the Cherokee Indian Hospital in North Carolina. This community-based hospital, funded in part by the tribe's casino revenues, is guided by four core principles: "The one who helps you from the heart", "A state of peace and balance", "it belongs to you" and "Like family to me" "He, she, they, are like my own family". The hospital is based on the adoption of an Alaska Native model of healthcare called the "Nuka System of Care", a framework that focuses on patient-centered, self-determined health service delivery that heavily relies on Patient participation. The Nuka System of Care was developed by the Southcentral Foundation in 1982, a non-profit healthcare organization that is owned and composed of Alaska Natives. The Nuka System's vision is "A Native community that enjoys physical, mental, emotional and spiritual wellness". Every Alaska Native in the health system is a "customer-owner" of the system and participates as a self-determined individual who has a say in the decision-making processes and access to an intimate, integrated, long-term care team. When a customer-owner seeks care, their primary care doctor's foremost responsibility is to build a strong and lasting relationship with the beneficiary, and customer-owners have various options through which they can give input and participate in decisions about their health. These options include surveys, focus groups, special events and committees. The board is made up entirely of Alaska Natives who helped design the system and actively participate in running it effectively. Following the implementation of the Nuka System of Care in Alaska Native health, successes in improved standards of care have been achieved, such as increases in the number of Alaska Natives with a primary care provider, in childhood immunization rates, and customers satisfaction in regard to respect of culture and traditions. In addition, decreases in wait times for appointments, wait lists, emergency department and urgent care visits, and staff turnover have been reported. The North Carolina Cherokee Indian Hospital in 2012 as well as other tribes have implemented the Nuka System approach when planning their new or revamped health centers and systems. Some tribes are less optimistic about the role of Self Determination in Indian healthcare or may face barriers to success. Tribes have expressed concern that the 638 contracting and compacting could lead to "termination by appropriation", the fear that if tribes take over the responsibility of managing healthcare programs and leave the federal government with only the job of