Wieder is a member of the Confederated Salish and Kootenai Tribes in Montana and can access some health services free of charge through her tribe’s health clinics. But funding is limited, so, like a lot of Native American people, she relied on Medicaid for herself and Oakleigh.

Months before Oakleigh’s 1st birthday, the date when Wieder’s postpartum coverage would come to an end, Wieder completed and returned paperwork to enroll her daughter in Healthy Montana Kids, the state’s version of the Children’s Health Insurance Program. But her paperwork, caught up in the lengthy delays and processing times for applications, did not go through.

“As soon as she turned 1, they cut her off completely,” Wieder said.

It took six months for Wieder to get Oakleigh covered again through Healthy Montana Kids. Before health workers in her tribe stepped in to help her resubmit her application, Wieder repeatedly called the state’s health department. She said she would dial the call center when she arrived at her job in the morning and go about her work while waiting on hold, only for the call to be dropped by the end of the day.

“Never did I talk to anybody,” she said.

Wieder and Oakleigh’s experience is an example of the chaos for eligible Medicaid beneficiaries caused by the process known as the “unwinding,” which led to millions of people in the U.S. losing coverage due to paperwork or other procedural issues. Now, tribal health leaders fear their communities will experience more health coverage disruptions when new federal Medicaid work and eligibility requirements are implemented by the start of 2027.

The tax-and-spending law that President Donald Trump signed this summer exempts Native Americans from the new requirement that some people work or do another qualifying activity a minimum number of hours each month to be eligible for Medicaid, as well as from more frequent eligibility checks. But as Wieder and her daughter’s experience shows, they are not exempt from getting caught up in procedural disenrollments that could reemerge as states implement the new rules.

“We also know from the unwinding that that just doesn’t always play out necessarily correctly in practice,” said Joan Alker, who leads Georgetown University’s Center for Children and Families. “There’s a lot to worry about.”

The new law is projected to increase the number of people who are uninsured by 10 million.

The lessons of the unwinding suggest that “deep trouble” lies ahead for Native Americans who rely on Medicaid, according to Alker.

Changes to Medicaid

Trump’s new law changes Medicaid rules to require some recipients ages 19 to 64 to log 80 hours of work or other qualifying activities per month. It also requires states to recheck those recipients’ eligibility every six months, instead of annually. Both of these changes will be effective by the end of next year.

The Congressional Budget Office estimated in July that the law would reduce federal Medicaid spending by more than $900 billion over a decade. In addition, more than 4 million people enrolled in health plans through the Affordable Care Act marketplace are projected to become uninsured if Congress allows pandemic-era enhanced premium tax credits to expire at the end of the year.

Wieder said she was lucky that the tribe covered costs and her daughter’s care wasn’t interrupted in the six months she didn’t have health insurance. Citizens of federally recognized tribes in the U.S. can access some free health services through the Indian Health Service, the federal agency responsible for providing health care to Native Americans and Alaska Natives.

But free care is limited because Congress has historically failed to fully fund the Indian Health Service. Tribal health systems rely heavily on Medicaid to fill that gap. Native Americans are enrolled in Medicaid at higher rates than the white population and have higher rates of chronic illnesses, die more from preventable diseases, and have less access to care.

Medicaid is the largest third-party payer to the Indian Health Service and other tribal health facilities and organizations. Accounting for about two-thirds of the outside revenue the Indian Health Service collects, it helps tribal health organizations pay their staff, maintain or expand services, and build infrastructure. Tribal leaders say protecting Medicaid for Indian Country is a responsibility Congress and the federal government must fulfill as part of their trust and treaty obligations to tribes.

Lessons Learned During the Unwinding

The Trump administration prevented states from disenrolling most Medicaid recipients for the duration of the public health emergency starting in 2020. After those eligibility checks resumed in 2023, nearly 27 million people nationwide were disenrolled from Medicaid during the unwinding, according to an analysis by the Government Accountability Office published in June. The majority of disenrollments — about 70% — occurred for procedural reasons, according to the federal Centers for Medicare & Medicaid Services.

CMS did not require state agencies to collect race and ethnicity data for their reporting during the unwinding, making it difficult to determine how many Native American and Alaska Native enrollees lost coverage.

The lack of data to show how the unwinding affected the population makes it difficult to identify disparities and create policies to address them, said Latoya Hill, senior policy manager with KFF’s Racial Equity and Health Policy program. KFF is a health information nonprofit that includes KFF Health News.

The National Council of Urban Indian Health, which advocates on public health issues for Native Americans living in urban parts of the nation, analyzed the Census Bureau’s 2022 American Community Survey and KFF data in an effort to understand how disenrollment affected tribes. The council estimated more than 850,000 Native Americans had lost coverage as of May 2024. About 2.7 million Native Americans and Alaska Natives were enrolled in Medicaid in 2022, according to the council.

The National Indian Health Board, a nonprofit that represents and advocates for federally recognized tribes, has been working with federal Medicaid officials to ensure that state agencies are prepared to implement the exemptions.

“We learned a lot of lessons about state capacity during the unwinding,” said Winn Davis, congressional relations director for the National Indian Health Board.

Nevada health officials say they plan to apply lessons learned during the unwinding and launch a public education campaign on the Medicaid changes in the new federal law. “A lot of this will depend on anticipated federal guidance regarding the implementation of those new rules,” said Stacie Weeks, director of the Nevada Health Authority.

Staff at the Fallon Tribal Health Center in Nevada have become authorized representatives for some of their patients. This means that tribal citizens’ Medicaid paperwork is sent to the health center, allowing staff to notify individuals and help them fill it out.

Davis said the unwinding process showed that Native American enrollees are uniquely vulnerable to procedural disenrollment. The new law’s exemption of Native Americans from work requirements and more frequent eligibility checks is the “bare minimum” to ensure unnecessary disenrollments are avoided as part of trust and treaty obligations, Davis said.

Eligibility Checks Are ‘Complex’ and ‘Vulnerable to Error’

The GAO said the process of determining whether individuals are eligible for Medicaid is “complex” and “vulnerable to error” in a 2024 report on the unwinding.

“The resumption of Medicaid eligibility redeterminations on such a large scale further compounded this complexity,” the report said.

It highlighted weaknesses across state systems. By April 2024, federal Medicaid officials had found nearly all states were out of compliance with redetermination requirements, according to the GAO. Eligible people lost their coverage, the accountability office said, highlighting the need to improve federal oversight.

In Texas, for example, federal Medicaid officials found that 100,000 eligible people had been disenrolled due to, for example, the state system’s failure to process their completed renewal forms or miscalculation of the length of women’s postpartum coverage.

Some states were not conducting ex parte renewals, in which a person’s Medicaid coverage is automatically renewed based on existing information available to the state. That reduces the chance that paperwork is sent to the wrong address, because the recipient doesn’t need to complete or return renewal forms.

But poorly conducted ex parte renewals can lead to procedural disenrollments, too. More than 100,000 people in Nevada were disenrolled by September 2023 through the ex parte process. The state had been conducting the ex parte renewals at the household level, rather than by individual beneficiary, resulting in the disenrollment of still-eligible children because their parents were no longer eligible. Ninety-three percent of disenrollments in the state were for procedural reasons — the highest in the nation, according to KFF.

