On July 29, 1994, the director of the Indian Health Service signed a two-page memorandum saying the agency would help patients reach traditional healers. The money is not in that memorandum. It is in an undated document attached to it, signed by an earlier director, Emery A. Johnson, setting out policy and procedures under the American Indian Religious Freedom Act of 1978. That attachment is where the agency says contract health care funds can be authorized to pay for a native healer consultation when necessary.
Neither paper says how. Neither defines a healer, sets a rate, or creates a code. The 1994 memorandum reaffirms the existing policy under the 1978 statute and promises new ones later.
Those took thirty years. On October 16, 2024, the Centers for Medicare and Medicaid Services told tribal leaders it had approved four state Medicaid waiver amendments allowing coverage of traditional health care practices for the first time. By late September 2026 two more states had been added.
That is the story in this subject right now, and it is a payment story rather than a survey of ceremonies. Something that existed for centuries outside any insurance system, and then for decades inside a federal policy with no mechanism attached, now has a billing code and an approval letter with an expiration date on it.
What follows stays on that record: what the documents say, who wrote them, and where they disagree. It does not describe ceremonies, because the people whose ceremonies they are have been clear that describing them is not an outsider’s job, and because the documents themselves push every substantive definition back to the individual nation.
What was approved, and two documents that describe it differently
The October 2024 letter from Medicaid’s federal administrator is addressed “Dear Tribal Leader” and runs through four section 1115 demonstration amendments, a mechanism that lets a state test coverage outside the ordinary Medicaid rules. The practices it names as examples are sweat lodges, smudging, talking circles and herbal remedies. It also states that traditional practices can vary among federally recognized Tribes in the United States, which is the agency conceding the definitional point in its own first page.
Then there is a difference worth naming. The letter says the coverage reaches Indian Health Service facilities, Tribal facilities and Urban Indian Organizations in California, New Mexico and Oregon, while in Arizona it applies only to Indian Health Service and Tribal facilities. The press release the department issued the same day describes the coverage as provided by Indian Health Service facilities, Tribal facilities and urban Indian organizations without the Arizona limitation.
Two federal documents, one date, two scope statements. This article does not resolve that, because resolving it would require a judgment neither document supports. If you are an urban Indian organization in Arizona trying to work out whether you can bill, the letter and the press release point different ways, and the letter is the operational document.
The map has since grown. The Medicaid demonstration record for Utah’s Traditional Healing Demonstration shows an approval date of September 25, 2026, effective October 1, 2026 through September 30, 2031. Maine’s approval letter carries the same September 25 date, with its terms and conditions recording a September 23 approval of the renewal, and it adds Traditional Health Care Practices as a new authority through the same five-year window. The National Indian Health Board, which represents tribal health interests in Washington, reported both approvals on September 29, 2026 and noted that the scope of each waiver differs and that other state proposals remain pending.
How a ceremony becomes a billable service
The machinery here is dull and completely decisive, so it is worth walking through.
American medical billing runs on codes. A clinic cannot be paid for anything it cannot name in the system a payer reads. Maine’s approval document points to an existing code, HCPCS H0051, described there as covering traditional healing services, and treats the presence of that code as existing billing infrastructure the state can use. One line in a code set is the difference between a service that exists administratively and one that does not.
The documents also define which buildings count rather than which practitioners do. Maine’s terms describe covered facilities as those operated by Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act, alongside Indian Health Service facilities, with a footnote covering urban Indian organization facilities that receive agency funding. And before a state may claim federal dollars at all, it has to file an attestation with the federal agency.
Notice what is absent from every one of these documents. There is no federal definition of a traditional healer, no federal credential, no national registry and no examination. The payment flows to a facility, and who the facility recognizes is left where it already was.
Whose knowledge, and who decides
The question of whether “Indigenous healing” is even one subject has an answer in the record, and it is institutional rather than philosophical. Five sources point the same direction.
The federal Medicaid agency uses a category term and immediately says the practices vary among federally recognized Tribes. The Indian Health Service papers use “traditional medicine practices” and “native healer”, and the attached procedures give each Area Office the duty to consult the Native Americans in its own area rather than apply a national standard. The graves protection statute defines sacred objects by reference to traditional Native American religious leaders and their present-day adherents without ever defining those leaders federally. The arts and crafts statute defines an Indian as a member of an Indian tribe, or a person certified as an Indian artisan by a tribe, which hands the determination to the nation.
