funding these programs, then the federal government could easily "deny any further responsibility for the tribes, and cut funding". The fear of potential termination has led some tribes to refuse to participate in Self Determination contracting without a clear resolution of this issue. Some tribes also renounce Self Determination and contracting because of the chronic underfunding of IHS programs. They do not see any benefit in being handed the responsibility of a "sinking ship" due to the lack of a satisfactory budget for IHS services. Other tribes face various barriers to successful Self Determination. Small tribes lacking in administrative capabilities, geographically isolated tribes with transportation and recruitment issues, and tribes with funding issues may find it much harder to contract with the IHS and begin self-determination. Poverty and a lack of resources can thus make Self Determination difficult. Budget The IHS receives funding as allocated by the United States Congress and is not an entitlement program, insurance program, or established benefit program. The 2017 United States federal budget includes $5.1 billion for the IHS to support and expand the provision of health care services and public health programs for American Indians and Alaska Natives. The proposed 2018 budget proposes to reduce IHS spending by more than $300 million. This covers the provision of health benefits to 2.5 million Native Americans and Alaskan Natives for a recent average cost per patient of less than $3,000, far less than the average cost of health care nationally ($7,700), or for the other major federal health programs Medicaid ($6,200) or Medicare ($12,000). Affordable Care Act An integral focus of economic and health policy for Native American healthcare is Medicaid. Under the Affordable Care Act (ACA) of 2010, states could choose to expand Medicaid benefits. Many Native Americans stood to benefit from this expansion of healthcare coverage. IHS and tribal facilities rely on beneficiaries like Medicaid to help cover the Congressional underfunding of the IHS itself. During the formation of the ACA, tribal leaders pushed for the reauthorization of the Indian Health Care Improvement Act and further provisions for AI/NA recipients, which facilitated IHS Medicaid funding. The ACA also authorized funding to support residency training programs in tribal or IHS facilities through teaching health centers (THCs). Such initiatives support provider retention as a greater percentage of graduates from these THCs chose to work in rural and underserved settings compared to the national average. Expansion of