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Supreme Court: Feds Must Pay More For Native American Health Care

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OPINION: This article may contain commentary which reflects the author's opinion.


On Thursday, the Supreme Court ruled that the federal government must provide additional funding to cover certain administrative costs incurred by Native American tribes that manage their healthcare programs.

In a 5-4 decision, with Justice Neil Gorsuch—considered one of the strongest allies of Native Americans on the court—casting the deciding vote, the justices upheld two rulings by federal appeals courts in favor of the Native American tribes, SCOTUS Blog reported.

Writing for the majority, Chief Justice John Roberts argued that a ruling in favor of the federal government, which did not want to pay administrative costs, would create a “systemic funding shortfall” for tribes that chose to operate and manage their own healthcare plans—”penalty for pursuing self-determination.”

The court’s decision “could cost between $800 million and $2 billion,” according to Justice Brett Kavanaugh, who wrote a dissent with the support of Justices Clarence Thomas, Samuel Alito, and Amy Coney Barrett.

The Blog noted:

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A federal law known as the Indian Self-Determination and Education Assistance Act gives Native American tribes the option to enter into a contract with the Indian Health Service to run their own health-care programs, which the IHS would otherwise manage. When a tribe chooses this option, IHS gives the tribe the money that it would have used to run those programs. The tribe can also collect money from outside programs like Medicare, Medicaid, and private insurers.

To reimburse tribes for overhead and administrative costs that IHS does not have to pay when it runs health-care programs, Congress also requires the IHS to cover the tribes’ “contract support costs.”

The legal issue before the court involved the federal government and two tribes, the San Carlos Apache Tribe and the Northern Arapaho Tribe. All parties agreed that the Indian Health Service (IHS) must cover the contract support costs that the tribes incur from the funds IHS provides to operate their own healthcare programs.

The case specifically questioned whether the IHS is also required to reimburse the tribes for the costs incurred when they use funds from Medicare, Medicaid, and private insurers for these healthcare programs, SCOTUS Blog noted.

The high court decided the answer was “yes.”

Chief Justice Roberts, writing for himself and Justices Sonia Sotomayor, Elena Kagan, Gorsuch, and Ketanji Brown Jackson, explained that when tribes choose to manage their own healthcare programs, they must collect income from Medicare, Medicaid, and private insurers and utilize it for those programs.

“The reasonable direct and indirect contract support costs they incurred as a result,” Roberts continued, “are eligible for repayment” under federal law because the expenses came about as a result of the tribes’ contract with the IHS.

Roberts dismissed the government’s argument, ruling that it would not be consistent with both the text of the Indian Self-Determination and Education Assistance Act as well as the purpose behind the statute, which sought to provide tribes with an “effective voice in the planning and implementation of programs responsive to the true needs of their communities.”

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However, Roberts reasoned that if IHS was not covering the contract support costs for health care funded by outside programs such as Medicare, Medicaid, or private insurance, it would “inflict[] a penalty on tribes for opting in favor of greater self-determination.”

In his dissent, Kavanaugh argued that federal law does “not support the Court’s decision.” Speaking more broadly, he continued, “The extra federal money that the Court today green-lights does not come free.” If Congress fails to increase the overall funding for Native American healthcare programs, Thursday’s ruling will inevitably shift more of that funding from less affluent tribes, which are less likely to run their own healthcare programs, to wealthier ones, he wrote.

One other option for Congress, he added, would be to “substantially” increase funding for all Native American healthcare programs, “thereby drawing money away from other vital federal programs or requiring additional taxes.”

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