Another issue the federal agency identified was that some state agencies were not giving enrollees the opportunity to submit their renewal paperwork through all means available, including mail, phone, online, and in person.

State agencies also identified challenges they faced during the unwinding, including an unprecedented volume of eligibility redeterminations, insufficient staffing and training, and a lack of response from enrollees who may not have been aware of the unwinding.

Native Americans and Alaska Natives have unique challenges in maintaining their coverage.

Communities in rural parts of the nation experience issues with receiving and sending mail. Some Native Americans on reservations may not have street addresses. Others may not have permanent housing or change addresses frequently. In Alaska, mail service is often disrupted by severe weather. Another issue is the lack of reliable internet service on remote reservations.

Tribal health leaders and patient benefit coordinators said some tribal citizens did not receive their redetermination paperwork or struggled to fill it out and send it back to their state Medicaid agency.

The Aftermath

Although the unwinding is over, many challenges persist.

Tribal health workers in Montana, Oklahoma, and South Dakota said some eligible patients who lost Medicaid during the unwinding had still not been reenrolled as of this spring.

“Even today, we’re still in the trenches of getting individuals that had been disenrolled back onto Medicaid,” said Rachel Arthur, executive director of the Indian Family Health Clinic in Great Falls, Montana, in May.

Arthur said staff at the clinic realized early in the unwinding that their patients were not receiving their redetermination notices in the mail. The clinic is identifying people who fell off Medicaid during the unwinding and helping them fill out applications.

Marlena Farnes, who was a patient benefit coordinator at the Indian Family Health Clinic during the Medicaid unwinding, said she tried for months to help an older patient with a chronic health condition get back on Medicaid. He had completed and returned his paperwork but still received a notice that his coverage had lapsed. After many calls to the state Medicaid office, Farnes said, state officials told her the patient’s application had been lost.

Another patient went to the emergency room multiple times while uninsured, Arthur said.

“I felt like if our patients weren’t helped with follow-up, and that advocacy piece, their applications were not being seen,” Farnes said. She is now the behavioral health director at the clinic.

Montana was one of five states where more than 50% of enrollees lost coverage during the unwinding, according to the GAO. The other states are Idaho, Oklahoma, Texas, and Utah. About 68% of Montanans who lost coverage were disenrolled for procedural reasons.

In Oklahoma, eligibility redeterminations remain challenging to process, said Yvonne Myers, a Medicaid and Affordable Care Act consultant for Citizen Potawatomi Nation Health Services. That’s causing more frequent coverage lapses, she said.

Myers said she thinks Republican claims of “waste, fraud, and abuse” are overstated.

“I challenge some of them to try to go through an eligibility process,” Myers said. “The way they’re going about it is making it for more hoops to jump through, which ultimately will cause people to fall off.”

The unwinding showed that state systems can struggle to respond quickly to changes in Medicaid, leading to preventable erroneous disenrollments. Individuals were often in the dark about their applications and struggled to reach state offices for answers. Tribal leaders and health experts are raising concerns that those issues will continue and worsen as states implement the requirements of the new law.

Georgia, the only state with an active Medicaid work requirement program, has shown that the changes can be difficult for individuals to navigate and costly for a state to implement. More than 100,000 people have applied for Georgia’s Pathways program, but only about 8,600 were enrolled as of the end of July.

Alker, of Georgetown, said Congress took the wrong lesson from the unwinding in adding more restrictions and red tape.

“It will make unwinding pale in comparison in terms of the number of folks that are going to lose coverage,” Alker said.

This article was published with the support of the Journalism & Women Symposium (JAWS) Health Journalism Fellowship, assisted by grants from The Commonwealth Fund.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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“I want people to not kill themselves for who they are,” said organizer Myk Mendez, a trans and two-spirit citizen of the Fort Hall Shoshone-Bannock Tribes in Idaho. “I want people to love their lives and grow old to tell their stories.”

“Two-spirit” is used by Native Americans to describe a distinct gender outside of male or female.

The conference in Elko reflects how some tribal citizens are supporting their LGTBQ+ community members as President Donald Trump rolls back protections and policies. In March, the National Indian Health Board, which represents and advocates for federally recognized Native American and Alaska Native tribes, passed a resolution declaring tribal sovereignty over issues affecting the Native American community’s health, including access to gender-affirming care.

The resolution calls on the federal government to preserve and expand programs that support the health and well-being of two-spirit and LGBTQ+ Native Americans. Tribes and tribal organizations are navigating how to uphold their sovereignty without jeopardizing the relationships and resources that support their communities, said Jessica Leston, the owner of the Raven Collective, a Native public health consulting group, and a member of the Ketchikan Indian Community.

In January, Trump signed an executive order recognizing only two sexes — male and female — and another to terminate diversity, equity, and inclusion programs within the federal government.

An Indian Health Service website describing two-spirit people was removed this year but restored following a court order. The page now has a disclaimer at the top that declares any information on it “promoting gender ideology” is “disconnected from the immutable biological reality that there are two sexes, male and female.”

Two-spirit is not a sexual orientation but refers to people of a “culturally and spiritually distinct gender exclusively recognized by Native American Nations,” according to a definition created by two-spirit elders in 2021. According to two-spirit leaders, people who did not fit into the Western binary of male and female have lived in their communities since before colonization.

Already, tribal citizens and leaders say some people have had trouble accessing gender-affirming care in recent months, with some community members being denied hormone treatments or having their medications delayed, even in places where gender-affirming care remains legal. Panic has spread, and tribal citizens have considered leaving the country.

“There is a chilling effect,” said Itai Jeffries, who is trans, nonbinary, and two-spirit, of the Occaneechi people from North Carolina, and a consultant for the Raven Collective.

Mendez said he requested hormone treatment at his local Indian Health Service clinic at the end of June and was told by his provider that the facility has had trouble receiving the treatment for patients.

Lenny Hayes, a two-spirit citizen of the Sisseton-Wahpeton Oyate in South Dakota, said the Indian Health Service clinic on the reservation also isn’t dispensing hormone treatment, though it is legal for people 18 and older. Hayes is the owner and operator of Tate Topa Consulting and provides educational training on two-spirit and LGTBQ+ Native Americans and Alaska Natives.

The National Congress of American Indians passed a resolution in 2015 to encourage the creation of policies to protect two-spirit and LGBTQ+ communities. And the organization adopted a resolution in 2021 to support providing gender-affirming care in Indian Health Service, tribal, and urban facilities.

The National Indian Health Board’s resolution cites homophobia and transphobia as contributing to higher rates of truancy, incarceration, self-harm, attempted suicide, and suicide among two-spirit young people. The board also lists health disparities among the broader Native LGBTQ+ population, including increased risks of anxiety, depression, and suicide.

