Self-governance is an important legal right as well as a political and moral goal for many Native Americans in the United States. In this paper, I study policy changes that make it easier for tribal governments to exercise their self-governance rights to assume managerial control over the operation of Indian Health Service (IHS) facilities through specialized contracts called “compacts”. Since compacting with IHS was allowed in the 1990s, tribal governments have assumed control over more than half of IHS facilities. I gather data on IHS facilities from 1990 to 2019, which provides a way to measure the self-governance status of IHS facilities. I use the CDC Multiple Cause of Death county-level data to construct measures of mortality rates over time. Using a staggered adoption difference-in-differences design, I estimate that all-cause mortality increased by 16.3% following the change to self-governance. Therefore, on average, health outcomes worsen after take-up of tribal control. However, I find substantial treatment effect heterogeneity. For example, the Alaska region- which has more funding and reportedly higher administrative capacity- experiences an 15.1% decrease in mortality. Furthermore, I show that the presence of a tribal casino completely negates the negative impact. To better understand how to interpret these results, I also use a logistic model as well as a logistic LASSO to explore several potential explanatory factors to predict take-up of compacts with IHS. Mortality leads are generally not predictive, but regional fixed effects as well as exposure to laws decreasing tribal control are predictive. Therefore, tribal governments and citizens likely see a large benefit beyond direct impacts on health. Taken together, these results suggest that there is a decrease in health following the take-up of compacts which can be negated with higher revenue and administrative capacity.