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).
Tribal nations across North Dakota continue working to expand behavioral health services for their communities. Yet one of the most significant barriers is not a lack of motivation or clinical expertise, but a decades-old federal Medicaid regulation that restricts how behavioral health treatment facilities can be built and funded.
Approximately 10% of Native Americans meet criteria for a substance use disorder, including 7.1% with alcohol use disorder and 4% with illicit drug use disorder (American Addiction Centers, 2025). Nearly one-quarter report binge drinking in the past month, and Native American young adults experience substance use disorders at nearly twice the rate of the general population. Mental health disparities follow similar patterns. Native and Indigenous adults experience serious psychological distress at more than twice the rate of the overall U.S. population, and suicide rates among Indigenous adolescents are more than double those of non-Hispanic White peers (Mental Health America, 2022). Despite this elevated need, treatment access remains substantially lower than demonstrated demand.
These national trends are reflected locally. SHIFT Nursing (2022) describes large areas of North Dakota as “mental health care deserts,” with insufficient outpatient and inpatient behavioral health services. Community health assessments consistently identify mental health as one of the state’s leading unmet health needs. Native American communities face particularly high burdens. More than one-quarter of Native American adults in North Dakota reported experiencing depression in recent assessments, and suicide rates among Native American residents were substantially higher than statewide and national averages (SHIFT Nursing, 2022). Geographic isolation, transportation challenges, provider shortages, and limited culturally grounded services further compound barriers to care.
Within this context of high need and limited service availability, tribal health systems in North Dakota have sought to develop local behavioral health treatment programs that are accessible and culturally responsive. However, federal Medicaid policy imposes a critical limitation. The Institution for Mental Disease (IMD) exclusion restricts federal Medicaid reimbursement for most adults receiving treatment in behavioral health facilities with more than sixteen beds when the primary focus is mental health or substance use care. While originally intended to prevent long-term institutionalization decades ago, this regulation now limits the financial feasibility of modern treatment facilities in rural and underserved settings.
Tribal leaders in North Dakota have identified the IMD exclusion as a primary barrier to expanding tribally operated treatment programs (North Dakota Monitor, 2025). Smaller facilities often struggle to remain financially sustainable, while larger facilities capable of meeting regional demand cannot receive Medicaid reimbursement for most adult patients. As a result, many individuals must travel long distances for treatment or rely on crisis stabilization services and emergency departments. This contributes to delayed care, fragmented treatment continuity, and increased strain on an already limited behavioral health system.
This policy issue sits at the intersection of federal Medicaid regulation, state health system planning, and tribal health sovereignty. Examining how the IMD exclusion affects behavioral health service development in North Dakota’s tribal communities provides an opportunity to assess whether current reimbursement structures align with contemporary public health needs.
References
American Addiction Centers. (2025). Native American addiction statistics and demographics.
https://americanaddictioncenters.org/rehab-guide/addiction-statistics-demographics/native-americans
Mental Health America. (2022). Native and Indigenous communities and mental health.
https://mhanational.org/position-statements/native-and-indigenous-communities-and-mental-health/
North Dakota Monitor. (2025). North Dakota tribal treatment programs hindered by archaic regulation, leaders say.
https://northdakotamonitor.com/2025/10/29/north-dakota-tribal-treatment-programs-hindered-by-archaic-regulation-leaders-say/
SHIFT Nursing. (2022). A mental health care desert: Disparities in North Dakota’s mental health resources.
https://www.shiftnursing.com/articles/mental-health/
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I have a child with mental health challenges, and trying to access care for him has been a twenty-year nightmare. I can not imagine what it is like when other health disparities and societal barriers add to the challenge.
Thank you for shining a light on this. Your format is beautiful and culturally inspiring.
I can't help but wonder if telehealth is a mediating resource. I think direct personal presence is critically important, but perhaps the telehealth format could be designed with cultural norms in mind. I'm sure you have explored this, and it may be addressed in your other posts.
