When the Indian Health Service can’t provide care to Native Americans, the federal agency can refer them to other providers, but each year the agency denies tens of thousands of requests to subsidize such care, leaving patients without treatment or forced to pay high medical bills out of pocket.
In theory, Native Americans are entitled to free health care when the Indian Health Service covers the costs at its facilities or tribally run facilities, but in reality the agency is chronically underfunded and understaffed, leaving medical services limited and inaccessible in vast swaths of the country.
Purchased and referred care programs are intended to fill that gap by paying outside providers for services that patients might not be able to get at agency-funded clinics or hospitals, such as cancer treatment or pregnancy care. But patients, elected officials and people who work with government agencies say a lack of resources, complex rules and administrative inefficiencies have severely hindered access to the referral programs.
The Indian Health Service, part of the Department of Health and Human Services, serves approximately 2.6 million Native Americans and Alaska Natives.
Native Americans are eligible for the referral care program if they live on tribal lands (only 13%) or if they live within a national “delivery area,” which usually includes surrounding counties. Those who live in other tribes’ delivery areas are eligible in limited cases, but Native Americans who live outside such boundaries are not.
But eligible patients are not guaranteed financial or timely assistance, with some of the Indian Health Service’s 170 service units running out of annual funding or reserving funds for their most serious medical problems.
The referral care program denied or deferred about $552 million in spending on about 120,000 requests from eligible patients in fiscal year 2022.
As a result, Native Americans may have less access to health care and may be at increased risk of death or serious illness for those with preventable or treatable medical conditions.
The problem is not new: Federal watchdogs have reported concerns about the program for decades.
Connie Brushbraker, a member of the Rosebud Sioux Tribe, has been denied funding or put on a waiting list at least 14 times since 2018. She said it doesn’t make sense for officials to refuse to pay for treatment that is approved after her health problems become more severe and expensive.
“We try to take precautions before it gets to the point where we need surgery,” said Brushbraker, who lives on a tribal reservation in South Dakota.
Many Native Americans claim the U.S. government is violating treaties with tribal nations under which it promises to provide for tribal health and welfare services in exchange for land.
“Elders here keep saying, ‘By treaty right, they should be able to provide us with these services,'” said Lyle Rutherford, a council member for the Blackfoot tribe in northwestern Montana who also worked for the Indian Health Service for 11 years.
Native Americans suffer from higher rates of disease than the general population, and the median age of death is 14 years younger than whites. Researchers who have studied the issue say much of the problem stems from colonization and government policies that forced Native Americans into boarding schools and segregated reservations, and forced them to abandon healthy traditions like bison hunting and religious ceremonies. They also point to continuing underfunding of health care.
Congress has appropriated about $7 billion for the Indian Health Service this year, about $1 billion of which goes to referral care programs. The Commission on Tribal Health and Government Leaders has long proposed budgets that far exceed the agency’s budget. The commission’s most recent report said the Indian Health Service needs $63 billion to meet patient needs in fiscal year 2026, including $10 billion for referral care.
Improving referral care programs is a top goal for the Indian Health Service, said agency spokesman Brendan White, who said about 83 percent of the health stations the agency manages were able to approve all of their eligible funding requests this year.
White said the department has recently improved how the referral care program prioritizes such requests and is addressing staffing shortages that can slow the process. Roughly a third of the positions in the referral care program were vacant as of June, he said.
The Indian Health Service also recently expanded some delivery areas to cover more people and is considering whether it could create statewide eligibility across the Dakotas.
Johnny Kroll, of the Little Shell Tribe of Montana Chippewa Indians, is not eligible for the referral care program because he lives in Deer Park, Washington, about 400 miles from his tribe’s headquarters.
She said tying eligibility to tribal lands reflects old government policies intended to keep Native people in one place, even if it meant limiting their access to jobs, education and health care.
Kroll, 58, said she sometimes worries about the medical costs of aging, and that moving to qualify for the program seems unrealistic.
“There are people all over the country,” she said. “What do we do? Do we sell our homes, leave our families, our jobs?”
People applying for the funds face such a complicated system that the Indian Health Service has created a flowchart outlining the process.
Misty and Adam Heiden of Mandan, North Dakota, experienced this firsthand: Their local Indian Health Service hospital no longer offers birthing services, so late last year Misty Heiden asked a referral care program to pay for her to give birth at an outside facility.
Hyden, 40, is a member of the Sisseton Wahpeton Oyate Tribe, based in South Dakota, but lives within the delivery area of the Standing Rock Sioux Tribe. Native Americans who live in other tribes’ territories, like hers, are eligible if they have close ties. Hyden is married to a Standing Rock tribal member, but decided that hospital staff were not eligible.
Now the family has had to cut back on their grocery budget to pay off more than $1,000 in medical debt.
“It was like a slap in the face,” Adam Heiden said.
White, the Indian Health Service spokesman, said many health care providers offer educational materials to help patients understand their eligibility, but the Standing Rock rules, for example, aren’t adequately explained in pamphlets.
If a patient is eligible, their needs are ranked using a medical priority list.
Connie Brushbraker’s doctor at the Indian Health Service Hospital in Rosebud, South Dakota, said she needed to see an orthopedic surgeon, but hospital officials said the department only sees patients who are at imminent risk of death.
At one point, a staff member at the referral care program told her that the pain was tolerable, even though it was so severe that it limited her work load and forced her to rely on her husband to put her hair in a ponytail.
“I feel ignored and unworthy,” Brushbraker wrote in her petition. “Please reconsider.”
The 55-year-old was eventually approved for funding and underwent surgery in July this year, two years after injuring her shoulder and four months after being referred.
Patients said they sometimes struggle to reach referred medical departments due to staffing shortages.
Patty Konica, a member of the Standing Rock Sioux Tribe, developed a serious infection in June 2023 and required emergency treatment. She applied for financial assistance to cover the costs of her treatment, but says she has yet to receive a decision, despite multiple calls and in-person visits with referred care staff.
“We’ve been passed around from one place to another,” said Konica, 58, who lives in the tribe’s home base in Fort Yates, North Dakota.
She now owes more than $1,500 in medical bills, some of which have been turned over to debt collection agencies.
Rep. Tyler Tordsen, a Republican who represents Sisseton-Wahpeton, South Dakota, said the referral care program needs more funding, but that officials could do “better manage their finances.”
Some service divisions have large amounts of cash sitting around, but it’s unclear how much of that money is unspent and how much is being used to cover approved claims that are in the claims process.
Meanwhile, more tribes are taking control of their health care facilities (a system that still uses federal funding) and trying new ways to improve services.
Many health care organizations also try to help patients obtain outside care in other ways, including providing free transportation to appointments, arranging for specialist visits on reservations, and creating tribal health insurance programs.
For Brushbreaker, begging for financial assistance “felt like having to sell my soul to the IHS gods.”
“I just got tired of fighting the system,” she said.
KFF Health News is a national newsroom producing in-depth journalism on health issues and is one of the core operating programs of KFF, an independent source of health policy research, polling and journalism.
