Indian Health Service & Tribal Health Care

The Indian Health Service (IHS) — authorized under the Indian Health Care Improvement Act (25 U.S.C. §§ 1601–1683) — is the federal agency responsible for providing healthcare to approximately 2.6 million American Indians and Alaska Natives across 575 federally recognized tribes (Lumbee added by FY2026 NDAA), funded at approximately $7 billion/year (FY 2024) through an appropriation that covers roughly 60% of the actual cost of care, leaving a persistent and well-documented funding gap. Healthcare for Native Americans is a federal treaty obligation rooted in 19th-century agreements by which tribes ceded lands in exchange for federal services including medical care — making IHS one of the few federal programs with a direct treaty basis. IHS operates 26 hospitals and 50+ health centers directly; under the Indian Self-Determination and Education Assistance Act (P.L. 93-638), tribes can contract or compact with IHS to run their own health programs, and about 60% of the IHS budget now flows through tribal self-governance compacts. Native American populations experience significantly higher rates of diabetes, cardiovascular disease, substance use disorders, and infant mortality than the general population — disparities directly linked to chronic underfunding. IHS patients are also eligible for Medicaid and CHIP, which provide supplemental coverage and have been a critical source of additional funding post-ACA.

Current Law (2026)

Legal Authority

• 25 U.S.C. § 1601 — Congressional findings (federal government has a responsibility for Indian health care based on special government-to-government relationship; American Indians suffer from disproportionate health disparities)
• 25 U.S.C. § 1602 — Declaration of national Indian health policy (federal government shall provide Indian health services; raise the health status of Indians to the highest possible level; encourage Indian participation in health program planning and management)
• 25 U.S.C. § 1613a — Indian health professions scholarships (scholarships for AI/AN students in health professions; service obligation to IHS, tribal, or urban Indian health programs)
• 25 U.S.C. § 1616a — IHS Loan Repayment Program (student loan repayment for health professionals who serve in IHS facilities; 2-year minimum commitment; addresses critical shortage areas)
• 25 U.S.C. § 1621 — Indian Health Care Improvement Fund (additional funding to reduce disparities between health care available to Indians and the general population)
• 25 U.S.C. § 1641-1647 — Third-party reimbursement and collections (IHS may collect from Medicare, Medicaid, CHIP, and private insurance; collections supplement rather than replace appropriations)
• 25 U.S.C. § 1680 — California contract health services demonstration program and other facility-specific provisions

How It Works

The Indian Health Service provides health care to approximately 2.8 million American Indians and Alaska Natives as part of the federal government's treaty and trust obligations to tribal nations. It is the only federal health care system based on a legal obligation to a specific population — rooted in treaties, federal law, and the government-to-government relationship between the United States and the 575 federally recognized tribes (Lumbee added by FY2026 NDAA).

The federal government's obligation to provide health care to American Indians and Alaska Natives derives from treaties in which tribes ceded land and sovereignty in exchange for health and other services — a trust responsibility codified in the Snyder Act (1921) and the Indian Health Care Improvement Act (IHCIA) under 25 U.S.C. § 1601, which was permanently reauthorized by the ACA in 2010. Unlike Medicare, Medicaid, or VA health care — entitlement programs funded by formula — IHS is a discretionary program funded through annual Congressional appropriations, which has resulted in chronic underfunding. Services are delivered through three models: IHS Direct Service (IHS-operated hospitals and clinics with federal employees, primarily in the Great Plains, Southwest, and Alaska); Tribal Programs under the Indian Self-Determination and Education Assistance Act (P.L. 93-638), through which tribes contract or compact with IHS to operate their own programs using federal funding — over 60% of IHS funding now flows through these 638 arrangements; and approximately 41 Urban Indian Health Programs serving the ~70% of AI/AN people who live in urban areas, though urban funding is a small fraction of total IHS spending.

IHS spending per capita — approximately $4,000 per user — is consistently lower than any comparable federal health program ($12,000+ for Medicare, $8,000+ for VA enrollees). This underfunding means many IHS facilities cannot provide a full range of services, requiring referrals to outside providers through the Purchased/Referred Care (PRC) program, which itself is often underfunded and prioritizes referrals by medical urgency, leaving many patients without care. The AI/AN population suffers significant health disparities: diabetes rates 2–3 times the national average, higher rates of heart disease, substance abuse, suicide, and unintentional injuries, life expectancy approximately 5.5 years below the national average, and higher infant mortality — reflecting both IHS underfunding and broader social determinants including poverty, geographic isolation, and historical trauma. IHS bills Medicare, Medicaid, the VA, and private insurers for eligible patients, generating approximately $1+ billion annually in third-party collections that supplement appropriations; Medicaid expansion in participating states has improved the financial picture for many tribal facilities, but collections cannot substitute for adequate baseline funding.

How It Affects You

IHS behavioral health programs support families involved in Indian Child Welfare Act proceedings, providing culturally appropriate services that keep children connected to their tribes.

