WASHINGTON — The Supreme Court sided with Native American tribes on Thursday in a dispute over health care costs when tribes manage their own programs. The 5-4 decision mandates that the federal government cover millions in overhead costs incurred by two tribes, who assumed control of their health care services under a law designed to grant Native Americans greater local control.
Chief Justice John Roberts, writing for the majority, emphasized that covering these costs is essential to avoid a funding shortfall. The decision was supported by the three liberal justices and conservative Justice Neil Gorsuch. Roberts stated that not reimbursing these expenses penalizes tribes for seeking self-determination.
The Department of Health and Human Services (HHS) had argued that it was not responsible for the overhead costs related to billing insurance companies, Medicare, and Medicaid. According to HHS, covering these costs for all tribes running their own health care programs could range from $800 million to $2 billion annually.
Justice Brett Kavanaugh, in the dissent joined by conservative Justices Clarence Thomas, Samuel Alito, and Amy Coney Barrett, argued that such funding decisions should be left to Congress. He cautioned that the additional federal money approved by the court does not come without financial implications.
The federal Indian Health Service (IHS) has historically provided health care to tribes under treaty obligations, but these services are often inadequate and understaffed. The San Carlos Apache Tribe in Arizona highlighted these issues in court documents. Health care spending per person by the IHS is only one-third of the federal spending in the rest of the country, noted the Northern Arapaho Tribe in Wyoming. They also pointed out that the average life expectancy for Native Americans is about 65 years, nearly 11 years less than the national average.
Attorney Adam Unikowsky, representing the Northern Arapaho Tribe, hailed the decision as a significant step towards equality in health care between tribes and the IHS. He believes it will enhance tribal sovereignty and provide much-needed resources for health care in underserved communities.
The tribes had contracted with the IHS to manage their own health care programs, including emergency services and substance-abuse treatment. While the IHS paid the tribes the funds it would have used to provide these services, the contracts did not cover overhead costs for billing insurance companies or Medicare and Medicaid. This oversight required the tribes to handle billing themselves, costing the San Carlos Apache Tribe nearly $3 million over three years and the Northern Arapaho Tribe $1.5 million over two years. Lower courts had previously ruled in favor of the tribes.
HHS appealed to the Supreme Court, maintaining that while tribes receive some funds for overhead, the government is not liable for costs associated with third-party income. Currently, the majority of federally recognized tribes contract with the IHS to manage at least part of their own health care services.
