Evers agreed, noting that “the way health care is delivered in Indian Country is very different from the other parts of the state.”

The federal government provides health care to American Indians and Alaska Natives through the Indian Health Service, established to fulfill the nation’s trust responsibility created in treaties with tribes who gave up their land during the formation of the United States.

For decades, tribes have argued IHS is underfunded and understaffed, noting incorrect diagnoses, the high rates at which referral care is denied and the rationing of health services based on available funds. Because of the federal sequester, many Montana IHS clinics have operated at “priority one” status for years, funding only the most urgent and serious care. That limited access to preventive care also often results in the late diagnosis of serious illnesses, such as cancer.

Few tribes have opted for self-governance of health services, which provides more administrative freedom but also requires additional expertise and funding strategies.