Edward J. Fox, PhD

From Numbers to Decisions

The course began with a simple question: How does Indian health care
actually get paid for? We then followed the financing streams,
examined IHS, Medicaid, Medicare and dual eligibility, considered adequacy,
and worked through the problems of measuring the population and the money.

The final step is to ask what those findings mean for policy.

What the Evidence Can Tell Us

Evidence Should Lead to Better Questions

A strong research finding does not always produce a single policy answer.
Sometimes its most important contribution is to identify the next question
that needs to be answered.

For example, if Medicaid enrollment is rising, the next question may be
whether Indian health programs are receiving corresponding reimbursement.
If Medicare payments are increasing, the next question may be which services
and populations account for the increase.

If IHS funding increases, the relevant question may be whether the increase
keeps pace with population, costs, staffing, facilities, utilization, and
other requirements.

Policy Is About More Than the IHS Appropriation

Indian health policy discussions often focus on the IHS budget. That is
understandable, because federal appropriations are foundational to the system.
But the course has shown that the financing system extends beyond the
appropriation.

Medicaid, Medicare, third-party reimbursement, Tribal resources, Purchased/
Referred Care, and other federal programs can all affect the resources
available to provide care.

Current federal policy also recognizes the large role Tribes play in operating
Indian health programs. IHS reported in 2026 that approximately 65 percent of
IHS funding was being managed by Tribes through contracts and compacts.

That makes financing policy inseparable from questions of Tribal
self-determination, governance, and control over health programs.

Advance Appropriations and Predictability

One example of financing policy is the use of advance appropriations.
Predictable funding can help health programs plan staffing, contracts,
purchases, and services without the uncertainty associated with annual
appropriation delays.

The policy question is therefore not only “How much money is provided?”
It can also be “When is the money available, how predictable is it, and how
much flexibility does the health program have in using it?”

Mandatory Versus Discretionary Financing

Another major policy question concerns the structure of federal financing.
The IHS has historically relied heavily on discretionary appropriations.
Proposals for mandatory financing have sought to change that structure.

Recent research has examined the IHS underfunding problem from both fiscal
and economic perspectives and has argued that the federal trust responsibility
and equity considerations are relevant to how IHS resources should be allocated.

For students, the important lesson is that a financing proposal contains
assumptions about risk, predictability, equity, and federal responsibility—not
just a dollar amount.

Tribal Self-Determination Changes the Policy Question

The Indian health system is not simply a federal delivery system. Tribes can
operate health programs under the Indian Self-Determination and Education
Assistance Act, including through self-determination contracts and
self-governance compacts.

Federal law provides for funding agreements that allow participating Tribes
to plan, conduct, consolidate, administer, and receive their tribal share
funding for programs, services, functions, and activities carried out for
the benefit of Indians because of their status as Indians.

Therefore, a financing policy should be evaluated not only by how much money
it provides but also by who controls the resources and how the financing
supports Tribal decision-making.

What Makes a Good Policy Analysis?

The Researcher’s Responsibility

Indian health financing research has consequences beyond an academic paper.
A denominator choice can change a per-person estimate. A definition of
“AI/AN” can change the population being studied. A decision to combine two
financing sources can change the apparent size of the system.

For that reason, transparency is part of the research itself.

A reader should be able to determine what was counted, what was excluded,
where the data came from, how the calculation was performed, and what the
result does—and does not—mean.

A Framework for Future Research

The eight segments of this course can be reduced to a practical research
framework:

The Course Is Only the Beginning

Indian health financing is not a static subject. Federal policy changes,
Medicaid and Medicare rules evolve, Tribal health programs change, data
systems improve, and new research changes what we understand about the
financing system.

The goal of this course is therefore not to provide a final answer to every
financing question. It is to give the student a framework for asking better
questions and evaluating the evidence.

Where to Go From Here

The course can now lead in several directions: deeper study of Medicaid and
Medicare financing, analysis of IHS budget formulation, examination of active
user populations, replication of published financing estimates, or development
of new research using linked administrative data.

The papers, graphics, data sources, and research materials on this website
provide the next layer of study.