The fifth is the one that answers the credentialing question in Indigenous-led words. In a comment letter dated May 2, 2024, National Indian Health Board chairperson William Smith of the Valdez Native Tribe wrote to the Medicaid administrator about the draft framework for reviewing exactly these demonstration proposals. Tribes, the letter states, have already created various means of verifying the skill and qualifications of practicing traditional healers, and it names three: tribal-based traditional healer associations, specialized tribal review councils, and tribal letters of endorsement. The same letter asks that the framework protect the authority of traditional medicine practitioners to determine and complete the appropriate course of services, and that it caution against using Western benchmarks to evaluate Indigenous practices of medicine.
So the answer is not that the category is meaningless, and not that it names one thing. Every document that uses the category pushes the substance of it down to the individual nation. That observation is this article’s, drawn from what the documents do, and not a finding any single one of them states.
You can see the same structure in a tribe’s own written policy. Redding Rancheria’s tribal government policy TP 10-200 was adopted by tribal council resolution on May 15, 2008. It puts traditional health services under the tribe’s Cultural Resources Program and charges that program with administering funds provided annually by the Indian Health Service. Among its activities it lists providing individual access, on a limited basis, to traditional healers and healing practices.
Its definitions section is marked reserved. The policy sets out no credentialing process at all. That is not an oversight. It is what a policy looks like in a community where the question of who a healer is does not need a form.
There is also a federal absence worth reporting. The National Center for Complementary and Integrative Health, the agency that publishes consumer pages on dozens of practices, has no health topic page on Indigenous, Native American, American Indian or Alaska Native healing. A check of its A to Z index in October 2026 found entries for traditional Chinese medicine and naturopathy and nothing under any of those headings.
Where the evidence sits
Tradition is history, and history by itself says nothing about whether something works. The honest position in most of this subject is that the practices have not been tested in the form they are practiced, partly because testing them would require the kind of standardization the communities concerned have not asked for.
One recent trial is a real exception and is worth reporting precisely. Published in JAMA Internal Medicine in 2026, the MUTTON-HF study randomized 206 adults with heart failure at two Indian Health Service sites in the rural Navajo Nation, all of whom had been hospitalized or seen in an emergency department in the previous year. Half received eight weeks of medically tailored meals built around traditional Navajo foods and recipes, designed using community-based participatory methods. Half received usual dietary advice.
Within 90 days, 40.6 percent of the intervention group had a hospitalization or emergency visit against 57.0 percent of the comparison group, a relative risk of 0.72 with a 95 percent confidence interval of 0.54 to 0.96. Heart failure hospitalizations specifically ran 4 against 13. Food security measures and quality-of-life scores improved more in the meal group.
Read that for what it is. It is an open-label trial of a food program over twelve weeks of follow-up against usual advice, built around one nation’s foods, and it measures hospital use rather than survival. It is also a measured benefit from a culturally grounded intervention, designed with the community that would receive it, and it is the kind of result that gets ignored when a subject is treated as folklore.
A second 2026 paper shows what the design work looks like. Writing in the Journal of Public Health Research, a team including the California Consortium for Urban Indian Health describes convening a guiding coalition of traditional healers and knowledge keepers. Cultural leaders, young people and people with lived experience sat with academic researchers to build an evaluation framework for crisis response across California’s Indigenous communities.
Its working categories came from Indigenous definitions of health: Indigenous spirituality, cultural practices, world view and place-based sacred sites. The authors are clear about what they produced. It is a toolkit awaiting pilot testing, not an outcome study.
What federal law protects
The statute most often described as protecting Native religion protects less than its reputation suggests, and the shape of what followed is the interesting part.
The American Indian Religious Freedom Act of 1978 is a single sentence of policy. It declares that it shall be the policy of the United States to protect and preserve for American Indians their inherent right to believe, express and exercise their traditional religions, including access to sites, possession of sacred objects and worship through ceremonials. It names no remedy, no enforcement mechanism and no agency duty. Calling it a protection overstates it; calling it meaningless understates it, because it became the hook for later consultation policy.
In 1990 the Supreme Court decided Employment Division v. Smith. Congress, writing four years later, described the holding bluntly in its own findings: that the First Amendment does not protect Indian practitioners who use peyote in Indian religious ceremonies. The 1994 amendment then wrote one narrow, enforceable protection. Use, possession or transportation of peyote by an Indian, for bona fide traditional ceremonial purposes in connection with the practice of a traditional Indian religion, is lawful and may not be prohibited by the United States or any state.
The graves protection statute, enacted November 16, 1990, did something similar with objects. It defines cultural patrimony as an object of ongoing importance central to a Native American group or culture, rather than property owned by one person. Such an object, the statute says, cannot be alienated, appropriated or conveyed by any individual, regardless of whether that individual belongs to the tribe. Congress wrote that into law. It is the legal answer to the argument that one Native person’s permission settles the matter. The same Act allows a museum to keep requested items only where they are indispensable to a scientific study of major benefit to the United States, and requires return within 90 days of the study’s completion.
