Much of the work on this site was written to explain how Indian health is financed. The same material can help anyone writing a proposal on behalf of a Tribe, Tribal organization, or Urban Indian Organization. That includes Tribal grants staff, health directors, and consultants and Indian-owned firms working for Tribal clients. This page shows where to find what you need and how to use it responsibly.
Matching the site to your proposal
Most federal and foundation proposals ask for the same core sections. These are the places on the site that speak to each one.
| If you are writing… | Start with |
|---|---|
| Statement of need | Paper V (Full-Funding Requirement) and the Synthesis Coda. Graphics: Estimating Funding Equity, Purchased/Referred Care Does Not Keep Up With Inflation, Access Has Grown, But Capacity Has Not Kept Pace |
| Population to be served | Paper I (How We Count Matters) and Paper IV-F (2020 Census artifact). Graphics 1–3 on population definitions |
| Background and policy context | Paper I-B (IHCIA Reauthorization), Paper II (CMS–IHS Tribal Data Improvement), “Who Built the Indian Health Care Improvement Act?” |
| Sustainability plan | Paper III (Effective FMAP Subsidy), “The IHS-OMB Rate and FMAP,” “How Many Signatures?”, Paper IV (Data Match), Paper IV-H (Dual Eligibles and 100% FMAP) |
| Evaluation and data capacity | “Turning Tribal Health Clinic Data into Management Information” and Your Tribe Already Has Excellent Health Data (Resources page) |
| Facilities or access projects | Paper IV-D (Facility Growth and Population Change, 2000–2025) and Paper IV-E (Coverage Expansion and “Leakage”) |
| Urban Indian projects | Papers VI–VIII (Urban Indian Health extension) |
| References | The Bibliography page, already formatted in APA 7th edition |
Papers: Publications · Related Papers · Graphics · Resources · Bibliography
Key figures
These are the headline numbers from the series. Each one carries a data year and a note on its proper use. A figure quoted without its context can mislead a reviewer, or later work against the Tribe that relied on it.
About 1.3 million AI/ANs report access to IHS-funded services. (ACS PUMS, 2010–2024. Papers I, IV-A, IV-F)
This is the denominator I find most useful for Indian health financing. It has stayed essentially stable at about 1.28 million across ACS periods. Post-2020 Census counts of the total AI/AN population rose sharply because the race question was redesigned, not because the population grew. Comparisons across 2020 need care.
941,168 AI/AN IHS registrants were enrolled in Medicaid in 2023. (NIHB, October 2025 CMS/IHS Data Match Report. Paper IV)
This figure comes from matched administrative records, not a survey. State-by-state results are in the NIHB report linked on the Resources page.
About $6.42–$6.56 billion in annual Medicaid expenditures are attributable to that population. (2023. Paper IV estimate)
This is an estimate built from the Data Match, so please cite it as a range.
Full-spectrum need is about $37–$38 billion a year, against about $19.3–$19.9 billion in current combined federal investment. That leaves an annual gap of $17.8–$18.0 billion. (Paper V)
The paper treats this gap as a floor, not a ceiling. Purchased/Referred Care understatement and Tribal own-source spending are not fully captured in it.
The IHS National Tribal Budget Formulation Workgroup’s estimate is considerably higher: $76.1 billion for IHS in its FY 2028 recommendations. (National Tribal Budget Formulation Workgroup, April 2026)
The two figures measure different things. Paper V estimates the annual cost of health services against a National Health Expenditure parity benchmark, counts Medicaid, Medicare, and other federal sources toward meeting that need, and treats facilities as a separate investment of about $30–$34 billion over 10–15 years. The Workgroup’s figure is a line-by-line recommendation for the IHS budget itself, developed by Tribes from all twelve IHS Areas, and it carries facilities, sanitation, maintenance, and other capital needs inside the annual total. Paper V’s primary estimate also uses an unadjusted benchmark; its sensitivity analysis, including an adjustment for AI/AN disease burden, reaches about $45 billion. A proposal can cite either figure, as long as it says which one it is using and what it measures.
AI/AN Medicare enrollment grew from about 671,000 in 2014 to 792,000 in 2024. (ACS 1-Year PUMS. Paper IV-C)
61,648 people in the IHS-access population were dually enrolled in Medicare and Medicaid, up 38.8 percent since 2013. (ACS 5-Year PUMS, 2020–2024. Paper IV-G)
2,652,345 enrolled Tribal citizens across 578 funded Tribal entities. (Henson, Jorgensen, Kalt & Leonaitis, 2021, Harvard Kennedy School Ash Center, Policy Brief No. 7)
This is Tribal citizenship, a different population from the people who use IHS-funded services. Please don’t substitute one for the other without stating the difference it makes.
