Indian Health Service (IHS) has been and continues to be a vital partner in supporting the health of Tribal Nations. For generations, IHS has provided essential services, staffed Tribal clinics, and helped Tribal communities navigate chronic underfunding and health disparities across Indian Country. Its presence is indispensable in many areas, and its efforts have saved countless lives.
But even IHS has its limitations. Federal oversight, inconsistent appropriations, and standardized models can prevent Tribal Nations from creating healthcare systems that truly reflect their values, cultures, and priorities. For those ready to go further, full sovereign control opens the door to something more powerful: a healthcare system designed by your Tribe, for your Tribe — one that is flexible, culturally grounded, and financially self-sustaining.
Across the country, Tribal Nations are stepping into that space. They are using their sovereignty to move beyond the boundaries of federal programs and build community-owned healthcare models that restore traditional practices, generate new revenue streams, and ensure care is shaped by community needs, not outside mandates.
Below are five key strategies to help you do just that, with deeper insights into why they matter and how they work.
Five Key Strategies to Exercise Healthcare Sovereignty
1. Assume Control Through P.L. 93-638 Contracting and 105(l) Facility Leasing
Why it matters:
Contracting and compacting under P.L. 93-638 allows Tribes to reclaim control over their health services from IHS. Section 105(l) leasing provides a mechanism to receive lease payments from IHS for using Tribal facilities, even while fully managing operations. Together, these tools put the decision-making power where it belongs: with your community.
How it helps:
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Service Design Tailored to Community Needs: With compacting, you no longer have to rely on IHS to dictate what services are offered. You can prioritize behavioral health, addiction services, traditional healing, or any area of need specific to your people.
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Increased Funding Through Leasing: Section 105(l) lease agreements bring additional federal dollars directly to your Tribe for facilities you already own. These funds can cover maintenance, renovations, or be reinvested into service delivery.
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Self-Determined Staffing and Operations: Rather than waiting for federal hiring processes, you choose your providers, set salary scales, and define standards of care.
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Faster Response to Emergencies and Opportunities: You will not be bound by federal timelines when responding to crises or implementing new programs.
Bottom line: Sovereign control means healthcare decisions are made on your terms, not within federal constraints.
2. Strengthen Financial Sustainability Through Billing and Pharmacy Programs
Why it matters:
Federal funding is never guaranteed to keep pace with need. Healthcare revenue can. By tapping into Medicaid, Medicare, private insurance, and 340B pharmacy savings, Tribes can build diversified, recurring income that reduces dependence on federal allocations.
How it helps:
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Third-Party Billing Reimbursement: Every service provided to an insured patient is an opportunity to bring money back into the Tribal health system. With the right infrastructure, even a small clinic can generate millions annually through billing.
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340B Pharmacy Program Access: The 340B Drug Pricing Program allows eligible clinics to purchase prescription medications at significantly reduced prices, then bill insurers at standard rates. The difference, often substantial, can be reinvested in staff, supplies, or expanded services.
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Health Corporations for Flexibility and Reinvestment: Forming a Tribal health corporation gives your community more autonomy in managing operations, applying for grants, and partnering with outside entities. It can also help insulate revenue from political changes and ensure accountability.
Bottom line: Sovereign systems must be financially strong. These tools help you build the foundation for long-term independence.
3. Design Care that Reflects Tribal Values and Community Needs
Why it matters:
Standard healthcare models often fail to account for cultural, linguistic, and spiritual dimensions of healing that are central to Indigenous communities. Sovereignty allows Tribes to build systems that are rooted in tradition, not disconnected from it.
How it helps:
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Integration of Traditional Healing: You can include medicine people, healing circles, sweat lodges, or plant-based therapies alongside western clinical practices. This creates a holistic model that resonates with your people.
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Language Revitalization in Care Settings: Elders and others may be more comfortable receiving care in their Native language. Incorporating translators or bilingual providers enhances trust and communication.
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Community-Specific Program Development: Instead of using generic public health campaigns, Tribes can create services that reflect local customs, values, and challenges. This includes youth mentorship and elder home-visiting programs.
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Cultural Safety and Belonging: Patients are more likely to seek and trust care when they see their culture reflected in it. That means better engagement, better follow-up, and ultimately, better outcomes.
