A Graduate-Level Course on Indian Health Care Finance
UNDERSTANDING INDIAN HEALTH FINANCing
How is health care for American Indians and Alaska Natives actually financed—and what does the evidence tell us about resources, need, and policy?
Indian health financing is not simply a matter of how much money is appropriated to the Indian Health Service. Health care is financed through multiple streams, including federal appropriations, Medicaid, Medicare, Purchased/Referred Care, Tribal resources, and other sources.
This course follows the money. It explains how these financing streams fit together, examines the evidence behind them, and shows what the evidence tells us about the resources available for Indian health care.
WHAT YOU WILL LEARN
By the end of the course, you will be able to:
- Explain why Indian health financing differs from ordinary health care financing.
- Identify the major sources of funding for Indian health care.
- Distinguish IHS appropriations from total Indian health financing.
- Understand the roles of Medicaid, Medicare, Purchased/Referred Care, and Tribal resources.
- Use data to examine financing, coverage, need, and disparities.
- Evaluate claims about whether Indian health care is adequately financed.
- Connect financing evidence to Indian health policy.
THE GRADUATE COURSE
Indian Health Financing is a 15-week graduate seminar organized around one empirical question:
How is health care for American Indian and Alaska Native people actually financed, and is that financing adequate?
The course follows the financing system from its legal foundation through the Indian Health Service, Medicaid, Medicare, Purchased/Referred Care, Tribal resources, and the administrative data that now allow important parts of that financing system to be measured.
How the Indian Health Finance (This Page) and Course Notes Pages Work Together
The Indian Health Finance page and the Course Notes and Lectures page are designed to work together as two parts of the same learning resource. The Indian Health Finance page provides the overall framework for the course: it introduces the major topics, organizes the subject matter, and provides the broader context for understanding how Indian health financing has developed and how its major funding systems operate. It functions as the road map and reference page for the course.
The Course Notes and Lectures page provides the detailed instructional material behind that framework. It contains the lecture notes, scripts, and supporting explanations organized by week. Links from the Indian Health Finance page take the reader to the appropriate course material, while links on the Course Notes and Lectures page allow the reader to return to the main Indian Health Finance page or move among the course sections. In this way, the two pages are complementary rather than duplicative: Indian Health Finance explains what the course covers and how the pieces fit together; Course Notes and Lectures provides the detailed material used to study each piece.
THREE-TRACK ARCHITECTURE
All students follow the same 15-week course, but examine the material through three professional perspectives:
Policy & History
What does Indian health financing mean for federal policy, sovereignty, and the federal trust responsibility?
Research & Methods
How do we know what we know, and how reliable are the data?
Operations & Administration
How does Indian health financing actually work for an I/T/U health program
15-WEEK COURSE
UNIT I — FOUNDATIONS
Weeks 1–2
The Trust Responsibility, the IHS System, and Why Financing Matters
What is the Indian Health Service, why does it exist, how is it financed, and why does that financing structure produce a chronic funding gap that Medicaid has increasingly been called upon to fill?
Week 1 — The Trust Responsibility and the Architecture of Indian Health
Legal foundations • Snyder Act • Indian Health Care Improvement Act • I/T/U system • eligibility • federal health care obligation
Week 2 — The IHS Funding Gap and Medicaid’s Entry Point
Appropriations • funding gap • Medicaid financing • 100% FMAP • Medicaid as a growing component of Indian health financing
UNIT II — THE SURVEY ERA AND ITS LIMITS
Weeks 3–4
From Survey Estimates to Administrative Data
Why was survey data insufficient for Indian health financing analysis—and what did each successive methodological innovation reveal that the previous approach could not?
Week 3 — Counting the Population
ACS estimates • AI/AN identification • Medicaid coverage estimates • sampling limitations • population denominators
Week 4 — From Survey Data to Administrative Data
CMS Medicaid data • the AIR proxy • administrative records • methodological limitations • why better measurement matters
UNIT III — BUILDING THE DATA MATCH
Weeks 5–7
How the CMS–IHS Data Match Was Built
The technical, institutional, legal, and Tribal-governance foundations of the CMS–IHS Data Match.
Week 5 — The Political History of the Data Match
How Tribal advocacy, CMS–IHS collaboration, and the development of administrative data made a national financing analysis possible.
Week 6 — Data Governance, Legal Authority, and the VRDC
How legal authority, data-use agreements, privacy protections, and the Virtual Research Data Center established the foundation for secure research.
Week 7 — Matching, Validation, and Tribal Review
How IHS and Medicaid records were matched, validated, reviewed, and prepared for analysis.
UNIT IV — WHAT THE DATA SHOWS
Weeks 8–10
The 2023 Data Match and Population A/B
What did the administrative data actually show, and why does the distinction between Population A and Population B matter?
Week 8: The 2023 Results
Week 9: Population A/B and the Medicaid Financing Picture
Week 10: From Enrollment to Expenditure
UNIT V — POLICY IMPLICATIONS
Weeks 11–12
What Happens If Medicaid Contracts?
