Tribal healthcare organizations operate in a complex and dynamic environment where federal funding fluctuations, changes to Indian health services (IHS) and Medicaid programs, regulatory updates, and evolving community health needs can quickly disrupt clinic operations and patient care.
Medicaid and 340B program changes
Recent federal actions and legislation underscore the vulnerability of revenue streams on which Tribal clinics rely. The One Big Beautiful Bill Act (OBBBA) does not directly reduce Indian Health Service (IHS) appropriations or alter the 100% Federal Medical Assistance Percentage for services delivered to American Indian and Alaska Native Medicaid beneficiaries. However, by tightening rules on state Medicaid financing mechanisms and imposing stricter eligibility and redetermination processes, the OBBBA may indirectly affect Tribal health programs.
While Tribal, IHS, and Urban Indian health centers will retain their statutory eligibility for the 340B Drug Pricing Program — since participation is not tied to Disproportionate share hospital ratios — declines in Medicaid enrollment or service utilization could still reduce 340B savings and overall revenue.
These changes may increase administrative burdens and constrain state flexibility to sustain provider payments, creating downstream financial pressure for Tribal and Urban Indian health systems that depend heavily on Medicaid and 340B resources to support service delivery.
Planning for continuity of service
As essential community institutions, Tribal health clinics, hospitals, and programs must plan to maintain services, protect revenue, and ensure continuity during unexpected events. Developing a contingency plan encourages meaningful conversations among clinical, administrative, and Tribal leadership teams.
Effective contingency planning reflects the organization’s responsibility to the Tribal community, guiding operational decisions in a way that honors sovereignty, upholds cultural values, and ensures continuity of high-quality, culturally responsive care.
Tribal healthcare organizations face unique risks across clinical, administrative, financial, and governance operations:
Revenue Cycle Risks. Delays in Medicaid or IHS reimbursements, interruptions or cancellations in grant funding, billing errors, or claim denials may occur. Additional risks include state Medicaid variability in recognizing Tribal providers, restrictions such as the four walls rule, and reliance on encounter-rate billing or the 340B program. These unique rules make third-party revenue streams more fragile than those of non-Tribal providers.
Clinical Operations Risks. These risks include staff shortages, electronic health record (EHR) outages, supply chain disruptions, or temporary closure of services.
Human Capital Risks. Turnover in critical clinical or administrative roles are often compounded by the challenge of recruiting to remote reservation-based communities.
Compliance and Regulatory Risks. These risks include changes to federal or state reporting requirements, IHS or Office of Inspector General (OIG) audits, or loss of accreditation.
Community and Communications Risks. Maintaining patient trust and clear communication during service disruptions could be a risk, especially in communities where oral communication, Tribal radio, or community gatherings remain trusted channels.
Contingency planning process
Contingency planning is critical to helping your organization continue to provide care — especially for vulnerable populations — while maintaining operational and financial stability during crises. This four-step process can guide your preparation.
Identify your highest risk areas
A tool such as an enterprise risk assessment or business impact analysis can help you understand and prioritize your organization’s specific risks. It’s important to surface external and internal risk factors from many sources, so while this work is typically led by a senior management team, it’s critical to include staff, Tribal Council members, and community stakeholders in the process.
The next step after identifying risks is to choose those that are most likely to occur and would have the greatest impact on your organization to focus on for your initial contingency planning phase.
Plan for the most likely or highest impact scenarios
Spend time planning for three to five of the most likely or highest possible impact scenarios, including the worst-case scenario. Preparing for worst-case events — such as multi-week EHR downtime, pharmacy supply interruptions, or funding freezes — ensures the team can respond effectively to more moderate disruptions.
Once you’ve selected scenarios, develop strategies to address the risks in each of them. While strategies may be targeted and operational, or broader and policy oriented, identify which of them are permanent versus which can be temporary or reversible. In every scenario, the strategies should be informed by the mission and values of your Tribe.
Assign and track responsibilities
An owner within the staff or board should be assigned to be responsible for the execution and communication of each strategy. While some strategies and actions will apply to a specific scenario, others, such as a crisis communications strategy, will be applicable in all or most scenarios. Assigning clear owners for each strategy and defining triggers for action enable you to activate the plan quickly when disruptions occur.
Implement, monitor, and update
Once developed, the contingency plan should be shared with all staff, leadership, and the appropriate governing body — whether that is the Tribal council, a board of directors, or both.
The plan should be revisited and updated regularly to reflect changes in funding streams, staffing levels, technology, or community health needs. Ongoing communication with the governing body ensures oversight remains strong, decisions reflect community values, and sovereignty is upheld.
Contingency planning considerations for Tribal healthcare organizations
When undertaking contingency planning, your organization should consider your holistic operations and operating environment. These areas can include but are not limited to the following aspects of your organization.