Two-spirit and LGBTQ+ Native American and Alaska Native young people are particularly vulnerable to depression, suicidality, and sexual exploitation. In Minnesota, a 2019 state survey found that two-spirit and LGBTQ+ Native American and Alaska Native students had the highest rates of those ages 15-19 who responded “yes” to having traded sex or sexual activity for money, food, drugs, alcohol, or shelter.

Tribal leaders are also concerned that Medicaid cuts recently approved in Trump’s budget law will undercut efforts to expand testing and treatment for HIV infection in Native American communities.

The rates of HIV diagnosis among Native American and Alaska Native gay and bisexual men increased 11% from 2018 to 2022, according to the Centers for Disease Control and Prevention.

Despite this increase, Native American and Alaska Native gay and bisexual men are among the groups with the least access to HIV tests outside of health care settings, such as community-based organizations, mobile testing units, and shelters.

As tribes respond to state and federal regulations of two-spirit and LGBTQ+ people, organizations and communities are focused on providing information and resources to protect those in Indian Country, even from the president.

“He will never, ever wipe out our identity, no matter what he does,” Hayes said.

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The hospitals would be at a disproportionate risk of closure, service reductions, or ending inpatient care, according to a report authored by experts from the Cecil G. Sheps Center for Health Services Research following a request from Senate Democrats, who released the findings publicly Thursday. Many of those hospitals are in Kentucky, Louisiana, California, and Oklahoma, according to the analysis.

Trump’s budget plan, dubbed the “One Big Beautiful Bill Act,” contains nearly $800 billion in Medicaid cuts, according to the nonpartisan Congressional Budget Office. House Republicans passed the bill in late May, and it now awaits Senate consideration.

The proposed cuts to Medicaid raise the stakes for rural hospitals nationwide, many of which already operate on razor-thin, if not negative, margins. Diminished reimbursements from the state-federal health insurance program for those with low incomes or disabilities would further erode hospitals’ ability to stay open and maintain services for their communities — populations with more severe health needs than their urban counterparts.

“It’s very clear that Medicaid cuts will result in rural hospital closures,” said Alan Morgan, CEO of the National Rural Health Association, a nonprofit advocacy and research organization.

The Senate Democrats sent a letter to Trump, Senate Majority Leader John Thune, and House Speaker Mike Johnson asking them to reconsider the Medicaid cuts.

Sen. Edward Markey (D-Mass.), one of the Senate Democrats who requested the information from Sheps, in a statement said communities should know exactly what they stand to lose if Congress approves the reductions to Medicaid.

“People will die” if rural hospitals close, he said. “No life or job is worth a yes vote on this big billionaire bill.”

The legislation passed by the House in May would require most working-age, nondisabled Medicaid beneficiaries to prove they’re working, studying, or volunteering to retain coverage, and it would cut Medicaid reimbursement to states that use their own money to extend coverage to immigrants living in the country without authorization. Also, the bill would curtail taxes that nearly every state levies on providers to help draw down billions in additional federal money, which generally leads to more money for hospitals.

The Congressional Budget Office has estimated that the bill’s Medicaid provisions would lead to 7.8 million people becoming uninsured by 2034.

Johnson, a Louisiana Republican, has repeatedly claimed that the bill’s reductions in federal Medicaid spending don’t amount to cuts to the program. “If you are able to work and you refuse to do so, you are defrauding the system,” Johnson said May 25 on the CBS show “Face the Nation.”

Hospitals that do stay afloat likely will do so by cutting services that are particularly dependent on Medicaid reimbursements, such as labor and delivery units, mental health care, and emergency rooms. Obstetric services are among the most expensive and are being eliminated by a growing number of rural hospitals, expanding the areas that lack nearby maternity or labor and delivery care. Iowa, Texas, and Minnesota had the most rural obstetrics service closures between 2011 and 2023, according to the health analytics and consulting firm Chartis, which also studies rural hospital finances.

Nearly half of rural hospitals are operating in the red and 432 are vulnerable to closure. Medicaid cuts would push them further into financial peril.

That vulnerability stems at least partly from rural Americans’ being more likely to depend on Medicaid than the general population. For instance, nearly 50% of rural births are covered by the program, compared with 41% of births overall. But Medicaid covers only about half of what private insurance reimburses for childbirth-related services. Rural health systems have been struggling to meet the needs of their communities without the cuts to Medicaid, which brings in $12.2 billion, or nearly 10% of rural hospital net revenue, according to a Chartis report from May.

Hospitals in rural areas would collectively lose more than $1.8 billion with a 15% cut to Medicaid. That loss in revenue is roughly equivalent to 21,000 full-time hospital employees’ salaries.

Rural hospitals’ margins have been deteriorating for 10 to 15 years, said Michael Topchik, executive director for the Chartis Center for Rural Health, which analyzes and consults on rural hospital finances. Ten years ago, about one-third of rural hospitals were operating in the red. That’s closer to 50% now, he said.

It’s even higher in the 10 states that did not expand Medicaid eligibility under the Affordable Care Act, with 53% of rural hospitals there already operating in the red and more than 200 vulnerable to closure.

Other policies continue to affect rural hospitals, according to Chartis. Facilities will lose $509 million this year due to a 2% Medicare reimbursement cut — what’s known as sequestration — and $159 million in reimbursement for bad debt and charity care combined.

Some rural hospitals have responded to the increasing financial pressures in recent years by joining larger networks, such as Intermountain Health or Sanford, which are connected to facilities in the Mountain West and Midwest. But about half of rural hospitals are still independent, Topchik said, and struggle with a perennial collision of low patient volume and high fixed costs.

“We can’t Henry Ford our way out of this by increasing volumes to dilute costs and reduce prices,” he said. “It’s expensive, and that’s the reason the federal government, for a long time, has reimbursed rural hospitals in a variety of manners to help keep them whole.”

Rural hospitals play an important role in their communities. They provide health care to Americans who are older, sicker, and poorer and have less access overall to providers compared with people who live in urban areas. In many cases, a local rural hospital is the largest employer in a community and can trigger substantial local economic declines if it closes.

“When you close a hospital, oftentimes, the community follows,” Morgan said.

More than 10 million Americans enrolled in Medicaid live in counties that have at least one rural hospital, according to Chartis estimates. Kentucky, Texas, New York, North Carolina, California, and Michigan have the largest estimated populations of rural Medicaid enrollees.

And while Utah is not a state identified as especially vulnerable, health leaders there are concerned about rural hospital closures if Medicaid funding is cut, said Matt McCullough, the rural hospital improvement director for the Utah Hospital Association.

Facilities in rural parts of Utah are often governed by a board made up of community members — farmers, ranchers, and business owners who care about keeping their hospitals open, McCullough said, because they were born there and their kids were born there.

“They’ll do anything to see it stay open and provide good quality care to their neighbors, family members,” he said. “It’s people that they know and care about.”

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In some ways, he has. 

When layoffs were set to hit the Indian Health Service — the federal agency responsible for providing health care to Native Americans and Alaska Natives — Kennedy’s department rescinded the actions hours later. 

In April, while visiting Arizona’s Navajo Nation, Kennedy told KFF Health News he was making sure broader budget cuts and layoffs at HHS do not affect Native American communities. 

