American Indian Culture and Research Journal

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.