Internationally, the instrument that matters is the United Nations Declaration on the Rights of Indigenous Peoples, adopted as resolution 61/295 in September 2007. A separate article in this library sets out what its Article 24 says about medicines and medicinal plants. The provision this article turns on is Article 31, which recognizes the right to maintain, control, protect and develop traditional knowledge, including medicines and knowledge of the properties of flora and fauna, and intellectual property over it. The text here was read at the Canadian Department of Justice’s reproduction, since the United Nations server blocks automated retrieval. How benefit-sharing treaties operate as institutions is the subject of a separate article in this series.
The asymmetry Congress wrote into the criminal code
Put two federal provisions next to each other and the gap in American law becomes obvious.
Under the arts and crafts statute, offering or selling a good in a manner that falsely suggests it is Indian produced is a federal crime. A first offense by an individual carries a fine of up to $250,000, up to five years in prison, or both. A first offense by a business carries up to $1,000,000. The civil remedies include injunctions, treble damages and a per-day minimum.
Now look for the equivalent provision covering a person who sells a ceremony, claims to be a medicine person, or advertises Native American healing sessions. There isn’t one. Congress built six-figure criminal penalties around mislabeling a beaded bracelet and wrote nothing comparable about mislabeling a sweat lodge.
What exists instead is ordinary criminal law applied after people are hurt. In October 2009, three participants died following a sweat lodge event at a commercial retreat center near Sedona, Arizona: Kirby Brown, 38, James Shore, 40, and Liz Neuman, 49. The operator, who was not Native, was convicted in June 2011 of negligent homicide in all three deaths and acquitted of the greater charge of reckless manslaughter. Reporting the verdict, Indian Country Today quoted its own West Coast editor, Valerie Taliman, who is Navajo, describing the event as a bastardized version of a sacred ceremony and the operator as a huckster posing as the real thing. She is a journalist writing in an Indigenous-owned publication, not a tribal government, and that is how she should be read.
There is also a statement in the tradition’s own voice. On March 13, 2003, Chief Arvol Looking Horse, the nineteenth generation Keeper of the Sacred White Buffalo Calf Pipe, issued a proclamation on the protection of ceremonies, published by Indian Country Today that April. Regarding the Seven Sacred Rites, it states that no non-Natives will be allowed in the sacred Ho-c’o-ka, and that at the Sundance the only participants in the center will be Native people. It also asks that no price be charged for participation in any sacred ceremony, while allowing that gifts may be given freely afterward.
That is one named office-holder speaking with stated authority over specific Lakota, Dakota and Nakota rites. It is not a rule for hundreds of other nations, and it should never be reported as one.
If you are not Native, what this means
The practical answer is narrower than either the respectful version or the scolding version of this article would suggest.
Almost nothing described above is available to you, and that is by design rather than by oversight. The Medicaid coverage runs through Indian Health Service, tribal and urban Indian facilities and serves the people those systems serve. The peyote protection runs to an Indian as federal law defines the term, for ceremonial purposes. The ceremonies in the Looking Horse proclamation are closed by the stated decision of the person responsible for them.
What is available to you is a set of checks when someone offers you a version of it for money.
- Who is this person accountable to? A tribal healer association, a tribal review council or a letter of endorsement from a nation are the mechanisms the National Indian Health Board named. A workshop certificate is not one of them.
- Can the tribal nation being invoked confirm the claim? Nations answer questions about their own members. Nobody else can answer for them.
- Is there a price on a ceremony? The most widely circulated Native statement on this asks that there not be.
- Is this being offered in place of care for something that has a diagnosis?
That last question is the one with a body count attached, and it deserves to be plain. If you have chest pain, a lump, bleeding that is new, a wound that is not healing, a child who is getting worse rather than better, or a condition someone has already treated you for, those belong in front of a clinician this week, whatever else you are doing. Three people died in a commercial imitation of a ceremony in 2009, and the operator was not a healer of any tradition.
The most useful thing to take from the record is that the arguments about authenticity have largely been settled, in writing, by the people and institutions with standing to settle them. Congress put the identity determination inside tribal governments. The federal health agency put the verification of healers inside tribal structures and said so again in 2024. A Lakota office-holder published what he was asking of outsiders in 2003. None of it requires an outsider’s judgment, and all of it is public.
