Supreme Court decision a win for Tribal health finances

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The Supreme Court has ruled that the federal Indian Health Service is required to reimburse Tribes for overhead costs for contracted health services from third parties, including private insurers, Medicare and Medicaid.

The 5-4 Supreme Court decision in Becerra v. San Carlos Apache Tribe issued on Thursday is a win for Tribal finances, according to attorney Mike Andrews, senior vice president at MaquireWoods Consulting. Andrews is head of the Native American Policy group at the firm and is former chief counsel to the Senate Committee on Indian Affairs.

The case involves reimbursement for third-party billing, Andrews said. Tribes have been paying for the third-party administrative services. In some cases, the third-party billing represents millions of dollars, he said.

Since non-Tribal providers also don't get reimbursed for administrative expenses, Tribes were asking for what other hospitals don't get, Andrews said.

However, in 2019, Congress authorized the Tribes to allow for the administrative costs of third-party billing to be covered. 

It's taken a Supreme Court ruling for the Tribes to get reimbursed.

The Supreme Court's four dissenting judges - Brett Cavanaugh, Amy Coney Barrett, Samuel Alito and Clarence Thomas – did not want to give Tribes a benefit that was not available to everybody else, Andrews said.

When contacted, Indian Health Service (IHS) referred comment to that of Health and Human Services Secretary Xavier Becerra.

"The court has rendered its decision, and we remain firmly committed to executing our obligations under federal law and supporting Tribal self-determination and sovereignty," Becerra said. "In recognition of the potential budgetary impact of this decision, we urge Congress to act on the FY 2025 President's Budget proposal to shift the IHS budget from discretionary to mandatory funding starting in FY 2026 to protect the overall appropriation for the Indian Health Service and create more adequate and stable funding into the future."

In terms of the federal cost, the administrative reimbursement is a small part of the overall budget, Andrews said.

"I thought this one was a resolution for Tribal sovereignty," Andrews said. "This is a win for Tribes."

WHY THIS MATTERS

In the 5-4 decision, the justices affirmed that the 1975 Indian Self-Determination Act (ISDA) mandates the Indian Health Service to reimburse Tribal Nations for the expenditures of revenues collected from third-party payers such as Medicare, Medicaid and private insurers. 

The court consolidated Becerra v. San Carlos Apache Tribe and Becerra v. Northern Arapaho Tribe, and held that the Indian Self-Determination Act and the ISDA contracts require the Tribal Nations to collect revenues from third-party payers and spend that revenue to further their respective healthcare programs. 

"Today's decision is a victory for tribal self-determination and tribal sovereignty," said National Congress of American Indians (NCAI) President Mark Macarro in a statement. "This ruling ensures that Tribal Nations administering healthcare services to their citizens and communities do so with the full funding to which they are entitled under federal law and contracts with the Indian Health Service."

John Echohawk, executive director of the Native American Rights Fund (NARF), said in a statement, "Congress passed the Indian Self-Determination Act with the purpose of empowering Tribal Nations and ensuring that tribally-run healthcare programs would be on equal footing with those run by the Indian Health Service. This decision honors the commitment Congress made to Tribal Nations' rights to self-determination."

THE LARGER TREND

The decision affirms that federal support for Tribally run healthcare programs must be on equal footing with IHS run programs.

Becerra v. San Carlos Apache Tribe and Becerra v. Northern Arapaho Tribe affirm the Ninth and Tenth Circuit Court of Appeals wins by the Tribes, making these victories applicable nationwide. Both Tribal Nations sued to ensure full contract support cost-reimbursement from IHS related to the direct healthcare services they provide on their respective reservations.

Email the writer: SMorse@himss.org