Ahmad Razaghi is the CEO of Razaghi Healthcare, a Scottsdale, Arizona-based firm that supports Native Nations in developing and managing private healthcare systems through PL 93-638 Indian Self-Determination contracting. In this work, he advises tribal boards on corporate governance, strategic planning, and approaches to securing funding that can strengthen tribal health programs. His experience includes helping establish tribal corporations that meet U.S. Department of Health and Human Services and Indian Health Service requirements, and guiding organizations through accreditation, licensure, and contract continuity challenges. He also led efforts that negotiated a historic $200 million settlement for a 638 Corporation with the Department of Health and Human Services and the Indian Health Service. The article below reviews how 638 contracts can expand tribal control of care, while also introducing the operational and compliance demands these agreements can bring.
638 Contracts – Opportunities and Challenges for Tribal Health
For many Native American communities, access to quality healthcare has long been a challenge. Geographic isolation, systemic barriers, and chronic underfunding have made it difficult for tribes to deliver the care their members need. Over the years, one legal framework has helped change that dynamic: the Indian Self-Determination and Education Assistance Act of 1975 (PL 93-638). Commonly called 638 contracts, these agreements let tribes take direct control of health, education, and social service programs that were once managed by federal agencies.
At their heart, 638 contracts give tribes the ability to design, run, and manage their own healthcare systems. Under a typical agreement, a tribal nation negotiates a multi-year contract with the U.S. Department of Health and Human Services (DHHS) and the Indian Health Service (IHS) to receive federal funding for health programs. That funding can cover everything from hospital operations to community clinics, public health initiatives, and administrative support. By taking the reins, tribes gain the flexibility to tailor programs to their communities’ cultural, social, and geographic needs, moving away from the “one-size-fits-all” federal approach.
The benefits can be profound. Studies show that tribally operated healthcare programs often deliver higher patient satisfaction, better continuity of care, and stronger community engagement compared with federally managed systems. Tribes can offer culturally tailored programs, hire local staff, and make investments that align with their community’s priorities. Financially, 638 contracts allow tribes to control their budgets directly, directing resources toward preventive care and chronic disease management. Additionally, tribes can earmark funds for behavioral health services. These areas are critically important in communities facing higher rates of diabetes, heart disease, and mental health challenges.
That said, 638 contracts aren’t without their hurdles. Negotiating and managing these agreements takes strategic planning and legal expertise. Tribes need to stay on top of federal reporting requirements, audits, and quality standards. A misstep can risk funding or trigger federal intervention. On top of that, tribes now carry operational and financial responsibilities that the federal government previously managed. Staffing gaps, infrastructure needs, and unexpected health crises can quickly stretch resources, making strong leadership and contingency planning essential.
Real-world examples highlight both the promise and the pitfalls. Some tribes that successfully negotiate and manage 638 contracts have expanded services, stabilized finances, and retained skilled healthcare professionals. A powerful example of the potential impact of 638 contracts comes from Ahmad R. Razaghi’s work with tribal healthcare organizations. Razaghi led a team that negotiated a historic $200 million settlement for the 638 Corporation with the U.S. Department of Health and Human Services (DHHS) and the Indian Health Service (IHS). This settlement not only stabilized the organization’s finances but also safeguarded critical healthcare services for the community it served.
Other cases, where oversight or planning fell short, have struggled to maintain accreditation or deliver consistent care. These cases emphasize the importance of robust governance, ongoing training, and close collaboration with federal partners.
Ultimately, 638 contracts are about more than just funding; they are a tool for tribal sovereignty in healthcare. They allow Native nations to reclaim control, shape programs to meet local needs, and invest in long-term health outcomes. For tribal leaders, understanding the legal, financial, and operational dimensions of these agreements is critical. With careful planning, strong governance, and strategic execution, 638 contracts can transform healthcare delivery and create lasting benefits for generations.
About Ahmad Razaghi
Ahmad Razaghi is the CEO of Razaghi Healthcare, collaborating with Native Nations on PL 93-638 Indian Self-Determination contracting and corporate governance. He advises tribal boards on planning and funding considerations, and supports organizations in meeting U.S. Department of Health and Human Services and Indian Health Service expectations. His work includes helping a tribal healthcare organization restore accreditation and licensure, secure a long term Indian Self-Determination Contract, and negotiate a historic $200 million settlement with federal partners. He holds an MBA from the University of Utah.