But tribal leaders expressed skepticism. They said they’ve already seen fallout from the sweeping reorganization across federal health agencies. Public health data is incomplete and agency communication has become less reliable. Tribes have also lost at least $6 million in grants from other HHS agencies, according to a letter the National Indian Health Board sent to Kennedy in May. 

“There may be a misconception among some of the administration that Indian Country is only impacted by changes to the Indian Health Service,” said Liz Malerba, a tribal policy expert and citizen of the Mohegan Tribe. “That’s simply not true.” 

Native Americans face higher rates of chronic diseases and die younger than other populations. Those inequities stem from centuries of systemic discrimination. The Indian Health Service has been chronically underfunded and understaffed, leading to gaps in care. 

Janet Alkire, chairperson of the Standing Rock Sioux Tribe in the Dakotas, said during a May Senate hearing that the canceled grants paid for community health workers, vaccinations, data modernization, and other public health efforts. 

Other programs — including ones aimed at Native American youth interested in science and medicine and increasing access to healthy foods — were slashed after the government said they violated the Trump administration’s ban on “diversity, equity, and inclusion.” 

Native leaders and organizations have requested tribal consultation, a legal process required when federal agencies consider changes that would affect tribal nations. Alkire and other tribal leaders at the Senate committee hearing said federal officials had not responded. 

“This is not just a moral question of what we owe Native people,” Sen. Brian Schatz (D-Hawaii) said at the hearing. “It is also a question of the law.” 

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Buu Nygren, president of the Navajo Nation, paused at the edge with Health and Human Services Secretary Robert F. Kennedy Jr. Below them, tribal government buildings, homes, and juniper trees dotted the tan and deep-red landscape.

Nygren said he wanted Kennedy to look at the capital for the nation of about 400,000 enrolled members. The tribal president pointed toward an antiquated health center that he hoped federal funding would help replace and described life for the thousands of locals without running water due to delayed government projects.

Nygren said Kennedy had already done a lot, primarily saving the Indian Health Service from a round of staffing cuts rippling through the federal government.

“When we started hearing about the layoffs and the freezes, you were the first one to stand up for Indian Country,” he told Kennedy, of his move to spare the federal agency charged with providing health care to Native Americans and Alaska Natives.

But Nygren and other Navajo leaders said cuts to federal health programs outside the Indian Health Service are hurting Native Americans.

“You’re disrupting real lives,” Cherilyn Yazzie, a Navajo council delegate, told KFF Health News as she described recent changes.

Kennedy has repeatedly promised to prioritize Native Americans’ health care. But Native Americans and health officials across tribal nations say those overtures are overshadowed by the collateral harm from massive cuts to federal health programs.

The sweeping reductions have resulted in cuts to funding directed toward or disproportionately relied on by Native Americans. Staffing cuts, tribal health leaders say, have led to missing data and poor communication.

The Indian Health Service provides free health care at its hospitals and clinics to Native Americans, who, as a group, face higher rates of chronic diseases and die younger than other populations. Those inequities are attributable to centuries of systemic discrimination. But many tribal members don’t live near an agency clinic or hospital. And those who do may face limited services, chronic underfunding, and staffing shortages. To work around those gaps, health organizations lean on other federally funded programs.

“There may be a misconception among some of the administration that Indian Country is only impacted by changes to the Indian Health Service,” said Liz Malerba, a tribal policy expert and citizen of the Mohegan Tribe. “That’s simply not true.”

Tribes have lost more than $6 million in grants from other HHS agencies, the National Indian Health Board wrote in a May letter to Kennedy.

Janet Alkire, chairperson of the Standing Rock Sioux Tribe in the Dakotas, said at a May 14 Senate committee hearing that those grants paid for community health workers, vaccinations, data modernization, and other public health efforts.

The government also canceled funding for programs it said violated President Donald Trump’s ban on “diversity, equity, and inclusion,” including one aimed at Native American youth interested in science and medicine and another that helps several tribes increase access to healthy food — something Kennedy has said he wants to prioritize.

Tribal health officials say slashed federal staffing has made it harder to get technical support and money for federally funded health projects they run.

The firings have cut or eliminated staff at programs related to preventing overdoses in tribal communities, using traditional food and medicine to fight chronic disease, and helping low-income people afford to heat and cool their homes through the Low Income Home Energy Program.

The Oglala Sioux Tribe is in South Dakota, where Native Americans who struggle to heat their homes have died of hypothermia. Through mid-May the tribe hadn’t been able to access its latest funding installment from the energy program, said John Long, the tribe’s chief of staff.

Abigail Echo-Hawk, director of the Urban Indian Health Institute at the Seattle Indian Health Board, said the government has sent her organization incomplete health data. That includes statistics about Native Americans at risk for suicide and substance use disorders, which the center uses to shape public health policy and programs.

“People are going to die because we don’t have access to the data,” Echo-Hawk said.

Her organization is also having trouble administering a $2.2 million federal grant, she said, because the agency handling the money fired staffers she worked with. The grant pays for public health initiatives such as smoking cessation and vaccinations.

“It is very confusing to say chronic disease prevention is the No. 1 priority and then to eradicate the support needed to address chronic disease prevention in Indian Country,” Echo-Hawk said.

HHS spokesperson Emily Hilliard said Kennedy aims to combat chronic diseases and improve well-being among Native Americans “through culturally relevant, community-driven solutions.”

Hilliard did not respond to questions about Kennedy’s specific plans for Native American health or concerns about existing and proposed funding and staffing changes.

As Kennedy hiked alongside Navajo Nation leaders, KFF Health News asked how he would improve and protect access to care for tribal communities amid rollbacks within his department.

“That’s exactly what I’m doing,” Kennedy responded. “Making sure that all the cuts do not affect these communities.”

Kennedy has said his focus on Native American health stems from personal and family experience, something he repeated to Navajo leadership. As an attorney, he worked with tribes on environmental health lawsuits. He also served as an editor at ICT, a major Native American news outlet.

The secretary said he was also influenced by his uncle, President John F. Kennedy, and his father, U.S. Attorney General Robert F. Kennedy, who were both assassinated when Robert F. Kennedy Jr. was a child.

“They thought that America would never live up to its moral authority and its role as an exemplary nation around the world if we didn’t first look back and remediate or mitigate the original sin of the American experience — the genocide of the Native people,” Kennedy said during his visit.

Some tribal leaders say the recent cuts, and the way the administration made them, violate treaties in which the U.S. promised to provide for the health and welfare of tribes in return for taking their land.

“We have not been consulted with meaningfully on any of these actions,” said Malerba, director of policy and legislative affairs for the United South and Eastern Tribes Sovereignty Protection Fund, which advocates for tribes from Texas to Maine.

Alkire said at the congressional hearing that many Native American health organizations sent letters to the health department asking for consultations but none has received a response.

Tribal consultation is legally required when federal agencies pursue changes that would have a significant impact on tribal nations.

“This is not just a moral question of what we owe Native people,” Sen. Brian Schatz (D-Hawaii) said at the hearing. “It is also a question of the law.”

Tribal leaders are worried about additional proposed changes, including funding cuts to the Indian Health Service and a reorganization of the federal health department.

Esther Lucero, president and CEO of the Seattle Indian Health Board, said the maneuvers remind her of the level of daily uncertainty she felt working through the covid-19 pandemic — only with fewer resources.

“Our ability to serve those who are desperately in need feels at risk,” Lucero said.

Among the most pressing concerns are congressional Republicans’ proposed cuts to Medicaid, the primary government health insurance program for people with low incomes or disabilities.

About 30% of Native American and Alaska Native people younger than 65 are enrolled in Medicaid, and the program helps keep Indian Health Service and other tribal health facilities afloat.

Native American adults would be exempt from Medicaid work requirements approved by House Republicans last month.

After Kennedy summited Window Rock with Navajo Nation leaders, the tribe held a prayer ceremony in which they blessed him in Diné Bizaad, the Navajo language. President Nygren stressed how meaningful it was for the country’s health secretary to walk alongside them. He also reminded Kennedy of the list of priorities they’d discussed. That included maintaining the federal low-income energy assistance program.

“We look forward to reestablishing and protecting some of the services that your department provides,” Nygren said.

As of mid-May, the Trump administration had proposed eliminating the energy program, which remains unstaffed.

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At the same time, people with limited English proficiency have scaled back their requests for language services, which health care advocates attribute in part to President Donald Trump’s immigration crackdown and his executive order declaring English as the national language.

Such policy and funding changes could leave some without lifesaving care, particularly children and seniors. “People are going to have a hard time accessing benefits they’re entitled to and need to live independently,” said Carol Wong, a senior rights attorney for Justice in Aging, a national advocacy group.

Nearly 69 million people in the U.S. speak a language other than English, and 26 million of them speak English less than “very well,” according to the most recent U.S. Census data available, from 2023. A KFF-Los Angeles Times survey from that year found that immigrants with limited English proficiency reported more barriers accessing health care and worse health than English-proficient immigrants.

Health advocates fear that, without adequate support, millions of people in the U.S. with limited English proficiency will be more likely to experience medical errors, misdiagnosis, neglect, and other adverse outcomes. During the start of the pandemic in 2020, ProPublica reported that a woman with coronavirus symptoms died in Brooklyn after missing out on timely treatment because emergency room staffers could not communicate with her in Hungarian. And, at the height of the crisis, The Virginian-Pilot first reported that a Spanish translation on a state website erroneously stated that the covid-19 vaccine was not necessary.

In 2000, President Bill Clinton signed an executive order aimed at improving access to federal services for people with limited English proficiency. Research shows language assistance results in higher patient satisfaction, as well as fewer medical errors, misdiagnoses, and adverse health outcomes. Language services also save the health care system money by reducing hospital stays and readmissions.

Trump’s order repealed Clinton’s directive and left it up to each federal agency to decide whether to maintain or adopt a new language policy. Some have already scaled back: The Department of Homeland Security and the Social Security Administration reportedly reduced language services, and the Justice Department says it is reviewing guidance materials. A link to its language plan is broken.

It’s unclear what the Department of Health and Human Services intends to do. HHS did not respond to questions from KFF Health News.

An HHS plan implemented under President Joe Biden, including guidance during public health emergencies and disasters, has been archived, meaning it may not reflect current policies. However, HHS’s Office for Civil Rights still informs patients of their right to language assistance services when they pick up a prescription, apply for a health insurance plan, or visit a doctor.

And the office added protections in July that prohibit health providers from using untrained staff, family members, or children to provide interpretation during medical visits. It also required that translation of sensitive information using artificial intelligence be reviewed by a qualified human translator for accuracy.

Those safeguards could be undone by the Trump administration, said Mara Youdelman, a managing director at the National Health Law Program, a national legal and health policy advocacy organization. “There’s a process that needs to be followed,” she said, about making changes with public input. “I would strongly urge them to consider the dire consequences when people don’t have effective communication.”

Even if the federal government ultimately doesn’t offer language services for the public, Youdelman said, hospitals and health providers are required to provide language assistance at no charge to patients.

Title VI of the Civil Rights Act of 1964 prohibits discrimination based on race or national origin, protections that extend to language. And the 2010 Affordable Care Act, which expanded health coverage for millions of Americans and adopted numerous consumer protections, requires health providers receiving federal funds to make language services, including translation and interpretation, available. 

“English can be the official language and people still have a right to get language services when they go to access health care,” Youdelman said. “Nothing in the executive order changed the actual law.”

Insurers still need to include multi-language taglines in their correspondence to enrollees explaining how they can access language services. And health facilities must post visible notices informing patients about language assistance services and guarantee certified and qualified interpreters.

State and local governments could broaden their own language access requirements. A few states have taken such actions in recent years, and California state lawmakers are considering a bill that would establish a language access director, mandate human review of AI translations, and improve surveys assessing language needs.

“With increasing uncertainty at the federal level, state and local access laws and policies are even more consequential,” said Jake Hofstetter, policy analyst at the Migration Policy Institute.

The Los Angeles Department of Public Health and San Francisco’s Office of Civic Engagement and Immigrants Affairs said their language services have not been affected by Trump’s executive order or federal funding cuts.

Demand, however, has dropped. Aurora Pedro of Comunidades Indígenas en Liderazgo, one of the few medical interpreters in Los Angeles who speaks Akatek and Qʼanjobʼal, Mayan languages from Guatemala, said she has received fewer calls for her services since Trump took office.  

And other pockets of California have reduced language services because of the federal funding cuts. 

Hernán Treviño, a spokesperson for the Fresno County Department of Public Health, said the county cut the number of community health workers by more than half, from 49 to 20 positions. That reduced the availability of on-the-ground navigators who speak Spanish, Hmong, or Indigenous languages from Latin America and help immigrants enroll in health plans and schedule routine screenings.

Treviño said staffers are still available to support residents in Spanish, Hmong, Lao, and Punjabi at county offices. A free phone line is also available to help residents access services in their preferred language.

Mary Anne Foo, executive director of the Orange County Asian and Pacific Islander Community Alliance, said the federal Substance Abuse and Mental Health Services Administration froze $394,000 left in a two-year contract to improve mental health services. As a result, the alliance is planning to let go 27 of its 62 bilingual therapists, psychiatrists, and case managers. The organization serves more than 80,000 patients who speak over 20 languages.

“We can only keep them through June 30,” Foo said. “We’re still trying to figure it out — if we can cover people.”

Orozco Rodriguez reported from Elko, Nevada.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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Al mismo tiempo, las personas con dominio limitado del inglés están pidiendo menos servicios lingüísticos, lo que los defensores de la atención de salud atribuyen en parte a la ofensiva migratoria del presidente Donald Trump y a su orden ejecutiva declarando al inglés como idioma nacional.

Estos cambios en las políticas y la financiación podrían dejar a algunas personas sin atención vital, especialmente a niños y adultos mayores.

“Las personas tendrán dificultades para acceder a beneficios a los que tienen derecho y que necesitan para vivir de forma independiente”, expresó Carol Wong, abogada senior de derechos humanos de Justice in Aging, un grupo nacional de defensa.

Cerca de 69 millones de personas en el país hablan un idioma que no es inglés, y 26 millones de ellas hablan inglés a un nivel por debajo de “muy bien”, según los datos más recientes disponibles de 2023 de la Oficina del Censo de Estados Unidos.

Una encuesta de KFF-Los Angeles Times de ese año reveló que los inmigrantes con un dominio limitado del inglés reportaron más obstáculos para acceder a la atención médica y peor salud que los que hablan mejor inglés.

Los defensores de salud temen que, sin el apoyo adecuado, millones de personas con un dominio limitado del inglés sean más propensas a sufrir errores médicos, diagnósticos equivocados, negligencia y otros resultados adversos.

Al inicio de la pandemia en 2020, ProPublica informó que una mujer con síntomas de coronavirus murió en Brooklyn luego de no recibir tratamiento oportuno porque el personal de emergencias no pudo comunicarse con ella en húngaro.

Y, en el punto álgido de la crisis, The Virginian-Pilot fue el primero en informar que una traducción al español en un sitio web estatal afirmaba erróneamente que la vacuna contra covid-19 no era necesaria.

En el año 2000, el presidente Bill Clinton firmó una orden ejecutiva destinada a mejorar el acceso a los servicios federales para las personas con inglés limitado. Investigaciones muestran que la asistencia lingüística se traduce en una mayor satisfacción del paciente, y también en una reducción de errores médicos, diagnósticos equivocados y consecuencias adversas para la salud.

Los servicios de interpretación de idiomas también ahorran dinero al sistema de salud al reducir las estadías en el hospital y los reingresos.

La orden de Trump derogó la directiva de Clinton y dejó en manos de cada agencia federal la decisión de mantener o adoptar una nueva política sobre lenguas. Algunas ya han reducido sus servicios: según se ha informado, el Departamento de Seguridad Nacional y la Administración del Seguro Social redujeron los servicios de idiomas, y el Departamento de Justicia afirma estar revisando las directrices. El enlace a su plan de lenguas no funciona.

No está claro qué pretende hacer el Departamento de Salud y Servicios Humanos (HHS). El HHS no respondió a las preguntas de KFF Health News.

Un plan del HHS implementado durante la presidencia de Joe Biden, que incluye directrices durante emergencias y desastres de salud pública, ha sido archivado, lo que significa que podría no reflejar las políticas actuales. Sin embargo, la Oficina de Derechos Civiles del HHS sigue informando a los pacientes sobre su derecho a recibir servicios de asistencia en sus idiomas nativos cuando recogen una receta médica, solicitan un seguro de salud o van al médico.

Además, en julio pasado, la oficina agregó protecciones que prohíben a los proveedores de salud utilizar personal no capacitado, familiares o niños para brindar interpretación durante las consultas médicas. También requiere que un traductor humano calificado revise traducciones de información confidencial  realizadas con herramientas de inteligencia artificial (IA), para garantizar su precisión.

La administración Trump podría anular estas salvaguardas, afirmó Mara Youdelman, directora general del National Health Law Program, una organización nacional de defensa de políticas legales y de salud. “Hay un proceso que debe seguirse”, agregó, refiriéndose a la implementación de cambios con la participación del público.

“Les insto encarecidamente a que consideren las graves consecuencias cuando las personas no tienen una comunicación efectiva”, enfatizó.

Youdelman dijo que, incluso si el gobierno federal finalmente no ofrece servicios de idiomas al público, los hospitales y proveedores de salud están obligados a proporcionar esta asistencia a los pacientes de manera gratuita. El Título VI de la Ley de Derechos Civiles de 1964 prohíbe la discriminación por raza u origen nacional, y sus protecciones se extienden al idioma. Además, la Ley de Cuidado de Salud a Bajo Precio (ACA) de 2010, que amplió la cobertura médica para millones de estadounidenses y adoptó numerosas protecciones al consumidor, exige que los proveedores de salud que reciben fondos federales ofrezcan servicios de idiomas, incluyendo traducción e interpretación.

“El inglés puede ser el idioma oficial y las personas aún tienen derecho a obtener servicios de idiomas cuando acceden a la atención médica”, dijo Youdelman. “Nada en la orden ejecutiva cambió la ley vigente”.

Las aseguradoras aún deben incluir eslóganes multilingües en la correspondencia a sus miembros, explicando cómo pueden acceder a los servicios de idiomas.

Los centros de salud deben colocar avisos visibles que informen a los pacientes sobre los servicios de asistencia lingüística, y garantizar intérpretes certificados y calificados.

Los gobiernos estatales y locales podrían ampliar sus propios requisitos de acceso a idiomas. Algunos estados han tomado medidas similares en los últimos años, y los legisladores estatales de California están considerando un proyecto de ley que establecería un director de acceso lingüístico, exigiría la revisión humana de las traducciones de IA y mejoraría las encuestas que evalúan las necesidades lingüísticas.

“Con la creciente incertidumbre a nivel federal, las leyes y políticas de acceso estatales y locales son aún más importantes”, afirmó Jake Hofstetter, analista de políticas del Migration Policy Institute.

En California, el Departamento de Salud Pública de Los Ángeles y la Oficina de Participación Cívica y Asuntos de Inmigrantes de San Francisco afirmaron que sus servicios de idiomas no se han visto afectados por la orden ejecutiva de Trump ni por los recortes de fondos federales.

Sin embargo, la demanda ha disminuido. Aurora Pedro, de Comunidades Indígenas en Liderazgo, una de las pocas intérpretes médicas en Los Ángeles que habla akatek y qʼanjobʼal, lenguas mayas de Guatemala, dijo que recibe menos llamadas solicitando sus servicios desde que asumió Trump.

Y otras áreas de California han reducido los servicios lingüísticos por los recortes de fondos federales.

Hernán Treviño, vocero del Departamento de Salud Pública del condado de Fresno, dijo que el condado redujo el número de trabajadores de salud comunitarios a más de la mitad, de 49 a 20 puestos. Esto ha limitado la disponibilidad de guías locales que hablan español, hmong o lenguas indígenas de Latinoamérica, y que ayudan a los inmigrantes a inscribirse en planes de salud y programar exámenes de rutina.

Treviño indicó que, en las oficinas del condado, el personal sigue disponible para atender a los residentes en español, hmong, lao y panyabí. También hay una línea telefónica gratuita disponible para ayudar a acceder a servicios en el idioma preferido.

Mary Anne Foo, directora ejecutiva de la Asian and Pacific Islander Community Alliance del condado de Orange, informó que la Administración de Servicios de Abuso de Sustancias y Salud Mental congeló los $394.000 restantes de un contrato de dos años para mejorar los servicios de salud mental. Como resultado, la alianza planea despedir a 27 de sus 62 terapeutas, psiquiatras y administradores de casos bilingües. La alianza atiende a más de 80.000 pacientes que hablan más de 20 idiomas.

“Solo podemos mantenerlos hasta el 30 de junio”, dijo Foo. “Todavía estamos tratando de ver si podremos cubrir a las personas”.

Orozco Rodríguez reportó desde Elko, Nevada.

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For those living in Duck Valley, a reservation of about 1,000 people that is home to the Shoshone-Paiute Tribes, there’s just one grocery store where prices are too high for many to afford, said Brandy Bull Chief, local director of a federal food distribution program for tribes. The next-closest grocery stores are more than 100 miles away in Mountain Home, Idaho, and Elko, Nevada. And the local food bank’s troubles are mirrored by many nationwide, squeezed between growing need and shrinking aid.

Reggie Premo, a community outreach specialist at the University of Nevada-Reno Extension, grew up cattle ranching and farming alfalfa in Duck Valley. He runs workshops to teach residents to grow produce. Premo said he has seen increased interest from tribal leaders in the state worried about high costs while living in food deserts.

“We’re just trying to bring back how it used to be in the old days,” Premo said, “when families used to grow gardens.”

Food bank managers across the country say their supplies have been strained by rising demand since the covid pandemic-era emergency Supplemental Nutrition Assistance Program benefits ended two years ago and steepening food prices. Now, they say, demand is compounded by recent cuts in federal funding to food distribution programs that supply staple food items to pantries nationwide.

In March, the U.S. Department of Agriculture cut $500 million from the Emergency Food Assistance Program, which buys food from domestic producers and sends it to pantries nationwide. The program has supplied more than 20% of the distributions by Feeding America, a nonprofit that serves a network of over 200 food banks and 60,000 meal programs.

The collision between rising demand and falling support is especially problematic for rural communities, where the federal program might cover 50% or more of food supplied to those in need, said Vince Hall, chief government relations officer of Feeding America. Deepening the challenge for local food aid organizations is an additional $500 million the Trump administration slashed from the USDA Local Food Purchase Assistance Cooperative Agreement Program, which helped state, tribal, and territorial governments buy fresh food from nearby producers.

“The urgency of this crisis cannot be overstated,” Hall said, adding that the Emergency Food Assistance Program is “rural America’s hunger lifeline.”

Farmers who benefited from the USDA programs that distributed their products to food banks and schools will also be affected. Bill Green is executive director for the Southeast region of Common Market, a nonprofit that connects farmers with organizations in the Mid-Atlantic, the Southeast, Texas, and the Great Lakes. Green said his organization won’t be able to fill the gap left by the federal cuts, but he hopes some schools and other institutions will continue buying from those farmers even after the federal support dries up.

“I think that that food access challenge has only been aggravated, and I think we just found the tip of the iceberg on that,” he said.

Food Bank for the Heartland in Omaha, Nebraska, for example, is experiencing four times the demand this year than in 2018, according to Stephanie Sullivan, its assistant director of marketing and communications. The organization expects to provide food to 580,000 households across the 93 counties it serves in Nebraska and western Iowa this fiscal year, the highest number in its history, she said.

“These numbers should be a wake-up call for all of us,” Sullivan said.

The South Plains Food Bank in Texas projects it will distribute approximately 121,000 food boxes this year to people in need across the 19 counties it serves, compared with an average 90,000 annually before the pandemic. CEO Dina Jeffries said the organization now is serving about 25% more people, while shouldering the burden of decreased funding and food products.

In Nevada, the food bank that helps serve communities in the northern part of the state, including the Shoshone-Paiute Tribes of the Duck Valley Reservation, provides food to an average of 160,000 people per month. That’s a 76% increase over its clientele before the pandemic, and the need continues to rise, said Jocelyn Lantrip, director of marketing and communications for the Food Bank of Northern Nevada.

Lantrip said one of the most troubling things for the food bank is that the USDA commodities shipped for local distribution often are foods that donations don’t usually cover — things like eggs, dairy, and meat.

“That’s really valuable food to our neighbors,” she said. “Protein is very difficult to replace.”

Forty percent of people who sought assistance from food banks during the pandemic did so for the first time, Hall said. “Many of those families have come to see their neighborhood food bank not as a temporary resource for emergency help but an essential component of their monthly budget equation.”

About 47 million people lived in food-insecure households in 2023, the most recent USDA data available.

Bull Chief, who also runs a small food pantry on the Duck Valley Reservation, said workers drive to Elko to pick up food distributed by the Food Bank of Northern Nevada. But sometimes there’s not much to choose from. In March, the food pantry cut down its operation to just two weeks a month. She said sometimes they must weigh whether it’s worth spending money on gas to pick up a small amount of food.

When the food pantry opened in 2020, Bull Chief said, it helped 10 to 20 households a month. That number is 60 or more now, made up of a broad range of community members — teens fresh out of high school and living on their own, elders, and people who don’t have permanent housing or jobs. She said providing even small amounts of food can help households make ends meet between paychecks or SNAP benefit deposits.

“Whatever they need to get to survive for the month,” Bull Chief said.

Pinched food banks, elevated need, and federal cuts mean there’s very little resiliency in the system, Hall said. Additional challenges, like an economic slowdown, policy changes to SNAP or other federal nutrition programs, or natural disasters could render food banks unable to meet needs “because they are stretched to the breaking point right now.”

A proposed budget resolution passed by the U.S. House of Representatives in April would require $1.7 trillion in net funding cuts, and anti-hunger advocates fear SNAP could be a target. More people living in rural parts of the country rely on SNAP than people in urban areas because of higher poverty rates, so they would be disproportionately affected.

An extension of the federal 2018 Farm Bill, which lasts until Sept. 30, included about $450 million for the Emergency Food Assistance Program for this year. But the funding that remains doesn’t offset the cuts, Hall said. He hopes lawmakers pass a new farm bill this year with enough money to do so.

“We don’t have a food shortage,” he said. “We have a shortage of political will.”

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Indian Country has a unique relationship to Medicaid, because the program helps tribes cover chronic funding shortfalls left by the Indian Health Service, the federal agency responsible for providing health care to Native Americans.

With the related Children’s Health Insurance Program, Medicaid provides coverage to more than a million Native Americans. The joint state-federal program also accounts for about two-thirds of non-IHS revenue for tribal health providers. That income helps create financial stability and covers some operational costs for tribal hospitals and clinics. Tribal leaders want an exemption from any cuts and are preparing for a fight to preserve their access.

“Medicaid is one of the ways in which the federal government meets its trust and treaty obligations to provide health care to us,” said Liz Malerba, director of policy and legislative affairs for the United South and Eastern Tribes Sovereignty Protection Fund, a nonprofit advocacy organization for 33 tribes spanning from Texas to Maine. Malerba is a citizen of the Mohegan Tribe.

“So we view any disruption or cut to Medicaid as an abrogation of that responsibility,” she said.

Last month, the House approved a budget resolution that requires lawmakers to cut spending to offset tax breaks. The House Committee on Energy and Commerce, which oversees spending on Medicaid, is instructed to slash $880 billion over the next decade.

The IHS projects that it will bill Medicaid about $1.3 billion this fiscal year, which represents less than half of 1% of overall federal spending on Medicaid.

If Congress makes big cuts to the program, tribal health facilities will likely need to scale back services for a population that experiences severe health disparities, a high incidence of chronic illness, and a shorter life expectancy.

