Self-Determination & 638 Contracts
The ISDEAA of 1975 marked a significant shift in federal Indian policy by empowering tribes to assume control over the planning, implementation, and administration of federal programs, including healthcare services. Under ISDEAA, tribes have the authority to enter into self-determination contracts or agreements with federal agencies, such as the Indian Health Service (IHS), to assume management responsibilities for healthcare programs previously operated by the federal government.
ISDEAA recognizes the inherent sovereignty of tribal governments and affirms their right to self-governance in healthcare (among other areas), allowing tribes to tailor healthcare services to meet the unique needs and priorities of their communities. By assuming control over healthcare programs and services, tribes gain greater flexibility, autonomy, and accountability in addressing health disparities and promoting wellness among their members.
Central to the implementation of ISDEAA is the concept of 638 contracts, named after the section of the law that authorizes tribes to create self-determination contracts with federal agencies. Through these contracts, tribes can assume direct control over healthcare programs previously operated by the federal government, including hospitals, clinics, behavioral health services, and public health initiatives.
These contracts further allow tribes to manage their own healthcare programs with federal funding, providing tribes with greater decision-making authority, resource allocation flexibility, and accountability for healthcare outcomes. Tribes may use 638 contracts to design and implement culturally appropriate healthcare services, integrate traditional healing practices, and address the specific health needs of their communities.
In a nutshell, 638 contracts represent a key mechanism for advancing tribal self-governance in healthcare and promoting health sovereignty among Native American communities. By leveraging these agreements, tribes can exercise greater control over healthcare delivery, improve access to quality care, and address health disparities in accordance with their own values, priorities, and traditions—all of which are imperative for diabetic treatments.
Federal Funding: The Special Diabetes Program for Indians
In 1997, Congress took a significant step by launching the SDPI, responding directly to the diabetes crisis gripping Native American communities. Created with the support of the IHS, this program had a clear mission: to tackle the alarming prevalence of diabetes and its complications among tribal populations. After all, funding for specific healthcare disparities has been historically low or nonexistent.
From the outset, SDPI set out on a multifaceted journey, aiming to empower communities with knowledge, improve healthcare access, foster healthy lifestyles, and ultimately curb the devastating impact of diabetes. With an eye toward culturally sensitive approaches, the program sought to build bridges between modern medical science and traditional healing practices deeply rooted in tribal heritage.
At its core, SDPI is a lifeline for tribal communities, offering vital support for diabetes prevention and treatment initiatives. Through strategic allocation of federal funds, SDPI-backed programs provide a comprehensive suite of services tailored to the unique needs and challenges facing Native American populations.
These initiatives can be as diverse as the communities they serve, encompassing everything from educational outreach and clinical care to lifestyle interventions and community engagement. Each component works in harmony to empower individuals, strengthen support networks, and pave the way toward better health outcomes.
SDPI is a culmination of efforts to combat diabetes in Native American communities, with substantial resources dedicated to this cause. With an annual grant of $147 million, SDPI-funded programs reach an impressive 472,656 American Indians and Alaska Natives across 302 program sites spanning 35 states. Since its inception, these programs have played a pivotal role in improving health outcomes and reducing diabetes-related complications within tribal communities.
The impact of SDPI-funded programs is evident in the data representative of diabetes symptoms. Diabetes services offered at SDPI sites have expanded significantly since 1997, contributing to a remarkable 11% reduction in average blood sugar levels from 1996 to 2022. Similarly, average LDL cholesterol levels have decreased by 25% over the same period, while blood pressure has been well-maintained, indicating the effectiveness of interventions aimed at diabetic health. Furthermore, SDPI initiatives have made strides in addressing tobacco use, with a notable 28% decline observed from 2015 to 2022. These positive trends underscore the tangible benefits of SDPI funding in promoting healthier lifestyles and reducing risk factors associated with diabetes and its complications.
As Connie Barker, tribal legislator from the Chickasaw Nation, aptly summarizes, SDPI has been instrumental in generating “awareness and knowledge, two critical components of diabetes-related successes in Indian Country.” The program’s impact extends far beyond statistics—touching the lives of individuals and families affected by this devastating disease.
