barriers, and administrative burdens. Many Tribes must operate programs at levels below what the federal government originally managed them.

Governance capacity—trained boards, clear policies, and transparent reporting—is vital for long-term success. For example, one Tribe facing chronic IHS payment delays worked with Blue Stone to build a financial dashboard that stabilized payroll planning and improved compliance reporting.

The Next 50 Years: Vision and Policy

As Indian Country looks forward, several priorities are rising to the top:

• Full mandatory funding of IHS and Tribal programs
• Greater Tribal control over long-term care, elder services, and housing
• Expanded telehealth infrastructure and Tribal data sovereignty
• Youth leadership development and intergenerational planning
• Enhanced coordination between self-determination and federal funding programs

Blue Stone Strategy Partners is committed to advancing this vision by helping Tribes identify emerging opportunities, design integrated systems, and advocate for policies that reflect true government-to-government relationships.

Conclusion: The Legacy of Strength and Responsibility

ISDEAA has transformed the landscape of Indian Country. As Chickasaw Nation Lt. Governor Chris Anoatubby once noted, “Self-governance allows us to be responsive and culturally appropriate in how we serve our people. It’s about Tribal solutions to Tribal challenges.”[5]

Blue Stone Strategy Partners stands ready to support Tribes as they build on this legacy—providing tailored, data-driven strategies that strengthen sovereignty and improve community wellness.

Self-determination is not just a policy—it is the foundation of Tribal strength, prosperity, and identity. The next 50 years must be built with the same vision and resolve that shaped the last.

Sources:

[1] Washington Tribal Health Reports

[2] Coquille Indian Tribe & Ko-Kwel Wellness Center

[3] National Indian Health Board, “105(l) Lease Opportunities Report” (2022)

[4] U.S. Bureau of Labor Statistics, American Indian and Alaska Native Establishment Employment (2023)

[5] Chickasaw Times, 2021 Health & Policy Report