[5][6] The Tribes subsequently sued the U.S. Department of Health and Human Services, IHS, and the United States, regarding the healthcare costs for the years of 2011–2013.

[10] Additionally, Unikowsky emphasized that the nature of the IHS harmonized with the purpose of the legislation, noting that "Such costs are recoverable if they're incurred in connection with the operation of the federal program function, service or activity pursuant to the contract.

[14][15] In his opinion, Roberts contended that the arguments of the government were inconsistent with the text and purpose of the ISDA as the ISDA was intended to provide an "effective voice in the planning and implementation of programs responsive to the true needs of their communities”, and noted that the potential of IHS not covering contract costs of outside programs would result in "a penalty on tribes for opting in favor of greater self-determination".

In his opinion, Kavanaugh countered the majority's reading of the ISDA, stipulating that the law did "not support the Court's decision" and that the decision was at odds with a long-standing understanding of payment, stating "For the past 30 years, the Executive Branch has interpreted the relevant statutory provisions […] to require tribes to pay those overhead costs out of the third-party income […] And Congress has never overturned that consistent Executive Branch practice".

[21][22][23] In addition, Kavanaugh commented that reimbursement by the IHS, had it been included, should have been specified via further deliberations of Congress, noting that "The extra federal money that the Court today green-lights does not come free".