Indian health financing isn’t a subject most people spend a career on. I did — and this site is where that work lives now that I’m retired. It’s not a stack of papers to wade through; it’s a map of how the funding, the policy, and the people connect, built from decades of seeing it up close.
I worked in Indian health as a Tribal health program administrator, a Tribal health director for the Port Gamble S’Klallam, Skokomish, and Squaxin Island Tribes. I worked for two leading Indian health organizations: in executive leadership and policy at the Northwest Portland Area Indian Health Board and as the Director of National Indian Health Board’s 2020 to 2023 Data Project.
Below is a map of how that work fits together — the funding streams, the policy shifts, and the papers that trace them.
How the Papers Fit the Research Map
The papers in this archive represent different parts of a continuing examination of how Indian health care is financed, delivered, measured, and improved. The Indian Health Finance Research Map provides a framework for understanding how these individual studies connect.
The research begins with Federal Funding Foundations. Several papers examine the federal responsibility for Indian health, the adequacy of federal appropriations, and the financial foundations of the Indian Health Service and tribal health programs. These studies establish the broader fiscal context in which Indian health care operates.
The next area, IHS and Tribal Health Systems, focuses on how those resources are translated into health care delivery. The papers examining IHS, tribal programs, urban Indian organizations, and related financing mechanisms help explain the capacity and constraints of the health system itself.
A substantial part of the research concerns Medicaid and Medicare. These programs are not simply sources of insurance coverage; they are important components of Indian health financing. The papers in this area examine enrollment, payment, reimbursement, and the ways Medicaid and Medicare interact with the federal trust responsibility and tribal health systems.
The Enrollment and Data section provides an important foundation for the rest of the research. Studies of American Indian and Alaska Native enrollment, data matching, population measurement, and administrative data address a basic policy question: How many people are being served, and how accurately can they be identified and counted? The CMS–IHS data-matching work is particularly important in connecting administrative data to questions of coverage, financing, and policy.
The research also examines State–Tribal Financing Relationships. These papers look at the practical relationships between tribes, states, Medicaid programs, and other financing systems. They illustrate how partnerships and changes in financing arrangements can affect both resources available to tribal health programs and access to care for AI/AN people.
Finally, the papers contribute to Policy Implications and Solutions. Rather than treating financing, enrollment, data, and health care delivery as separate issues, the research brings them together to identify opportunities for better policy, stronger state–tribal relationships, improved data, and more effective use of available resources.
The papers therefore should not be viewed simply as a collection of individual publications. Each addresses a particular question, but together they form an interconnected body of work. The Research Map provides the organizing framework: funding supports systems; systems depend on financing and coverage; financing depends on accurate enrollment and data; and the evidence from all of these areas can inform better policy.
The purpose of the archive is to make those connections visible and to provide a cumulative record of research on Indian health finance and the policies that shape it.The site also serves as an archive of completed work and continuing research. Materials are presented for informational and review purposes, with source materials and methodological notes provided where appropriate.
The Research Over Time
The timeline below is a way of understanding how earlier policy and data work laid the foundation for later research.
This timeline shows the development of the research across more than four decades. The work evolved from participation in national policy and technical advisory efforts into a broader body of research examining Indian health financing, data, coverage, and health system performance.
The early period reflects the development of Medicare and Medicaid policy and tribal health financing, including participation in the CMS Tribal Technical Advisory Group (TTAG), which began in 2003. This work provided a foundation for later research on how federal and state policy affects tribal health programs.
Over the following years, the research increasingly focused on data and measurement — including Medicaid enrollment, administrative data, and the CMS–IHS data match. These efforts addressed the importance of reliable information about AI/AN enrollment, coverage, and use of health services.
The later work extends these threads through studies of Indian Health Service and tribal health financing, state-tribal relationships, Medicaid and Medicare, and the adequacy of resources available for Indian health care.
Explore how each period’s work connects in the papers that follow.
Edward J. Fox, PhD 