American Indians, like many people of minority cultures in the United States, have access to the health care system of the traditional culture as well as hospitals and clinics operated in the biomedical model. Administrators and providers of health care in the federally funded Indian clinics are continually faced with the question of how to manage the persistence of traditional healing practices. Beginning in the second half of the nineteenth century, government officials viewed Western medical services as an instrument of assimilation. The self-defined role of the federal Indian service was to assist the Indians to live in the white society. Medical personnel argued for the construction of Indian hospitals because the use of Indian hospitals would diminish the influence of medicine men. Not until the mid-twentieth century was the value of traditional healing practices recognized by physicians. Since then, Indian health programs have experimented with consultation with traditional healers, facilitation of the use of traditional healing, provision of funds to hire and train traditional healers, and incorporation of traditional health beliefs in health education. These efforts demonstrate that traditional health does have a legitimate role in the delivery of health care by government institutions. Unfortunately, little is known about what Native people consider when choosing between traditional medicine and biomedicine. Nor is there an understanding of how people perceive the role of the two systems of medical practice. An examination of responses from Indian people from one Sioux reservation area regarding integration of biomedical practices into their traditional system of health care will serve as an example of how people make choices about health care. From 1930 to 1950, the Bureau of Indian Affairs (BIA) stationed public health nurses at Indian reservations throughout the country.

Legislation during the past three decades has gradually drawn Indian Health Service (IHS)–funded clinics into the mainstream of the US medical care environment. The Indian Self-Determination and Education Reform Act of 1973 and its Indian Education Amendments of 1984 began a movement away from federal management of health services to local tribal control of the more than five hundred facilities serving American Indians. At the same time the Indian Health Care Improvement Act granted authority to IHS-funded clinics to bill Medicaid, beginning a long and continuing negotiation among the tribes, states, IHS, and Centers for Medicare and Medicaid Services (CMS). In 1990, 6 percent (72,000 individuals) of IHS beneficiaries were more than sixty-five and eligible for Medicare. Some 31.6 percent lived below the poverty level and were eligible for Medicaid. The IHS has facilitated and encouraged enrollment of its beneficiaries in Medicare and Medicaid. By 2008, 18 percent of the IHS budget is assumed to be met by third-party collections, including CMS billing. The Alaska Native and American Indian Direct Reimbursement Act of 1999 gave tribal clinics the authority to bill Medicaid directly for services without using the IHS as an intermediary, thus further facilitating access to CMS programs.