638 self-determination, with an operator in the seat.
A 638 self-determination contract gives a tribe direct authority over clinical operations that would otherwise be run by IHS. IHA's clinic work is structured to hand that authority off on a defined timeline, with operational continuity and no gap in care.
What a 638 self-determination contract actually is.
Section 638 of Public Law 93-638, the Indian Self-Determination and Education Assistance Act, authorizes federally recognized tribes to contract with the Indian Health Service to operate health programs that IHS would otherwise run directly. The tribe receives the funding IHS would have spent, plus indirect cost allowances, and assumes operational authority over the program.
In practice: the tribe owns the clinic, hires the staff, sets the clinical priorities, and answers to its own tribal council rather than the IHS chain of command. The federal government remains the funder; the tribe becomes the operator.
The pathway is not a shortcut. It requires a tribal resolution, a contract proposal, compliance infrastructure, financial controls, and the operational capacity to run a health program. Most tribes need outside help to stand up that capacity. That is where IHA comes in.
Build. Operate. Transition.
Build
We stand up the clinic operation from scratch: site design, regulatory licensing, compliance architecture, RCM, credentialing, IT, and clinical staffing. In parallel, we structure the tribal employment model and the governance framework that the tribe will inherit. Build is typically 9 to 12 months.
Operate
IHA runs the clinic as a Management Services Organization under tribal direction. The tribe retains clinical authority; IHA handles the operational complexity. Operate includes quality assurance, audit readiness, workforce development, and the data infrastructure the tribe will need to demonstrate readiness for direct operation. Operate is typically 6 to 18 months.
Transition
The tribe assumes direct operation under a 638 contract. IHA's role shifts from operator to supporter: cross-site specialty services, shared infrastructure, technical assistance, and whatever the tribe wants to keep outsourced. Transition is a defined handoff, not a fade.
Our Northern California clinic is the first live transition.
Our Northern California clinic opens in June 2026. One month later, in July 2026, the clinic converts to operation under a 638 self-determination contract. The timeline is short on purpose.
Every non-physician role at the clinic is structured as direct tribal employment from day one. Governance, policy, quality assurance, and community accountability structures are all built to tribal standards before the 638 conversion. When the transition happens, operations do not have to change. They are already tribal.
Clinic opens, IHA management services, tribally-employed staff
Conversion to 638 self-determination contract
Direct tribal operation, IHA cross-site support continues
Who the pathway works for, and who it does not.
Good fit
- Federally recognized tribes with tribal resolution authority to contract under Public Law 93-638
- Tribes with community support for tribal operation of health services
- Tribes that want clinical authority, not just funding flow
- Tribes willing to build operational capacity, either in-house or through a partner like IHA
Not a fit
- Tribes that want a vendor to run a clinic indefinitely with no tribal operational handoff
- Tribes whose current IHS allocation would not support a contracted program (requires financial modeling)
- Tribes without the governance infrastructure to assume contracting authority (solvable, but not in this scope)
Evaluating 638 for your tribe?
Start with a scoping conversation. We will walk through the financial model, the governance implications, and the realistic timeline for your community.
Book a discovery callWant the consulting-side view?
Our 638, FQHC, and CAH consulting service line runs engagements independent of clinic operation.
See 638 consulting