Sources
- Centers for Medicare and Medicaid Services. “Dear Tribal Leader letter: Medicaid and CHIP coverage of traditional health care practices (October 16, 2024).” medicaid.gov
- Centers for Medicare and Medicaid Services. “Biden-Harris Administration Takes Groundbreaking Action to Expand Health Care Access by Covering Traditional Health Care Practices (press release, October 16, 2024).” cms.gov
- Centers for Medicare and Medicaid Services. “Utah Traditional Healing Demonstration, section 1115 demonstration and waiver record (approved September 25, 2026; effective October 1, 2026 to September 30, 2031).” medicaid.gov
- Centers for Medicare and Medicaid Services. “Maine's Whole Person Care Waiver, section 1115 demonstration approval and special terms and conditions (September 25, 2026), including Traditional Health Care Practices and HCPCS code H0051.” medicaid.gov
- Indian Health Service. “Special General Memorandum 94-08, Statement of Policy for the Traditional Cultural Advocacy Program (July 29, 1994), signed by Michael H. Trujillo, M.D., M.P.H., Assistant Surgeon General and Director, together with its attachments, including the undated 'Policy and Procedures in reference to P.L. 95-341' signed by Director Emery A. Johnson, M.D., which carries the contract health care funds authorization and the Area Office consultation duty.” ihs.gov
- National Indian Health Board. “Comment on the Draft Framework for Reviewing Demonstration Proposals Including Traditional Health Care Practices, letter from Chairperson William Smith to CMS Administrator Chiquita Brooks-LaSure (May 2, 2024).” nihb.org
- National Indian Health Board. “CMS Approves Traditional Healing Waivers for Maine and Utah (September 29, 2026).” nihb.org
- U.S. Government Publishing Office. “42 U.S.C. 1996a, Traditional Indian religious use of peyote (Pub. L. 103-344, October 6, 1994, 108 Stat. 3125), including the congressional finding on Employment Division v. Smith.” govinfo.gov
- U.S. Government Publishing Office. “25 U.S.C. chapter 32, Native American Graves Protection and Repatriation Act (Pub. L. 101-601, November 16, 1990), definitions at section 3001(3) and repatriation at section 3005.” govinfo.gov
- Legal Information Institute, Cornell Law School. “42 U.S.C. 1996, Protection and preservation of traditional religions of Native Americans (Pub. L. 95-341, August 11, 1978, 92 Stat. 469).” law.cornell.edu
- U.S. Department of the Interior, Indian Arts and Crafts Board. “The Indian Arts and Crafts Act of 1990, including 18 U.S.C. 1159 prohibitions, the definition of Indian, and criminal and civil penalties.” doi.gov
- Advisory Council on Historic Preservation. “United Nations Declaration on the Rights of Indigenous Peoples (General Assembly resolution 61/295, adopted 13 September 2007 at the 107th plenary meeting).” achp.gov
- Department of Justice Canada. “United Nations Declaration on the Rights of Indigenous Peoples, full text (reproduction used here for Articles 24 and 31, the United Nations server being closed to automated retrieval).” justice.gc.ca
- Redding Rancheria. “Tribal Government Policy TP 10-200, Traditional Health Program (adopted by Tribal Council Resolution #040-05-15-08, May 15, 2008).” reddingrancheria-nsn.gov
- National Center for Complementary and Integrative Health, National Institutes of Health. “Health Topics A-Z (checked October 2026; no entry for Indigenous, Native American, American Indian, Alaska Native or traditional healing).” nccih.nih.gov
- Eberly LA, George C, Sandman S, et al.. “An Indigenous Food Is Medicine Intervention: The MUTTON-HF Randomized Clinical Trial. JAMA Intern Med, 2026;186(9):1077-1087. PubMed. DOI: 10.1001/jamainternmed.2026.2879.” pubmed.ncbi.nlm.nih.gov
- Armenta-Belen K, Rey L, Severns J, et al.. “Cultural Guideposts of Health: A crisis response evaluation framework for California's diverse Indigenous communities. J Public Health Res, 2026;15(1). PubMed. DOI: 10.1177/22799036251410263.” pubmed.ncbi.nlm.nih.gov
- ICT (Indian Country Today). “James Arthur Ray Found Guilty of Negligent Homicide (June 23, 2011), including comment from West Coast Editor Valerie Taliman (Navajo).” ictnews.org
- ICT (Indian Country Today). “Looking Horse Proclamation on the Protection of Ceremonies, by Chief Arvol Looking Horse, 19th Generation Keeper of the Sacred White Buffalo Calf Pipe (proclamation dated March 13, 2003; published April 25, 2003).” ictnews.org