## **SELF-DETERMINATION**

[Indian Health Service Philosophy]{.underline}

The Indian Health Service (IHS) has implemented the Indian
Self-Determination and Education Assistance Act (ISDA), Public Law
93-638, as amended, in the spirit by which the Congress recognized the
special legal relationship and the obligation of the United States to
American Indian and Alaska Native peoples. In keeping with the concept
of tribal sovereignty, the ISDA, as amended, builds upon IHS policy that
maximizes opportunities for tribes to exercise their right to manage and
operate IHS health programs, or portions thereof, under Title I and
Title V, as well as those tribes who choose their health services to be
provided directly by the IHS. The IHS recognized that tribal decisions
to contract/compact or not to contract/compact are equal expressions of
self-determination.

[Title I Contracts and Title V Self-Governance Compacts]{.underline}

The IHS contracts/compacts with tribes and tribal organizations (T/TO)
pursuant to the authority provided under Title I and Title V of the
ISDA, as amended. This Act allows T/TO to enter into contracts/compacts
with the Government to plan, conduct, and administer programs that are
authorized under Section 102 of the Act. The IHS has been contracting
with T/TO pursuant to the authority of P.L. 93-638 since its passage in
1975. Today, the IHS currently administers self-determination contracts
under Title I and compacts authorized under Title V valued at more than
\$1 billion. Title V provides authorization to sign self-governance
compacts for a specific number of tribes who meet certain criteria.
Fifty-seven compacts and seventy-six funding agreements have been
negotiated to date with 280 tribes.

[IHS and Tribally-Operated Service Unit and Medical
Facilities]{.underline} (See Table)

The total dollars administered under ISDA contracts and compacts have
nearly doubled in recent years and the scope of services managed and
provided by tribal programs has also expanded greatly. Tribes have
historically assumed control of community services first and then
expanded into medical care. For example, the CHR program and
community-based components of the alcohol programs have been almost 100
percent tribally operated. Tribally operated hospitals have now started
to rise, and over 20 percent of the hospitals funded by IHS are managed
by tribes. This trend is expanding their scope and is also reflected in
the increasing number of ambulatory medical facilities now managed by
tribes.

# Self-Determination Implementation: Contract Support Cost Funding

Because the rate of T/TO entering into self-determination contracts and
compacts has been steadily increasing, the demand for contract support
cost (CSC) funding to support T/TO in their contracting/compacting has
also increased. The CSC funding is authorized pursuant to Section
106(a)(2) of the ISDA. This funding has been used by T/TO to develop
strong, stable tribal governments that have in turn enabled them to
professionally manage their contracts/compacts and the corresponding
services to their communities. Additionally, through the funding of CSC,
the IHS has helped in the development of T/TO who are maturing and now
achieving greater levels of self-sufficiency in all areas.

It is critical to point out that the requested increases for CSC are
attributed to increased contracting and compacting by T/TO under both
Title I and V of the ISDA, a stated goal of both the Congress and the
IHS. The Agency has taken steps to ensure that funding provided is
allowable, allocable, reasonable, and necessary. The T/TO have, out of
necessity, borne some of the burdens of administrative streamlining. The
IHS has, beginning in FY 1995, provided administrative shares of its
budget to T/TO associated with their contracting and compacting
activities.