While significant successes have been achieved through SDPI-funded programs, it is essential to remain mindful of the challenges and opportunities that lie ahead. One key challenge is ensuring the sustainability of diabetes prevention initiatives beyond the scope of SDPI funding cycles. Despite the annual grant of $150 million, the scale of the diabetes epidemic necessitates ongoing commitment and investment from federal, tribal, and community partners. It may be disadvantageous to become too reliant on this funding since a program’s funding could run out or a tribe could become federally unrecognized.
Additionally, addressing the complicated nature of diabetes disparities within tribal communities presents a complex challenge that demands a holistic approach. Adaptation and innovation are crucial, considering various factors such as healthcare delivery, education, socio-economic considerations, and cultural values and traditions.
Still, amidst these challenges, opportunities for growth and collaboration continue to emerge. SDPI-funded programs have the potential to leverage established infrastructure, partnerships, and community trust to advocate for sustained funding, policy support, and resources. By fostering collaboration among tribal governments, healthcare providers, researchers, and community leaders, the collective impact can be amplified, driving systemic changes to address the root causes of diabetes disparities.
Through continued momentum and collective action, progress can be made toward the shared goal of reducing the burden of diabetes in Native communities. This concerted effort holds the promise of making a meaningful difference in the lives of tribal communities and future generations.
Case Studies – A Dive into Federal Recognition and 638 Impacts
Confederated Tribes of the Umatilla Indian Reservation (CTUIR): Both Federally Recognized and 638-Contracted
CTUIR, located in the northeastern part of Oregon, was granted about $204,000 in 2024 by the SDPI. The tribe, through the Indian Reorganization Act, was able to create a constitution. This constitution was thought out and detailed, thus allowing CTUIR to create committees and delegate authority to said committees. Because of this, it was allowed to create the Tribal Health Commission and its applicable bylaws. The reservation, having a 638 contract as well, was able to create its own healthcare facility—Yellowhawk Tribal Health Center—which is also run by the Tribal Health Commission.
Yellowhawk has its own multidisciplinary Diabetes Prevention Program (DPP). The DPP is a monthly course that focuses on the “Waq’išáawit,” meaning “healthy way of life” in the Nez Perce language. One of the ways the team monitors and manages diabetic treatment is through the Government Performance and Results Act (GPRA) goals. These goals are a federal requirement to track how well the SDPI funds are being used. For 2023, the goals included: controlled blood pressure (<140/90), diabetes mellitus statin therapy, nephropathy assessed, and retinopathy assessed. The Yellowhawk Tribal Health Center surpassed every national target in terms of percentages, meaning that they have been extremely successful in their diabetes interventions.
One other reason the DPP has been so successful is because of the expansion of their pharmacy. One thing that may get overlooked is the requirement to have a pharmacist who is board certified in diabetic medication in order for the Yellowhawk pharmacy to be able to carry and distribute the medicine. Because the center was able to train and recruit such a pharmacist, it was able to expand its available resources for diabetic patients. For example, it now carries a sensor that is worn on the back of a patient’s arm and gives a continuous glucose reading over 14 days, helping a physician know exactly when the patient needs insulin therapy. The Yellowhawk Tribal Health Center continues to grow its resources by using some of its funds to implement the Pharmacy Technician Apprentice Program, which is a paid 18-month-long training that helps tribe members obtain pharmacy skills and certifications.
Crow Creek, Indian Health Service: Federally Recognized, but Does Not Have a 638 Contract
Crow Creek Reservation is headquartered in Fort Thompson, SD, and consists of roughly 4,600 tribal members. While Crow Creek’s facility in Fort Thompson receives funding through SDPI, it has not 638-contracted for more tailored diabetes prevention. The SDPI gave roughly $455,000 directly to the IHS in Fort Thompson—which is nearly double than what Yellowhawk received; had Crow Creek 638-contracted for medical services, it would have gone to its own health facility or directly to the tribe, not to an IHS facility.
