Can Indian Health Service Referrals for Nonemergent Care Be Allocated Equitably?

The Indian Health Service (IHS) administers health care services to American Indians and Alaska Natives (AI/ANs) in the United States. The agency funds referral care services through the Purchased/Referred Care (PRC) Program, which prioritizes its budget to pay for emergent care. This commentary responds to a case about a physician's disappointment that a referral for nonemergent care is deferred for payment by the PRC Program. Jonsen et al's 4-quadrant approach (a microethical case analysis model) is applied to suggest that deferring referrals is just only when the PRC Program operates fairly. This model, however, might inadequately account for structural inequities underlying referral care rationing by the IHS, a federal entity that is legally and ethically obligated to care comprehensively for AI/AN patients.