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I had the opportunity to interview Jonathon Holth, who serves as North Dakota’s Commissioner of Recovery & Reentry. In this role, Holth works across state agencies, local governments, and communities to improve outcomes for individuals experiencing addiction and those transitioning back into society after incarceration. His position was created to elevate recovery and reentry as key priorities within the state.

Behavioral health access remains a significant challenge for tribal communities in North Dakota, shaped by federal policy, structural inequities, and persistent resource gaps. One policy with a substantial impact is the Medicaid Institution for Mental Diseases (IMD) exclusion. Established in 1965, the IMD exclusion prevents Medicaid from reimbursing care for adults ages 21–64 in psychiatric facilities with more than 16 beds. Although originally grounded in evidence supporting deinstitutionalization, this policy has had unintended consequences for tribal populations, where access to community-based behavioral health services is often limited.

Previous posts in this blog explored the challenges tribal communities face when accessing behavioral health services. While those discussions highlighted disparities and regulatory barriers, improving tribal behavioral health systems requires understanding how healthcare policies are created, implemented, and changed. Behavioral health programs serving tribal communities are shaped by statutory laws, regulatory agencies, and multiple levels of government authority. Because these systems operate across federal, state, and tribal jurisdictions, policy advocates must navigate a complex policy landscape to accomplish meaningful reform.

Historical Framing: Cost Control and Deinstitutionalization

If you live in North Dakota, you’ve likely heard how difficult it can be to access mental health or substance use treatment. For some, getting care means driving long distances, waiting weeks for an appointment, or turning to emergency departments during a crisis. These challenges are even more pronounced in tribal communities, where behavioral health needs are high and culturally responsive treatment options remain limited (American Addiction Centers, 2025; Mental Health America, 2022; SHIFT Nursing, 2022).