What do the financing data mean for Indian health programs, federal policy, and the fiscal consequences of changes in Medicaid?
Week 11 — Medicaid as a Structural Pillar
Medicaid revenue • I/T/U financing • 100% FMAP • federal investment • the relationship between Medicaid and IHS appropriations
Week 12 — Fiscal Risk and the Federal Investment Framework
Medicaid contraction • revenue loss • Purchased/Referred Care • federal responsibility • implications for Indian health financing policy
UNIT VI — TRIBAL-LED RESEARCH AND SYNTHESIS
Weeks 13–15
The Tribal-Led Research Model
What did the NIHB-led research model make possible, and what does it tell us about Tribal data sovereignty and future Indian health research?
Week 13: Tribal Data Sovereignty
Week 14: The Tribal-Led Research Model
Week 15: Synthesis — What We Know, What We Don’t Know, and What Comes Next
COURSE MATERIALS
INSTRUCTOR LECTURE NOTES & SCRIPT
Weeks 1–15 • All Tracks • Three-Track Architecture
Complete instructor lecture notes, session structure, discussion guidance, activities, and teaching script for the 15-week graduate course.
[Open Instructor Lecture Notes & Script]
CORE ANALYTICAL READINGS
CMS–IHS Data Match Lecture Paper
AI/AN Medicaid enrollment, expenditures, and the federal investment in Indian health
The primary analytical spine of the course, used progressively from Weeks 1–2 through Weeks 13–14.
[Read the CMS–IHS Data Match Lecture Paper]
Revised Analysis 1999–2023
AI/AN Medicaid enrollment and expenditure longitudinal reconciliation
The longitudinal analysis connecting the historical 1999–2012 Medicaid payment series to the 2023 Data Match.
[Read the Revised Analysis 1999–2023]
Counting Who We Serve — Lecture Series, Parts 1–3
Methodological evolution in AI/AN Medicaid research
Extended material for the Research & Methods track, particularly Weeks 3–10 and the later analysis of findings and Tribal-led research.
CMS Investment Estimates Paper
ACS PUMS 2024 × NHE 2024 × Data Match 2023
The quantitative foundation for the federal investment framework developed in Weeks 11–12.
[Read the CMS Investment Estimates Paper]
COURSE SYLLABUS
15-Week Graduate Course Syllabus
Weekly topics • readings • activities • assignments • three-track integration
[Open Course Syllabus]
Instructor Lecture Notes & Scripts
Weeks 1–15 • All Tracks • Three-Track Architecture
Student Readings & Research Papers
CMS–IHS Data Match Materials
Data Sources & Methods
Assignments & Research Projects
Three graded assignments
- Midterm: Data Match governance timeline + sovereignty essay
- Data Memo: 3-state Population A/B comparison
- Final Research Paper: original Indian health financing research/policy paper
HOW THE COURSE WORKS
The course is organized into eight segments. Each segment builds on the preceding one: first understanding the financing system, then following the money, examining the major financing streams, working with the data, and finally connecting evidence to policy.
The Course
Why Is Indian Health Financing Different?
An introduction to the distinctive financing structure and why the IHS
appropriation is not the same thing as total Indian health financing.
Where Does the Money Actually Come From?
Follow federal appropriations, Medicaid, Medicare, PRC, Tribal resources,
and other financing streams through the health system.
What Does IHS Finance?
Examine direct care, Purchased/Referred Care, facilities, public health,
active users, and the relationship between financing and need.
How Does Medicaid Fit Into Indian Health?
Explore enrollment, utilization, reimbursement, provider participation,
and Medicaid’s distinctive role in Indian health financing.
What Happens When Coverage Overlaps?
Examine Medicare, Medicaid, dual eligibility, and the challenge of measuring
multiple financing streams around the same patient.
Is Indian Health Adequately Financed?
Move from describing financing to evaluating resources, population, utilization,
unmet need, and alternative measures of adequacy.
How Do We Measure Indian Health Financing?
Learn how population, enrollment, utilization, and spending measures differ,
and why definitions and denominators matter.
What Should We Do With the Findings?
Bring the financing and data analysis together and consider what the evidence
can contribute to Tribal, federal, and health policy decisions.
What You Will Learn
- Identify the major sources of Indian health financing.
- Distinguish IHS appropriations from broader health-care financing.
- Explain the roles of Medicaid, Medicare, and Purchased/Referred Care.
- Understand dual eligibility and overlapping financing streams.
- Evaluate population, enrollment, utilization, and spending measures.
- Recognize important data and methodological limitations.
- Connect financing evidence to Indian health policy.
A guided path:
Start with the financing system → follow the money → understand IHS →
examine Medicaid and Medicare → test adequacy → work with the data →
apply the evidence to policy.
Research & Further Study
The course is designed to lead into the papers, graphics, data sources,
and other Indian Health Finance research presented elsewhere on this website.
Those materials provide opportunities to go beyond the introductory lessons
and examine the evidence in greater depth.
The course is intended as a framework for study and research. Individual
segments can be used independently, but the sequence provides the clearest
introduction to the financing system.