Economic stress and geographic isolation are barriers to proper veterinary care for horses on Native American reservations. The 2011 South Dakota (SD) Equitarian Survey was distributed to 135 equine veterinarians in SD to detect perceptions of effectiveness and best methodologies for improving reservation equine welfare. There was a positive correlation (P < .005) between the perceived importance and effectiveness of increased veterinary access and the importance of free care and owner knowledge in changing the health and welfare of SD’s reservation equine population. Thirty-nine percent of respondents claimed to have an interest in providing help for reservation equines; those with no veterinary experience on reservations tended not to have interest (P = .05). Previous experience practicing on a reservation impacted how crucial they believed horse owner knowledge or awareness was in changing the health and welfare of reservation equines (P < .04). The most commonly noted health threat and strength were poor nutrition and the absence of internal disease, respectively. In a subsequent analysis, 299 horses on the Cheyenne River Sioux Reservation were observed for welfare indicators and divided into groups by use: saddle, production, bucking stock, and performance. Average body condition score was 5 of 9 and did not differ between the four groups. Coat (P < .001) and hoof (P < .007) conditions varied between groups, with optimal conditions in the performance and saddle horse groups, respectively. Variable hoof, coat, and vaccination practices among the groups of reservation equines present an opportunity for health care education and welfare improvement.