Because there is no 638 contract, it is readily apparent that the facility in Crow Creek is limited in what it is able to provide to its members. Compared to the Yellowhawk Tribal Health Center, the facility is much smaller, the hours are narrower, and there is no specific data available for this area. Instead, its health services are run directly through the IHS website or automated telephone operator, both which can be difficult to navigate, cumbersome with unrelated information, and overall, not user-friendly. There is simply no readily available data pertaining to what the IHS’s Fort Thompson building is doing for its diabetic patients. Rather, there is only generalized/clumped data pertaining to tribes across the entire U.S.
The good news, however, is that there are diabetes therapies that are available because funding is being provided for it. Potential patients are not being forced to go without diabetes treatments, unlike some other tribal areas. The one thing that Crow Creek could consider is creating a 638 contract to provide medical care, especially diabetes prevention, on a more individual level. As the general population knows, there is no such thing as a “one-size fits all” approach, and having the autonomy to create personalized and tribal-friendly approaches is key in circumventing that issue, thus creating a long-term solution.
Chinook Indian Nation: Not Federally Recognized, So There is No Option to Have a 638 Contract, Nor Are There Any Funds Being Supplied
Chinook Indian Nation, stretching across southern Washington in Willapa Bay to southern Oregon along the Pacific Coast near the mouth of the Columbia River, was once granted federal recognition in 2001. Eighteen months later, that federal recognition was withdrawn. Though the reason for the withdrawal is not readily apparent, the Chinook have been reapplying every year since then.
Since the Chinook Indian Nation does not currently hold federal recognition, it does not have the legal status requisite to enter into such contracts with the federal government. Without federal recognition, the tribe is not eligible for the benefits and privileges afforded to federally recognized tribes, including the ability to participate in ISDEAA programs like 638 contracts.
Chinook Chairman Tony Johnson, offers just how harming this can be: “We have community members who have no health insurance who never received treatment for cancer because they didn’t have the means to pay for it and IHS didn’t cover it.”
This devastation was more prominent during the COVID-19 pandemic, when many people had to forego medical treatment because the closest care was several hours away.
“We have lost folks in the community over the last year that would not have been lost were Chinook to have been a federally recognized community,” Johnson says. “And that is unbearable.”*
Devon Abing, who is a Chinook council member, is currently awaiting a heart transplant. His bills are covered by Medicaid, but there are many expenses and sacrifices that are not paid for. “With federal recognition, the tribe could designate him as an elder and cover wages for his chosen caregiver. Otherwise, his sister will likely take an unpaid leave of absence from her job managing a gas station. That’s what happened last time…” Abing went on to explain other cultural impacts, “You can’t eat deer, you can’t eat bear… All the Native foods that I enjoy, I can’t have. They said I can’t even eat fish. So I won’t really be able to take part in the salmon ceremony.”
Chinook’s story is not an uncommon one, as there are over 200 unrecognized tribes in the U.S. Though there are numerous reasons a tribe may be federally unrecognized, the Muwekma Ohlone Tribe aptly summarizes the complex reasoning:
To be federally recognized, a tribe must seek approval from the United States’s Department of Interior, Bureau of Indian Affairs, demonstrating a nation’s history which has shown continuous existence, political authority, and community since contact… If the recognition is not granted, a Tribe can try to go to court, petition the Bureau of Indian Affairs (BIA), a decision by the Assistant Secretary of Indian Affairs, have Congressional legislation, or try to receive a presidential executive order, which all five of these avenues are nearly impossible due to anti-Indian sentiment with the dominant society and from both political parties… While these processes are potentially available, it is extremely difficult, if not completely impossible, for a Tribe to gain or regain federal recognition. Some State Recognized tribes back east, have spent upwards to 20 million dollars of their petitions, on research, manpower, lobbying, retention of lawyers, collecting historical and genealogical records, printing, and submitting to the Office of Federal Acknowledgement. In some cases, Federally recognized tribes work in concert to conspire against smaller Tribes who do not have the monetary resources to regain their acknowledged status, thus employing political pressure on elected officials and government agencies to deny these historic tribes recognition.
Legal and Financial Challenges in Implementing Diabetes Prevention Programs
Tribes Face Financial Constraints and Funding is Often Convoluted
Even when tribes are federally recognized and have a 638 contract, it can be difficult to ensure members are receiving adequate healthcare. Take Yellowhawk’s Tribal Health Center for example:
