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Mr. Dorgan said he told Senate Majority Leader Harry Reid, Nevada Democrat, he would not vote for the larger health bill unless it included Indian health care. “That’s not a threat, just a statement of fact,” he said.

Mr. Dorgan also championed the Tribal Law and Order Act, which aims to give tribes more authority to combat crime on their reservations.

The measure authorizes more federal law enforcement officers and makes federal agencies collect data on crimes committed in Indian country. It also requires the Justice Department to maintain criminal data on cases that U.S. attorneys decline to prosecute for various reasons, including a lack of evidence. A recent report found that federal officials decline to prosecute more than 50 percent of violent crimes on reservations.

On some reservations, fewer than a dozen officers patrol areas the size of Connecticut.

“If you report a rape, a cop might show up the next day,” Mr. Dorgan said. “It’s a full-blown scandal.”

Congress approved $3.4 billion to settle the lost-royalties case, which covers claims that American Indians were swindled out of payments for oil, gas, timber and grazing rights for more than a century. As many as 500,000 American Indians will receive at least $1,500 apiece; some will get significantly more.

A total of $2 billion will be used to buy broken-up Indian lands from individual owners willing to sell, with the lands turned over to tribes. An additional $60 million will go to a scholarship fund for young Indians.

The settlement was reached in late 2009, but was not approved by Congress until the lame-duck session that ended just before Christmas.

A separate settlement with the Agriculture Department will pay Indian farmers $680 million for improper denial of farm loans. The settlements and new laws, Mr. Dorgan said, are a matter of honor.

“We signed these treaties and made promises — in writing — and then broke them all,” he said. “This is about keeping the country’s promises.”