Yes, Native Seniors in Yakima County Can Use Both IHS and Medicare at the Same Time for Kidney Disease — Here's Exactly How the Two Systems Work Together in 2026

Someone in the family typed that question into a search bar because an elder they love has kidney disease, is enrolled in Medicare, and doesn't know whether they still have the right to walk into the Yakama Reservation Health Center and be treated. The answer is yes. Unconditionally yes. Let me explain exactly why, and what it looks like in practice in Yakima County, Washington.

What Is the Legal Basis for IHS Care — and Why Does It Matter for Kidney Disease?

I've said this before at this desk and I'll keep saying it until it's printed on every Medicare Summary Notice in Indian Country: IHS is not a government benefit. It is not Medicaid. It is not charity care. It is a treaty obligation.

The United States acquired over 500 million acres of land from tribal nations through treaties that explicitly promised, in exchange, perpetual federal healthcare. For the Confederated Tribes and Bands of the Yakama Nation specifically, the 1855 Treaty of Camp Stevens — signed at a table set up in eastern Washington Territory — established the government-to-government relationship that underlies IHS funding to this day. That treaty didn't have an expiration date. Neither does the healthcare promise.

Here's why this matters specifically for kidney disease: Chronic kidney disease (CKD) progresses quietly. Many elders don't know they have it until they're already in Stage 3 or Stage 4. By the time dialysis becomes necessary, the financial and logistical stakes are enormous — treatments three times a week, every week, for years. If an elder believes (wrongly) that enrolling in Medicare means giving up IHS, they may avoid Medicare enrollment. That mistake costs them Part B coverage for outpatient dialysis — which is one of the most heavily covered Medicare services in existence.

Why Are Yakima County's Kidney Disease Numbers So Concerning Right Now?

Let's look at the data honestly. According to CDC PLACES 2023 data for Yakima County (population 256,643), two conditions are the primary drivers of CKD in this community:

Diabetes at 12.1%. Nationally, diabetes is the leading cause of kidney failure. Among American Indian and Alaska Native populations, the prevalence of Type 2 diabetes runs significantly higher than the national average — the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) reports AIAN adults experience diabetes at roughly twice the rate of non-Hispanic white adults. Yakima County's 12.1% county-wide rate almost certainly understates the rate within Yakama tribal enrollment specifically.

High blood pressure at 32.7%. Hypertension is the second leading cause of kidney failure. Nearly one in three Yakima County adults has high blood pressure. Uncontrolled hypertension accelerates CKD progression dramatically. Combined with the diabetes burden, our elders are facing a compounding kidney disease risk that requires coordinated, consistent specialty care — exactly the kind that IHS alone, perpetually underfunded, cannot always provide.

The 19% uninsured rate among adults 18–64 in Yakima County (CDC PLACES 2023) is particularly telling. It tells us that many people in this county — including Native people who may not fully understand their IHS entitlement — are navigating health crises without coverage. By the time they turn 65 and become Medicare-eligible, kidney disease that went unmanaged for years is that much worse.

And the 15.4% mobility disability rate matters too. Getting to dialysis three times a week is hard enough when you're healthy. When you have mobility limitations and you're 70 years old and the nearest certified dialysis center is a 30-minute drive from the reservation, "just use Medicare" becomes complicated very fast.

How Do IHS and Medicare Actually Coordinate When a Native Elder Has Kidney Disease?

Let me walk through this practically, because the theory is fine but elders and families need to know what actually happens at the billing window.

Step 1: IHS Provides Primary and Preventive Care

The Yakama Indian Health Service facility — operated through the Yakama Nation's 638 self-governance compact with IHS — provides primary care, labs, monitoring, and medication management. For an elder with CKD Stage 1–3, much of the ongoing management (quarterly labs, blood pressure medications, diabetes management, dietary counseling) can and should happen at the IHS/tribal facility. This costs the elder nothing out of pocket. This is the treaty in action.

Step 2: Medicare Part B Covers Outpatient Dialysis at Non-IHS Centers

When kidney disease progresses to End-Stage Renal Disease (ESRD) requiring dialysis, IHS facilities typically cannot run a dialysis center in-house — the equipment, staffing, and square footage requirements are significant. This is where Medicare Part B becomes critical. Part B covers dialysis at Medicare-certified outpatient dialysis facilities at 80% of the approved amount. The elder pays 20% — or nothing, if they're also enrolled in Medicaid (dual-eligible) or have a Medigap supplemental policy.

If an elder has Medicare Part B and is also IHS-eligible, here's what happens: The dialysis center bills Medicare first. Medicare pays its 80%. IHS — through its Purchased/Referred Care (PRC) program — can then be billed for the remaining 20% as payer of last resort. For dual-eligible elders who also have Medicaid, Medicaid covers that 20% instead.

Step 3: Medicare Part D Covers Prescription Drugs

Kidney disease means a long medication list: ACE inhibitors, ARBs, phosphate binders, erythropoiesis-stimulating agents, diuretics, iron supplements. The IHS/tribal pharmacy covers many of these for free to eligible beneficiaries. But when the IHS pharmacy is out of stock — and this happens — or when a specialist outside the IHS system prescribes a medication not on the IHS formulary, Medicare Part D becomes the backstop. Elders should have Part D even if they primarily use the IHS pharmacy, because the day the pharmacy is out of their blood pressure medication is not the day to find out they have no Part D coverage.

What Hospitals Serve Yakima County — and What Does That Mean for CMS Medicare Access?

According to CMS Hospital Compare data (retrieved April 2026), Yakima County has three hospitals with emergency services:

There's something I want to say about these hospital ratings plainly, without bureaucratic softening: A 1-star CMS rating means the hospital performed below average on the measures CMS uses — mortality rates, safety events, readmissions, patient experience. It doesn't mean the staff don't care or don't work hard. It often means the hospital is under-resourced, serving a high-acuity, lower-income population, without the infrastructure of a major academic medical center. Both Yakima Valley Memorial and Astria Sunnyside Hospital carry that 1-star designation. Astria Toppenish — the hospital physically closest to the Yakama Reservation — has no rating available at all.

For an elder with Stage 4 CKD who needs nephrology specialist consultations, the hospital landscape in Yakima County is not reassuring. This is exactly why the IHS Purchased/Referred Care program exists — to fund referrals to higher-level care in Seattle or Spokane when local capacity is insufficient. But PRC has waiting lists and funding limits. Medicare is the bridge.

What Is the Purchased/Referred Care (PRC) System and How Does It Fail — and Help — Kidney Patients?

PRC is IHS's program for paying for care that the local facility can't provide. Think of it as a referral system with a budget attached. If the Yakama Nation Health Center doesn't have a nephrologist on staff (and most IHS facilities don't — nephrology is a specialty in short supply even in well-funded health systems), a patient who needs a kidney specialist has to be referred out. PRC is supposed to fund that referral.

Here's the reality: PRC is funded at roughly half of what it would need to be to cover all medically necessary referred care. IHS itself has documented this shortfall. The Indian Health Service budget has been chronically underfunded at approximately 70 cents on the dollar compared to what the agency estimates is needed to provide care comparable to what the general U.S. population receives. (Source: IHS Justification of Budget, FY2026; available at ihs.gov.)

What Does the Coverage Matrix Look Like — IHS vs. Medicare vs. Both Combined?