State Variations

• IHS is a federal system, but Medicaid expansion under the ACA (state-by-state) has significantly affected IHS and tribal facility revenues — expanded Medicaid in participating states means more patients have Medicaid coverage that IHS can bill
• Some states have enacted supplemental Indian health programs
• State licensing and scope-of-practice laws affect IHS and tribal health care providers
• Urban Indian health programs are funded federally but must comply with state and local health regulations

Implementing Regulations

• 42 CFR Part 136 — Indian Health Service (IHS eligibility, contract health services, purchased/referred care)

• 42 CFR Part 136a — Indian Health: General Principles and Eligibility (24 sections — IHS implementing regulations governing eligibility for IHS health services, Contract Health Services authorization, and beneficiary identification; implements 42 U.S.C. § 2001 and 25 U.S.C. § 13):

  • § 136a.11 — Services available: the type and scope of services available at any IHS facility depends on the facilities, equipment, and personnel at that specific location; IHS operates hospitals, health centers, and health stations with widely varying capacity; services are provided "subject to the availability of funds appropriated" — there is no individual entitlement to a specific service level
  • § 136a.12 — Eligible beneficiaries: IHS provides health services to members of federally recognized Indian tribes and Alaska Natives who present documented tribal membership; individuals with eligibility questions may request reconsideration through § 136a.14
  • § 136a.13 — Contract health services (CHS) authorization: IHS will not pay for care obtained from non-Service providers unless the care was authorized in advance by the appropriate ordering official; emergency care obtained without prior authorization may be reimbursed if the patient notifies IHS within 72 hours of the emergency; CHS authorization is the gatekeeper for purchased/referred care — the funding mechanism by which IHS pays for specialty services its own facilities cannot provide; IHS CHS funds are chronically underfunded relative to patient needs, creating de facto rationing of specialty referrals
  • § 136a.14 — Reconsideration and appeals: any person denied health services or denied eligibility may request reconsideration; the reconsideration process provides an administrative avenue before any court challenge; denials of CHS authorization are among the most frequently contested decisions
  • § 136a.15 — Health Service Delivery Areas: IHS designates geographic territories served by each facility; a patient's eligibility for services at a specific IHS facility depends partly on whether their residence falls within that facility's designated area; the geographic constraints create access barriers for tribal members living off-reservation or distant from the nearest facility
  • § 136a.16 — Beneficiary Identification Cards: IHS issues Beneficiary Identification Cards (BIC) to eligible beneficiaries; IHS may require verification of current tribal membership at the time of service

  The IHS funding-dependent service model creates what advocates have called a "rationing" regime: unlike Medicare or Medicaid (which provide legally enforceable benefits), IHS services are constrained by annual appropriations. When CHS funds are exhausted for the fiscal year, IHS units stop authorizing referrals for non-emergency specialty care regardless of patient need. Congress has historically appropriated IHS at roughly one-third to one-half of the estimated funding needed for care equivalent to what the Indian Health Care Improvement Act envisions.

• 42 CFR Part 137 — Tribal self-governance (compacting for IHS programs under the Indian Self-Determination Act)

• 25 CFR Part 900 — Contracts under ISDEAA (P.L. 93-638 contracting for health programs, proposal/negotiation, reporting)

Pending Legislation

• HR 741 (Rep. Cole, R-OK) — Stronger Engagement for Indian Health Act: would elevate the IHS Director to an Assistant Secretary for Indian Health within HHS, increasing the agency's stature and direct access to the HHS Secretary. Status: Introduced.
• S 632 (Sen. Murkowski, R-AK) — IHS Workforce Parity Act: would allow Indian Health Service scholarship recipients to fulfill their service obligation through half-time service, improving recruitment flexibility. Status: Introduced.
• HR 1418 (Rep. Stauber, R-MN) — Purchased and Referred Care Improvement Act: would require IHS to reimburse outside providers within 30 days of receiving a clean claim, addressing chronic payment delays that discourage providers from accepting PRC referrals. Status: Introduced.
• S 2272 (Sen. Luján, D-NM) — Tribal Access to Clean Water Act: would authorize funding for clean water infrastructure serving tribal communities, addressing water quality disparities on reservations. Status: Introduced.

Recent Developments

• IHS budgets have increased in recent years but remain below the level needed to achieve health parity
• The COVID-19 pandemic highlighted both the vulnerability of AI/AN communities and the effectiveness of tribally managed health programs (many tribal programs achieved the highest vaccination rates in the country)
• Advance appropriations for IHS were enacted in 2024, providing more funding predictability and reducing the impact of government shutdowns on Indian health care
• Behavioral health and substance abuse services have expanded as IHS addresses the opioid and methamphetamine crises in Indian Country
• Facility construction and renovation backlogs remain a major concern — many IHS hospitals are 50+ years old
• In January 2026, the Indian Health Service published approved reimbursement rates for inpatient and outpatient medical care for calendar year 2026.