I read Richer (2025) below, and that was full of creative ideas for low-cost digital strategies for indigenous populations, only it had an urban emphasis. They used AI to match people with culturally resonant providers. What is possible is now being re-evaluated. I have even heard of AI used as a therapist.
Prochaska et al. (2021) frequently cite Woebot as an example of a chatbot that was effective in addressing substance abuse.
Prochaska, J. J., Vogel, E. A., Chieng, A., Kendra, M., Baiocchi, M., Pajarito, S., & Robinson, A. (2021).
A randomized controlled trial of a therapeutic relational agent for reducing problematic substance use during the COVID-19 pandemic. Drug and Alcohol Dependence, 229, 109091. https://doi.org/10.1016/j.drugalcdep.2021.109091
Richer, A. M. S., et al. (2025). Culturally tailored tele-mental health care linkage for urban Indigenous populations. JMIR Research Protocols.
Mason,
I appreciated how you described how behavioral health needs in tribal communities are affected by policy barriers like the IMD exclusion. The stats (always so powerful!) and local examples really helped me understand why this is such an important issue. Do you have any personal or professional connections as to why this topic matters to you or connects to your own work?
Dr M
Your post offers a thoughtful and well supported overview of the behavioral health challenges facing tribal communities in North Dakota. I appreciate how clearly you connect the epidemiologic data with the structural barriers that shape access to care. The disparities you highlight, such as elevated rates of substance use disorders among Native American adults (American Addiction Centers, 2025) and the disproportionate burden of serious psychological distress and suicide risk (Mental Health America, 2022), reflect long standing patterns that I see echoed across rural and underserved regions and the native communities in my own state. These statistics underscore the depth of need and the importance of expanding culturally grounded, community based behavioral health services.
Your discussion of the IMD exclusion is especially important because it illustrates how a policy originally designed to prevent institutionalization now functions as a barrier to modern, community driven treatment models. As you note, tribal leaders in North Dakota have identified this regulation as a major obstacle to developing sustainable treatment facilities (North Dakota Monitor, 2025). This resonates with broader conversations happening nationally about how Medicaid financing structures can unintentionally limit access in rural and tribal settings, where small facilities struggle to remain viable and larger facilities become ineligible for reimbursement. The result, as SHIFT Nursing (2022) describes, is a landscape of “mental health care deserts” where individuals must travel long distances or rely on emergency departments during crises.
I also appreciate the way you frame this issue at the intersection of federal regulation, state planning, and tribal sovereignty. Tribal nations have the cultural expertise and community trust needed to design treatment programs that integrate traditional healing practices and address the social determinants of health unique to Indigenous communities. Yet without the ability to secure Medicaid reimbursement for facility based care, these efforts are constrained by financial and regulatory limitations. Your post emphasizes that the challenge is not a lack of motivation or clinical capacity, but a policy environment that has not kept pace with contemporary behavioral health needs.
Overall, your analysis reinforces the importance of aligning reimbursement structures with the realities of rural and tribal health systems. Revisiting the IMD exclusion, particularly in the context of tribal health sovereignty, could open the door to more sustainable, culturally responsive behavioral health services. Your post brings needed attention to this issue and contributes meaningfully to ongoing conversations about equity, access, and policy reform. I look forward to reading more.
References
American Addiction Centers. (2025). Native American addiction statistics and demographics.
https://americanaddictioncenters.org/rehab-guide/addiction-statistics-demographics/native-americans
Mental Health America. (2022). Native and Indigenous communities and mental health.
https://mhanational.org/position-statements/native-and-indigenous-communities-and-mental-health/
North Dakota Monitor. (2025). North Dakota tribal treatment programs hindered by archaic regulation, leaders say.
https://northdakotamonitor.com/2025/10/29/north-dakota-tribal-treatment-programs-hindered-by-archaic-regulation-leaders-say/
SHIFT Nursing. (2022). A mental health care desert: Disparities in North Dakota’s mental health resources.
https://www.shiftnursing.com/articles/mental-health/