Bottom line: Culture is not a barrier to care. It is the foundation of healing. Sovereignty ensures it stays central.
4. Invest in Staff Housing to Recruit and Retain Healthcare Professionals
Why it matters:
Recruitment and retention are among the biggest challenges facing Tribal health systems. Many healthcare professionals are willing to serve Tribal communities but cannot commit without a stable place to live, especially in rural or remote areas.
How it helps:
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Removes a Major Barrier to Hiring: Offering housing as part of employment packages makes your positions more attractive and reduces start-up stress for incoming staff.
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Supports Long-Term Retention: Stable housing means providers can put down roots, build relationships, and stay longer. This leads to better continuity of care for patients.
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Enhances Emergency Readiness: On-site housing ensures quicker response times in emergencies, especially for critical services like labor and delivery, ER, or behavioral health crises.
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Economic Multiplier for the Tribe: Building and maintaining housing creates construction jobs, supports local materials suppliers, and grows your Tribe’s physical asset base.
Bottom line: A strong workforce needs a strong foundation. That begins with a place to call home.
5. Use Medicaid Waivers to Address Social Determinants of Health
Why it matters:
Health outcomes are shaped by far more than clinical care. Issues like poverty, housing, food insecurity, and transportation can have just as much or more impact. Medicaid waivers give Tribes the flexibility to design systems that address these realities directly.
How it helps:
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Section 1115 and 1915 Waivers: These waivers allow Medicaid funds to be used more creatively, supporting services like care coordination, nutrition education, supportive housing, or in-home care for elders.
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Custom Solutions for Complex Needs: Whether addressing youth mental health, elder independence, or chronic disease prevention, waivers allow your Tribe to design programs that reflect real-life challenges.
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Data-Driven Community Health Models: Waiver flexibility allows for better integration of health, social services, and education. This helps your Tribe create truly wraparound care models.
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Greater Leverage in State Medicaid Partnerships: As sovereign governments, Tribes can negotiate with states for better inclusion in waivers and demonstration projects.
Bottom line: True health equity means investing in the conditions that create health. Waivers let you do just that.
Your Sovereignty Is a Strategic Asset. Use It.
The choice to take full control of your healthcare system is more than administrative. It is cultural, economic, and deeply personal. Every decision made under Tribal governance reflects your values, priorities, and path forward. While IHS remains a valued ally, asserting your sovereign authority enables deeper transformation and greater opportunity.
How Blue Stone Can Help
At Blue Stone Strategy Partners, we understand that each Tribe’s path to healthcare sovereignty is unique. Whether you’re just beginning to explore your options or you’re ready to expand an existing system, our team brings deep experience and trusted relationships to guide your efforts. Here’s how we can help with each of the five strategies:
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P.L. 93-638 Contracting and 105(l) Leasing
We assist with readiness assessments, transition planning, and negotiations to help your Tribe successfully move from IHS-operated to Tribal-operated services. Our experts support you in preparing facility documentation and maximizing lease compensation under 105(l). -
Third-Party Billing and 340B Implementation
Blue Stone helps you build or enhance your billing systems, train staff, and evaluate financial operations. We also provide 340B program development support, including pharmacy feasibility assessments and compliance strategies to ensure long-term savings and revenue growth. -
Culturally Based Program Design
We work alongside your leaders, elders, and health staff to develop care models that honor your traditions and meet community-specific needs. This includes integrating traditional healing practices, language revitalization, and behavioral health programming rooted in your cultural framework. -
Healthcare Workforce and Staff Housing Strategy
Blue Stone provides strategic planning, site feasibility analysis, and funding alignment to help you develop housing that attracts and retains providers. We also help you assess workforce gaps and design recruitment strategies that reflect Tribal values and community priorities. -
Medicaid Waiver Utilization and Social Determinants of Health
Our team can help you identify applicable Medicaid waivers, prepare proposals, and engage with state Medicaid agencies. We’ll also work with you to design comprehensive care models that address food insecurity, housing, transportation, and other key health drivers.
If your Tribe is ready to strengthen its healthcare system using the full power of your sovereignty, Blue Stone is here to help.