In a significant triumph for Native American tribes, the United States Supreme Court recently ruled that tribes will no longer face financial penalties when they choose to manage their own health-care services in lieu of the federal government. The court’s decision is set to have far-reaching implications for tribal health-care administration, potentially leveling the playing field between tribes and the Indian Health Service (IHS).
Historical context provides vital background: the federal government, through the Indian Health Service, initially administered tribal health care. However, in 1975, the Indian Self-Determination and Education Assistance Act (ISDA) empowered tribes to contract with the federal government to take control over several programs and services, including health care. Under these contracts, tribes were obligated to collect funds from third-party payors such as private insurers, Medicare, and Medicaid, and utilize these “program income” collections to support their health-care services.
Initially, the ISDA fell short of its promise of equality as tribes incurred higher administrative costs, which the IHS managed to avoid by relying on other federal agencies for support. This situation effectively imposed financial burdens on tribes for choosing self-determination. Subsequent amendments to the ISDA aimed to address these disparities by making contract support costs recoverable through litigation, but the IHS resisted compensating tribes for these contractual expenses.
The Supreme Court’s recent decision consolidating Becerra v. San Carlos Apache Tribe and Becerra v. Northern Arapaho Tribe marks a pivotal point in this ongoing battle. By a 5-4 vote, the Court affirmed that contract support costs linked to expenditure of program income are recoverable, thereby dismissing the federal government’s argument that tribes have broader discretion over spending program income compared to the IHS.
Chief Justice Roberts, who authored the court’s opinion, highlighted that the decision underscores self-determination, noting that any concerns about the high costs of contract support cost reimbursements fall under Congress’s domain, not the court’s. The dissent by Justice Brett Kavanaugh, joined by Justices Clarence Thomas, Samuel Alito, and Amy Coney Barrett, cautioned about the substantial increase in federal appropriations that would result from this ruling, disrupting the status quo maintained for the past 30 years.
This ruling is a critical step forward but does not solve all issues facing tribal health care. Native American communities continue to experience severe health inequities, largely due to chronic underfunding of the IHS. In 2017, IHS’s health-care spending per capita was only one-third of the national average for federal healthcare spending per person. Such underfunding results in substandard facilities and services, exemplified by healthcare on the Wind River Reservation, where the Northern Arapaho and Eastern Shoshone Tribes receive care in a facility dating back to 1884. These systemic funding gaps have led to lower life expectancy and higher mortality rates among Native American populations compared to other demographic groups.
The Supreme Court’s decision may herald a long-awaited shift in ensuring fairness and support for tribes striving for self-determination in health care. However, the task of rectifying deeply entrenched health disparities continues to necessitate robust advocacy and increased funding.
The full decision can be accessed from the Supreme Court’s website.