Differences between Direct Service Tribes and
638 Tribes
1. Location: IHS operated programs tend to be more
remote than 638 programs with exceptions like Arizona
Tribes and the exception of the Alaska 638 Compacts
2. Economics: Direct Service Tribes are far more often
poorer due to unfavorable locations for enterprises like
gaming that thrive in urban areas where most 638 tribes
are located exceptions include New Mexico and Arizona
3. Size: Larger tribes are much more likely to be served
by IHS, Oklahoma's tribes are an exception to the rule,
with North and South Dakota Tribes, large Minnesota
Tribes, Montana tribes, and the Navajo typical of the large
tribes being more often served by IHS.
Differences between Direct Service Tribes and
638 Tribes
4. Cultural-legal perceptions of non-IHS services like
health insurance, public and private, view them
unfavorably.
While a federal agency is certainly not 'traditional'
in the sense that it is Indian, there is a clear correlation
between more traditional tribes, support for IHS and
antipathy to insurance, public and private.
Alaska is the exception to this rule.
States like Montana, and South Dakota are good
examples of it. They feel, often strongly, that IHS services
are the preferred way to honor treaty obligations-in fact
they more often have treaties that mention health care
services, although some direct service tribes do not have
treaties with the federal government.
Differences between Direct Service Tribes and
638 Tribes
5. Direct Service tribes have a much higher American
Indian alone census population than 638 tribes that are
more likely to have members who identify with multiple
races. Alaska is an exception to this.
Over 85% of AIANs in North Dakota, South Dakota,
Montana Arizona, New Mexico are “Indian Alone” much
higher than the national average of 50% indicating one
race only.
638 tribal members themselves or close
relatives have experience with health insurance, many
direct service tribes tribal members do not.
Note: The majority of AIANs do not identify
with 3 or more races. To say it another way about 50%
of AIAN, who self-identify to the Census are one race
AIANs; over 90% identify with just 1 or 2 races.
The impact of health care reform on Direct
Service Tribes will vary greatly from 638, tribally
operated programs.
The Affordable Care Act has no special provisions
to make sure Indian Health Service operated
programs (Direct Service Programs) are able to
access it's two main expansion programs,
Medicaid and Subsidies to purchase Health
Insurance Exchange health plans.
Medicaid Expansion

To the extent that Direct Service tribes experience greater
poverty, and they do, Medicaid expansion will result in
more eligible for these programs as Medicaid expands to serve
childless single adults up to 139% of poverty.

Medicaid expansion can be easily implemented by Direct Service
Tribes when compared to enrolling in health exchange health plans.

Medicaid Expansion will have a greater impact for Direct Service
Tribes than health exchange plans and subsidies.

Medicaid expansion's impact on Direct Service Tribes is likely
greater than its impact on 638 (contract and compact) Tribes and
the programs they operate.
Health Insurance Subsidies
•
1.
2.
Between 35% and 40% of tribal members in Direct
Service Tribes may be eligible for health insurance
subsidies to purchase exchange offered health
insurance plans. This is very similar to 638 tribes.
Unfortunately, the antipathy toward private insurance
combined with the inability of cash-strapped tribes to
sponsor health insurance will make take-up rates very
low.
Indian Health Services does not have clear legislative
authority to use Contract Health Service funds to
purchase health insurance as do 638 tribally operated
health programs.
Without affirmative actions:
Direct Service Tribes will have:
1. much lower enrollment in exchange-offered
health insurance than members of 638 tribes.
2. moderately less enrollment in Medicaid
expansion in states expanding Medicaid, but
unfortunately more Direct Service Tribes are in
states that may not expand Medicaid to 138%.
3. less access to care overall if the IHS budget
receives smaller annual increases after the rollout
of the ACA in 2014 due to faulty conclusions
about how well the ACA meets the needs of
direct service tribes
Conclusion
Direct Service Tribes and the populations they serve will
not benefit from the Affordable Care Act to the same
extent as 638 Tribes, they will have fewer enrolled in
Medicaid and far fewer enrolled in exchange-offered
health insurance plans.
The key to mitigating this less favorable outcome is to
identify best practices in Direct Services Tribes for
possible adoption (and adaptation) by other Direct
Service Tribes and the IHS programs that serve them.
For example, Contract the CHS Program in order to pay
premiums and reimburse incidentals.