For decades, Tribal Nations have climbed the summit of economic sovereignty, trailblazing through challenges with resilience and vision. One of the greatest peaks conquered was the rise of Tribal Gaming. With the passage of the Indian Gaming Regulatory Act (IGRA) in 1988, Tribes built a $42 billion industry—an achievement that empowered communities, funded self-governance, and proved that sovereignty and business success could go hand in hand.

That mountain has been climbed.

Now, a new summit rises before Indian Country—one even larger, with higher stakes and broader rewards. It’s not just about service delivery. It’s about transformation. This new challenge is called Mt. Healthcare.

While the gaming industry remains vital, it represents just 1.1% of a much larger economic landscape. The U.S. healthcare industry generates $3.8 trillion annually, nearly 88 times larger than gaming. That disparity presents not just a comparison—but an invitation.

What if Tribes could bring the same vision, determination, and sovereignty-driven approach to healthcare that they brought to gaming? What if healthcare wasn’t just about treatment, but about Tribal economic empowerment?

1. Climbing with Medicaid at Your Back

Tribal health enterprises are uniquely positioned for enhanced Medicaid reimbursement. Thanks to federal trust obligations, Tribally operated health facilities receive all-inclusive encounter rates (AIR) rather than billing for individual services. In 2024, the AIR is $801 per visit in the lower 48 states and $1,209 in Alaska—numbers that far surpass what non-Tribal providers typically receive.

This means that a single encounter—for primary care, dental, behavioral health, or pharmacy—can generate substantial, predictable revenue. For facilities offering multiple services in one day, the economic return multiplies without compromising patient care.

2. Bundled Services, Unbundled Opportunity

Integrated care models allow Tribes to build clinics that serve as economic hubs. With primary care, dental, pharmacy, mental health, optometry, and more under one roof, each patient visit becomes not only more effective—but more valuable. And each dollar earned stays within the community, circulating back into programs, employment, and growth.

3. Federal Dollars as the Rope and Anchor

Like base camps on a mountain face, federal funding programs can help launch the journey. Tribes can leverage P.L. 93-638 Indian Self-Determination & Education Assistance Act Contracts, Self-Governance Compacts, Joint Venture Construction Programs, the Small Ambulatory Program (SAP), 105(l) leasing opportunities, and strategies to maximize their Contract Support Costs (CSC).

These funding streams can help Tribes build new facilities, expand existing services, and strengthen healthcare infrastructure. However, it’s important to note that while these dollars are substantial, they must be reinvested into healthcare and cannot be used for unrestricted economic development purposes. Their true value lies in improving care, creating healthcare-related jobs, and establishing Tribal health enterprises that generate consistent revenue within the healthcare sector itself.

States: Michigan, New Mexico, Nevada, Oregon, Washington, Rhode Island
Key Features:

• Unlimited Pharmacy Encounters: There are no caps on pharmacy-related visits or prescriptions billed to Medicaid, allowing Tribes to fully capture pharmacy revenue.

• Medicaid Expansion: These states have adopted Medicaid expansion under the Affordable Care Act, greatly increasing the number of eligible Medicaid beneficiaries, including adults without dependent children—a key population for increasing service revenue.

• Can Serve Non-Beneficiaries (Non-Bens): Tribes can bill for services provided to individuals who may not traditionally be considered Indian Health Service (IHS) beneficiaries but are eligible for Medicaid.

• Multiple Encounters per Day: Allows clinics to bill Medicaid for more than one type of service provided to a patient in a single day (e.g., medical, behavioral health, and dental). This significantly increases revenue opportunities and supports integrated, whole-person care.

Why It Matters:
These states offer the most flexible and profitable Medicaid billing environments. Tribes can maximize revenue streams across multiple services without many of the limitations found elsewhere. This is the ideal environment for Tribes looking to aggressively grow their healthcare enterprise.

States: Alaska, Arizona, Colorado, Connecticut, Idaho, Illinois, Minnesota, Montana, New York, North Carolina, Oklahoma, North Dakota, Utah
Key Features:

• Medicaid Expansion: These states have expanded Medicaid, increasing the pool of potential patients and revenue opportunities.

• Standard Encounter Flexibility: While they don’t offer the full billing flexibility of 4-star states (e.g., pharmacy encounters might be capped or non-beneficiary billing may be limited), the expanded population base and encounter billing models still create significant opportunities.

Why It Matters:
These states provide strong Medicaid revenue potential, particularly because Medicaid expansion ensures a broader patient base. However, Tribes might encounter certain billing restrictions that could require more strategic planning to optimize reimbursement.

States: Arkansas, California, Iowa, Louisiana, Maine, Massachusetts, Nebraska, Texas, Virginia
Key Features:

• Partial Limitations: These states either have not expanded Medicaid or have implemented policies that restrict encounters (for example, limiting the number of services billable per day or capping pharmacy billing).

• Restricted Pharmacy or Encounter Billing: Unlike the higher-tier states, Tribes may face barriers in billing for pharmacy services or multiple daily encounters.

Why It Matters:
Revenue opportunities are moderate. Tribes will need to carefully navigate state Medicaid policies and may require strategic partnerships or innovative care delivery models to optimize funding streams.

States: Alabama, Florida, Kansas, Mississippi, South Carolina, Wisconsin, Wyoming
Key Features:

• No Medicaid Expansion: The patient pool eligible for Medicaid is much smaller, typically excluding low-income adults without dependent children—a significant portion of potential patients in many Tribal communities.

• Severe Billing Restrictions: These states often place heavy limits on encounter types, pharmacy billing, and do not allow multiple encounters per day.

Why It Matters:
Opportunities for healthcare revenue through Medicaid are very limited. Tribes in these states face significant challenges in leveraging Medicaid as a major revenue source and will need to rely more on other funding streams or advocate for policy changes.

Tribes across Indian Country are already rising to meet this new summit:

• The Cherokee Nation in Oklahoma runs one of the largest Tribal health systems in the U.S., demonstrating how clinics can become anchors for economic development, workforce growth, and comprehensive care.

• The Lummi Nation in Washington operates a highly integrated health and wellness center, offering services that reflect both modern best practices and traditional healing philosophies—showing how care and culture can scale side-by-side.
• The Jamestown S’Klallam Tribe in Washington has built a robust health enterprise that includes primary care, dental, behavioral health, and a state-of-the-art Healing Clinic. Their model blends economic opportunity with culturally competent care, expanding both community health outcomes and Tribal economic strength.

These aren’t just health centers. They’re economic engines, training grounds, and beacons of sovereignty.

Investing in healthcare is about more than clinics and claims—it’s about the future of Tribal Nations. It’s about reclaiming authority, generating revenue, and strengthening communities for generations to come.

Mt. Gaming was a triumph. But the next summit—Mt. Healthcare—is higher, more rewarding, and uniquely built for Tribal Nations to scale. This climb requires vision, strategic planning, and bold leadership—but the rewards will echo across every corner of Tribal governance: economic stability, improved wellness, job creation, and deeper self-determination.