The Supreme Court ruled in favor of Native American tribes on Thursday, resolving a dispute with the federal government over health care costs when tribes manage their own programs.
In a 5-4 decision, the court determined that the government must cover millions in overhead costs incurred by two tribes running their health care programs. This decision supports a law designed to give Native Americans more control over local health care.
Chief Justice John Roberts, writing for the majority, emphasized that covering these costs is essential to prevent a funding shortfall. The majority opinion was supported by three liberal justices and conservative Justice Neil Gorsuch. Roberts noted that without reimbursement, tribes effectively face a penalty for seeking self-determination.
The Department of Health and Human Services argued that it should not be responsible for overhead costs related to billing insurance companies, Medicare, and Medicaid. The agency estimated that covering these costs for all tribes could amount to $800 million to $2 billion annually.
Justice Brett Kavanaugh, dissenting along with Justices Clarence Thomas, Samuel Alito, and Amy Coney Barrett, argued that the court should defer such financial decisions to Congress. He pointed out that the additional federal funding approved by the court does not come without a cost.
Historically, the federal Indian Health Service (IHS) has provided health care to tribes since the 1800s under treaty obligations. However, the San Carlos Apache Tribe in Arizona described these facilities as often inadequate and understaffed in court documents. The Northern Arapaho Tribe in Wyoming highlighted that health care spending per person by the IHS is only one-third of federal spending elsewhere in the country. They also noted that the average life expectancy for Native American tribal populations is about 65 years, nearly 11 years less than the national average.
Adam Unikowsky, representing the Northern Arapaho Tribe, praised the decision for promoting tribal sovereignty and improving health care resources in under-served communities.
The tribes had contracted with IHS to manage their programs, including emergency services and substance-abuse treatment. While the agency paid the tribes the funds it would have spent on these services, the contracts did not cover the overhead costs for billing insurance companies or Medicare and Medicaid. These tasks fell to the tribes, costing the San Carlos Apache Tribe nearly $3 million in overhead over three years and the Northern Arapaho Tribe $1.5 million over two years. Lower courts had previously ruled in favor of the tribes.
The Department of Health and Human Services appealed to the Supreme Court, maintaining that while tribes receive some funding for overhead, the government should not cover costs related to third-party income.
Currently, the majority of federally recognized tribes contract with IHS to manage at least part of their health care programs.