A note on what I don’t use: I don’t rely on Census “AI/AN alone” counts. The measure has severe non-sampling error, and figures built on it can understate the population a program actually serves.
Making the numbers local
The figures above are national. Most proposals need numbers for one Tribe, one service area, or one state. A few starting points:
- The NIHB CMS/IHS Data Match Report on the Resources page gives state-level Medicaid enrollment for the IHS-registrant population, 2019–2023.
- The Census Bureau’s My Tribal Area tool gives ACS statistics for individual reservations and Tribal areas.
- The CMS Mapping Medicare Disparities tool shows county-level Medicare data by race, including AI/AN, and by dual eligibility.
- Your own program’s records are often the strongest local evidence a proposal can offer. That includes billing, claims, and especially PRC referral and denial records. The data paper on the Resources page explains how to turn them into usable information.
Where a national figure and a local figure point in different directions, the local figure usually tells the more accurate story for your proposal.
Other sources of Indian health data
These pages from other organizations carry AI/AN-specific health and coverage data that proposal writers can cite directly. Each source defines the AI/AN population in its own way, so note the definition and data year alongside any figure you use.
National Indian Health Board (NIHB)
- 2025 State Health Insurance Status Report — AI/AN Medicaid, Medicare, and uninsured estimates for the U.S., every state, and DC, comparing 2013 with 2023. Built on ACS 5-year estimates (AI/AN alone or in combination).
- CMS/IHS Data Match Report, October 2025 (PDF) — Medicaid enrollment of IHS registrants, by state, 2019–2023, from IHS registration data matched to CMS T-MSIS records.
Northwest Portland Area Indian Health Board (NPAIHB)
- Northwest Tribal Epidemiology Center — Data Reports — the hub for state community health profiles and topic-specific data briefs. Its figures correct for AI/AN racial misclassification, so they may differ from state or federal numbers.
- Washington AI/AN Community Health Profile (2024) (PDF)
- Oregon AI/AN Community Health Profile (2024) (PDF)
KFF (Kaiser Family Foundation)
- Key Data on Health and Health Care for American Indian or Alaska Native People (December 2025) — health, coverage, and access measures drawn from the ACS, BRFSS, and CDC WONDER, with subgroup detail where the data allow.
- Health and Health Care for American Indian or Alaska Native People: Key Issues — recent federal policy changes, including Medicaid changes, and their likely effect on AI/AN people and Tribal health systems.
- Health Coverage Among American Indian and Alaska Native and Native Hawaiian and Other Pacific Islander People — coverage analysis from 2017–2021 ACS data, with AI/AN subgroup breakdowns.
Managing the grant once it’s awarded
Success with a grant-funded program depends on two things that are in natural tension: performance and compliance. A project must meet the funder’s requirements and also achieve the Tribe’s own goals for the work. Four practices help:
- Work with the Tribe’s finance department from the start, so budgets, drawdowns, and reports stay accurate.
- Work with the grant writers, so the objectives promised in the proposal are ones the program can actually deliver.
- Take full responsibility for meeting the grant’s objectives. Train staff on compliance, and keep the project aligned with the Tribe’s goals.
- Maintain the partnership with the funding agency. The program officer is a partner in the project’s success, not just a monitor.
Adapted from Management & Policy Analysis for Indian Health (2017–2023): page “Grant Mgmt and Compliance.” For compliance with Medicare and Medicaid billing rules, see CMS Compliance.
Using and citing this work
You are welcome to use the papers, figures, and graphics on this site in grant proposals, reports, and presentations prepared for Tribes and Tribal organizations. This includes work done by consultants and firms for their Tribal clients. Please cite the source.
Suggested citation for a paper:
Fox, E. J. (2026). Title of paper. edfoxphd.com. https://edfoxphd.com/publications/
Suggested citation for a graphic:
Fox, E. J. (2026). Title of graphic [Graphic]. edfoxphd.com. https://edfoxphd.com/graphics/
When you use one of my figures, please carry its data year and source with it. Some figures come from other sources, such as the NIHB Data Match Report or the Henson et al. enrollment figures. For those, please cite the original source as well.
A last word
This site is a static archive, not a current-data service. Check current-year figures, especially appropriations and FMAP rates, against the original sources before submitting. Ask Dr. Fox, the assistant in the corner of each page, can help you find the paper that addresses your question and summarize its argument.