“When you’re talking about somewhere between 30% to 60% of a facility’s budget is made up by Medicaid dollars, that’s a very difficult hole to try and backfill,” said Winn Davis, congressional relations director for the National Indian Health Board.

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That’s because more than 40% of the about 15,000 patients the center serves are enrolled in Medicaid. Cuts to the program would be detrimental to those patients and the facility, said Debra Danforth, the director of the Oneida Comprehensive Health Division and a citizen of the Oneida Nation.

“It would be a tremendous hit,” she said.

The facility provides a range of services to most of the Oneida Nation’s 17,000 people, including ambulatory care, internal medicine, family practice, and obstetrics. The tribe is one of two in Wisconsin that have an “open-door policy,” Danforth said, which means that the facility is open to members of any federally recognized tribe.

But Danforth and many other tribal health officials say Medicaid cuts would cause service reductions at health facilities that serve Native Americans.

Indian Country has a unique relationship to Medicaid, because the program helps tribes cover chronic funding shortfalls from the Indian Health Service, the federal agency responsible for providing health care to Native Americans.

Medicaid has accounted for about two-thirds of third-party revenue for tribal health providers, creating financial stability and helping facilities pay operational costs. More than a million Native Americans enrolled in Medicaid or the closely related Children’s Health Insurance Program also rely on the insurance to pay for care outside of tribal health facilities without going into significant medical debt. Tribal leaders are calling on Congress to exempt tribes from cuts and are preparing to fight to preserve their access.

“Medicaid is one of the ways in which the federal government meets its trust and treaty obligations to provide health care to us,” said Liz Malerba, director of policy and legislative affairs for the United South and Eastern Tribes Sovereignty Protection Fund, a nonprofit policy advocacy organization for 33 tribes spanning from Texas to Maine. Malerba is a citizen of the Mohegan Tribe.

“So we view any disruption or cut to Medicaid as an abrogation of that responsibility,” she said.

Tribes face an arduous task in providing care to a population that experiences severe health disparities, a high incidence of chronic illness, and, at least in western states, a life expectancy of 64 years — the lowest of any demographic group in the U.S. Yet, in recent years, some tribes have expanded access to care for their communities by adding health services and providers, enabled in part by Medicaid reimbursements.

During the last two fiscal years, five urban Indian organizations in Montana saw funding growth of nearly $3 million, said Lisa James, director of development for the Montana Consortium for Urban Indian Health, during a webinar in February organized by the Georgetown University Center for Children and Families and the National Council of Urban Indian Health.

The increased revenue was “instrumental,” James said, allowing clinics in the state to add services that previously had not been available unless referred out for, including behavioral health services. Clinics were also able to expand operating hours and staffing.

Montana’s five urban Indian clinics, in Missoula, Helena, Butte, Great Falls, and Billings, serve 30,000 people, including some who are not Native American or enrolled in a tribe. The clinics provide a wide range of services, including primary care, dental care, disease prevention, health education, and substance use prevention.

James said Medicaid cuts would require Montana’s urban Indian health organizations to cut services and limit their ability to address health disparities.

American Indian and Alaska Native people under age 65 are more likely to be uninsured than white people under 65, but 30% rely on Medicaid compared with 15% of their white counterparts, according to KFF data for 2017 to 2021. More than 40% of American Indian and Alaska Native children are enrolled in Medicaid or CHIP, which provides health insurance to kids whose families are not eligible for Medicaid. KFF is a health information nonprofit that includes KFF Health News.

A Georgetown Center for Children and Families report from January found the share of residents enrolled in Medicaid was higher in counties with a significant Native American presence. The proportion on Medicaid in small-town or rural counties that are mostly within tribal statistical areas, tribal subdivisions, reservations, and other Native-designated lands was 28.7%, compared with 22.7% in other small-town or rural counties. About 50% of children in those Native areas were enrolled in Medicaid.

The federal government has already exempted tribes from some of Trump’s executive orders. In late February, Department of Health and Human Services acting general counsel Sean Keveney clarified that tribal health programs would not be affected by an executive order that diversity, equity, and inclusion government programs be terminated, but that the Indian Health Service is expected to discontinue diversity and inclusion hiring efforts established under an Obama-era rule.

HHS Secretary Robert F. Kennedy Jr. also rescinded the layoffs of more than 900 IHS employees in February just hours after they’d received termination notices. During Kennedy’s Senate confirmation hearings, he said he would appoint a Native American as an assistant HHS secretary. The National Indian Health Board, a Washington, D.C.-based nonprofit that advocates for tribes, in December endorsed elevating the director of the Indian Health Service to assistant secretary of HHS.

Jessica Schubel, a senior health care official in Joe Biden’s White House, said exemptions won’t be enough.

“Just because Native Americans are exempt doesn’t mean that they won’t feel the impact of cuts that are made throughout the rest of the program,” she said.

State leaders are also calling for federal Medicaid spending to be spared because cuts to the program would shift costs onto their budgets. Without sustained federal funding, which can cover more than 70% of costs, state lawmakers face decisions such as whether to change eligibility requirements to slim Medicaid rolls, which could cause some Native Americans to lose their health coverage.

Tribal leaders noted that state governments do not have the same responsibility to them as the federal government, yet they face large variations in how they interact with Medicaid depending on their state programs.

President Donald Trump has made seemingly conflicting statements about Medicaid cuts, saying in an interview on Fox News in February that Medicaid and Medicare wouldn’t be touched. In a social media post the same week, Trump expressed strong support for a House budget resolution that would likely require Medicaid cuts.

The budget proposal, which the House approved in late February, requires lawmakers to cut spending to offset tax breaks. The House Committee on Energy and Commerce, which oversees spending on Medicaid and Medicare, is instructed to slash $880 billion over the next decade. The possibility of cuts to the program that, together with CHIP, provides insurance to 79 million people has drawn opposition from national and state organizations.

The federal government reimburses IHS and tribal health facilities 100% of billed costs for American Indian and Alaska Native patients, shielding state budgets from the costs.

Because Medicaid is already a stopgap fix for Native American health programs, tribal leaders said it won’t be a matter of replacing the money but operating with less.

“When you’re talking about somewhere between 30% to 60% of a facility’s budget is made up by Medicaid dollars, that’s a very difficult hole to try and backfill,” said Winn Davis, congressional relations director for the National Indian Health Board.

Congress isn’t required to consult tribes during the budget process, Davis added. Only after changes are made by the Centers for Medicare & Medicaid Services and state agencies are tribes able to engage with them on implementation.

The amount the federal government spends funding the Native American health system is a much smaller portion of its budget than Medicaid. The IHS projected billing Medicaid about $1.3 billion this fiscal year, which represents less than half of 1% of overall federal spending on Medicaid.

“We are saving more lives,” Malerba said of the additional services Medicaid covers in tribal health care. “It brings us closer to a level of 21st century care that we should all have access to but don’t always.”

This article was published with the support of the Journalism & Women Symposium (JAWS) Health Journalism Fellowship, assisted by grants from The Commonwealth Fund.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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