Programs and clinical services
Evaluate all clinical programs and services to determine which are mission-critical, revenue-generating, and essential to patient outcomes. Primary care, behavioral health, pharmacy, and chronic disease management are often highest priority. Review contracts and grant agreements to understand obligations and potential penalties if services are reduced. Coordinate with other Tribal nations, Urban Indian Health Programs (UIHPs), and regional IHS facilities through memoranda of understanding (MOUs) to maintain critical services during disruptions in staffing or specialty coverage.
Tribal healthcare governance and engagement
Tribal healthcare governance structures vary, and contingency plans should reflect the system’s specific model. In some Tribes, the Tribal council serves as the governing body with direct oversight of health programs. In others — particularly those operating under Indian self-determination education and assistance act (ISDEAA) self-governance or as nonprofit corporations — a board of directors (or health board) may be established to oversee operations, finances, and strategy on behalf of the Tribe. Some systems have both, with the board handling operational oversight and the council retaining ultimate authority.
Contingency planning should clearly define:
Decision-making authority. Who makes urgent operational or financial decisions in a crisis — the council, the board, or delegated leadership?
Escalation protocols. When should issues be elevated from leadership to the board or council?
Sovereignty and cultural alignment. How do decisions reflect Tribal priorities, cultural values, and long-term community interests?
Jurisdictional coordination. How Tribal governance interacts with state, county, or federal emergency declarations while maintaining sovereignty?
Community engagement. Are there other structures — such as elders’ councils, youth advisory boards, and cultural committees — that should be included to reinforce trust and ensure culturally appropriate decision-making?
Clearly defining these roles and protocols in advance reduces confusion during crises, supports timely decision-making, and ensures accountability to both the Tribal community and external partners.
Caring for Tribal elders
Tribal elders often represent a vulnerable population with complex medical needs. Contingency planning should prioritize their care: maintaining medication schedules, monitoring chronic conditions, ensuring transportation for appointments, and providing home or telehealth services if clinic access is limited. Elder care planning should also integrate traditional healing practices — ceremonies, medicine men/women, and cultural wellness supports — which are essential components of holistic care. Maintaining a registry of elder patients and cross-training staff helps ensure continuity of services.
Provider engagement and clinical documentation
Maintaining patient volume and ensuring accurate, timely documentation are critical for revenue flow in Tribal clinics.
Providers should be educated and supported to:
See patients efficiently and consistently to maintain or increase clinic volume.
Close patient encounters and documentation on the same day of service to ensure billing can be submitted promptly.
Understand the link between thorough documentation, coding, and reimbursement, especially given unique Medicaid and IHS billing rules.
Collaborating with providers to reinforce these practices reduces delays in revenue cycle processes and mitigates the financial impact of lower patient volume or reduced funding.
Revenue cycle, finance and philanthropy
While the 340B drug pricing program is not unique to Tribal systems, it often plays an important role in their financial stability and in ensuring affordable access to medications — particularly in rural or reservation-based communities where other funding sources are limited. Contingency planning should account for potential risks to 340B revenue, such as eligibility changes, manufacturer restrictions, or pharmacy supply chain disruptions, which may have disproportionate effects on Tribal health programs.
Strategies may include:
Building relationships with foundations, corporate donors, and individual philanthropists.
Engaging Tribal members in giving campaigns to support local healthcare programs.
Leveraging philanthropic funds to pilot innovative services or fill gaps not covered by operational revenue.
Human resources
Identify critical roles across clinical, administrative, and revenue cycle functions. Develop succession and cross-training plans for essential positions. Workforce continuity planning should also emphasize Tribal workforce sovereignty — developing and retaining Tribal members in healthcare roles through partnerships with Tribal colleges, loan repayment programs, and pipeline initiatives.
Technology and data management
Document critical systems, including EHRs, telehealth platforms, scheduling software, and billing systems. Develop disaster recovery plans and backup workflows for potential outages. Cybersecurity protections are essential — but so is Tribal data sovereignty. Plans should clearly define data ownership, storage, and sharing agreements with state and federal agencies to protect both patient privacy and Tribal governance authority.
Communications
Develop a crisis communications plan for internal and external audiences, including staff, patients, Tribal leadership, funders, and community partners. Incorporate culturally appropriate messaging and traditional communication channels such as Tribal radio, newsletters, and community gatherings. Engaging respected elders or cultural leaders as spokespersons can help sustain trust during disruptions.
Increasing your organizational resilience
Contingency planning is not about reducing patient volumes or cutting services indiscriminately. Instead, it is an opportunity to review all clinical and operational processes with a lens of efficiency and sustainability. Examine workflows, resource allocation, staffing models, and program operations to identify opportunities for improvement, waste reduction, or process optimization — without compromising mission-critical services or culturally responsive care.
At the same time, some difficult but strategic decisions may be necessary, such as temporary reductions in non-essential services, redeployment of staff, or adjustments to clinic hours. These decisions should be guided by the organization’s priorities, community health needs, and financial realities, rather than default cost-cutting. Thoughtfully balancing efficiency and mission ensures continuity of care while strengthening long-term operational resilience.
Proactive planning enables Tribal healthcare organizations to protect patient care, stabilize revenue, and maintain both cultural and operational resilience — even in uncertain times.
