Washington Report

An NIHB Publication

The Washington Report is an e-newsletter produced by the National Indian Health Board. Each issue contains a listing of current events on Capitol Hill, information on passed and upcoming legislation, Indian health policy analysis and action items.

Read past broadcasts.

See the latest news.

Check out the latest federal updates and upcoming events in The Weekly

Legislative Action Alerts are only sent to your inbox when legislation relevant to Indian health is introduced, debated, or voted upon. These timely alerts will provide background information and a pathway for you to get involved in the issue at hand.


On June 6, 2024, the Supreme Court of the United States issued its opinion in Becerra v. San Carlos Apache Tribe (23-250). The question of the case was whether the Indian Health Service (IHS) must pay contract support costs (CSC) on 3rd party revenues collected from Medicare, Medicaid, and other private insurance. The Supreme Court ruled in favor of Tribes in a 5-4 decision. The Supreme Court found that,

  • ISDA requires IHS to pay the contract support costs that a tribe incurs when it collects and spends program income to further the functions, services, activities, and programs transferred to it from IHS in a self-determination contract. […] The Government’s arguments to the contrary find no support in ISDA’s text. […] A contrary reading of the statute would impose a penalty on tribes for opting in favor of greater self-determination.

You can read more about the oral argument and the issue in the case here. The National Indian Health Board (NIHB) filed an amicus curiae brief in this case that detailed the history of the IHCIA and how it interacts with 3rd party revenue. You can read that brief here.

“Today's Supreme Court decision represents a monumental victory for Tribal sovereignty and the future health of Our People. Now, in order to honor this decision, Congress must properly include these Contract Support Costs in future appropriations to not increase the burden on an already underfunded IHS budget,” said William “Chief Bill” Smith, Valdez Native Tribe, NIHB Chairman. “This is a win for Tribal sovereignty, and now Congress must fulfill the nation's promises to properly fund healthcare for Tribal Nations. It’s well past time to properly fund the Indian Health Service—mandatory appropriations is the path to health equity and full support for Tribal sovereignty, and the time for that is now.”

The Northern Arapaho Tribe (one of the main litigants in the case) said: “Today’s U.S. Supreme Court decision is a momentous victory for the Northern Arapaho people and the sovereignty of all tribes. This ruling upholds the promise of the Indian Self-Determination Act, which Congress passed with the intention of reimbursing Tribes for their costs in administering health care programs. A judicial finding to the contrary would have cost our Tribe alone millions of dollars, leading to reduced services and programs that our community relies upon."

Why it Matters

The decision in favor of the Tribes means that they will not have to diminish program capacity when they spend third-party revenue on health programs. Further, the decision will have major funding implications that will require a significant increase in the amount of funds provided for CSC by Congress. This means that Congress will either need to cut funding from IHS services or facilities budgets or appropriate additional funding to the IHS to make up the difference.

The government currently estimates that the appropriations impact will be between $800 million - $2 billion. To avoid a reduction in other areas of the IHS budget, CSC and 105(l) leases need to be transitioned to “mandatory” spending to avoid disruptions to other IHS accounts.

Impacts on IHS Funding

While this decision is a historic victory for Tribes, there will be major budget implications. During oral argument, the federal government estimated that the obligation for these new costs to be between $800 million- $2 billion. These costs would be in addition to the increases the CSC and 105(l) received in fiscal year 2024 which reduced funding to IHS services and facilities accounts by 2%. Coming out of the case, the additional fiscal obligations of the federal government to Tribes could create significant financial burden on the other areas of the IHS annual appropriation. NIHB and Tribes have long advocated that CSC and 105(l) lease costs be transitioned to “mandatory” spending so it would not disrupt the costs for the rest of the IHS annual appropriations. This approach has also been consistently supported by the Biden Administration. These costs are typically “capped” annually by budget agreements. This year, discretionary spending will increase by only 1% overall.

NIHB urges you to reach out to your Congressional delegation to advocate moving these costs to mandatory funding. Please reach out to NIHB’s Congressional Relations Director, Winn Davis ([email protected]) for more information on how you can help.

National Indian Health Board
50 F St NW, Suite 600 | Washington, DC 20001 | Phone: 202-507-4070 | Email: [email protected]