Those preliminary numbers from the open enrollment period that ended in January are less than a third of what state officials had projected. Nevada is the third state so far to launch a public option plan, along with Colorado and Washington state. The idea is to offer lower-cost plans to consumers to expand health care access.

But researchers said plans like these are unlikely to fill the gaps left by sweeping federal changes, including the expiration of enhanced subsidies for plans bought on Affordable Care Act marketplaces.

The public option gained attention in the late 2000s when Congress considered but ultimately rejected creating a health plan funded and run by the government that would compete with private carriers in the market. The programs in Washington state, Colorado, and Nevada don’t go that far — they aren’t government-run but are private-public partnerships that compete with private insurance.

In recent years, states have considered creating public option plans to make health coverage more affordable and to reduce the number of uninsured people. Washington was the first state to launch a program, in 2021, and Colorado followed in 2023.

Washington and Colorado’s programs have run into challenges, including a lack of participation from clinicians, hospitals, and other care providers, as well as insurers’ inability to meet rate reduction benchmarks or lower premiums compared with other plans offered on the market.

Nevada law requires that the carriers of the public option plans — Battle Born State Plans, named after a state motto — lower premium costs compared with a benchmark “silver” plan in the marketplace by 15% over the next four years.

But that amount might not make much difference to consumers with rising premium payments from the loss of the ACA’s enhanced tax credits, said Keith Mueller, director of the Rural Policy Research Institute.

“That’s not a lot of money,” Mueller said.

Three of the eight insurers on the state’s exchange, Nevada Health Link, offered the state plans during the open enrollment period.

Insurance companies plan to meet the lower premium cost requirement in Nevada by cutting broker fees and commissions, which prompted opposition from insurance brokers in the state. In response, Nevada marketplace officials told state lawmakers in January that they will give a flat-fee reimbursement to brokers.

The public option has faced opposition among state leaders. In 2024, a state judge dismissed a lawsuit, brought by a Nevada state senator and a group that advocates for lower taxes, that challenged the public option law as unconstitutional. They have appealed to the state Supreme Court.

Federal Policy Impacts

Recent federal changes create more obstacles.

Nevada is consistently among the states with the largest populations of people who do not have health insurance coverage. Last year, nearly 95,000 people in the state received the enhanced ACA tax credits, averaging $465 in savings per month, according to KFF, a health information nonprofit that includes KFF Health News.

But the enhanced tax credits expired at the end of the year, and it appears unlikely that lawmakers will bring them back. Nationwide ACA enrollment has decreased by more than 1 million people so far this year, down from record-high enrollment of 24 million last year.

About 4 million people are expected to lose health coverage from the expiration of the tax credits, according to the Congressional Budget Office. An additional 3 million are projected to lose coverage because of other policy changes affecting the marketplace.

Justin Giovannelli, an associate research professor at the Center on Health Insurance Reforms at Georgetown University, said the changes to the ACA in the Republicans’ One Big Beautiful Bill Act, which President Donald Trump signed into law last summer, will make it more difficult for people to keep their coverage. These changes include more frequent enrollment paperwork to verify income and other personal information, a shortened enrollment window, and an end to automatic reenrollment.

In Nevada, the changes would amount to an estimated 100,000 people losing coverage, according to KFF.

“All of that makes getting coverage on Nevada Health Link harder and more expensive than it would be otherwise,” Giovannelli said.

State officials projected ahead of open enrollment that about 35,000 people would purchase the public option plans. Of the 104,000 people who had purchased a plan on the state marketplace as of mid-January, 10,762 had enrolled in one of the public option plans, according to Nevada Health Link.

Katie Charleson, communications officer for the state health exchange, said the original enrollment estimate was based on market conditions before the recent increases in customers’ premium costs. She said that the public option plans gave people facing higher costs more choices.

“We expect enrollment in Battle Born State Plans to grow over time as awareness increases and as Nevadans continue seeking quality coverage options that help reduce costs,” Charleson said.

According to KFF, nationally the enhanced subsidies saved enrollees an average of $705 annually in 2024, and enrollees would save an estimated $1,016 in premium payments on average in 2026 if the subsidies were still in place. Without the subsidies, people enrolled in the ACA marketplace could be seeing their premium costs more than double.

Insights From Washington and Colorado

Washington and Colorado are not planning to alter their programs due to the expiration of the tax credits, according to government officials in those states.

Other states that had recently considered creating public options have backtracked. Minnesota officials put off approving a public option in 2024, citing funding concerns. Proposals to create public options in Maine and New Mexico also sputtered.

Washington initially saw meager enrollment in its Cascade Select public option plans; only 1% of state marketplace enrollees chose a public option plan in 2021. But that changed after lawmakers required hospitals to contract with at least one public option plan by 2023. Last year the state reported that 94,000 customers enrolled, accounting for 30% of all customers on the state marketplace. The public option plans were the lowest-premium silver plans in 31 of Washington’s 39 counties in 2024.

A 2025 study found that since Colorado implemented its public option, called the Colorado Option, coverage through the ACA marketplace has become more affordable for enrollees who received subsidies but more expensive for enrollees who did not.

Colorado requires all insurers offering coverage through its marketplace to include a public option that follows state guidelines. The state set premium reduction targets of 5% a year for three years beginning in 2023. Starting this year, premium costs are not allowed to outpace medical inflation.

Though the insurers offering the public option did not meet the premium reduction targets, enrollment in the Colorado Option has increased every year it has been available. Last year, the state saw record enrollment in its marketplace, with 47% of customers purchasing a public option plan.

Giovannelli said states are continuing to try to make health insurance more affordable and accessible, even if federal changes reduce the impact of those efforts.

“States are reacting and trying to continue to do right by their residents,” Giovannelli said, “but you can’t plug all those gaps.”

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After his mom finally saw a specialist in Glasgow, about an hour away, she was diagnosed with stage 4 colon cancer, Bighorn said.

Now, 16 years after his mother’s death, Bighorn has access to regular screenings for cancer and other specialty care that she didn’t have, through a health insurance program the Fort Peck Tribes created in 2016. The program, which covers most of the costs for the roughly 1,000 tribal citizens enrolled, is among a growing number of tribally sponsored health insurance programs.

Such programs vary by tribe, but they essentially screen and enroll people living within tribal boundaries in Affordable Care Act marketplace plans. They allow participating Native Americans flexibility to go to outside doctors and clinics when care through the Indian Health Service is unavailable.

“I’d be in a bind otherwise,” said Bighorn, a 65-year-old tribal game warden and member of the Dakota community.

But the Fort Peck Tribes now limit who has access to that coverage. Other tribal organizations that offer Native Americans similar coverage are struggling with rising costs, too.

The financial crunch began when congressional lawmakers allowed enhanced subsidies under the Affordable Care Act to expire on Dec. 31. Those tax credits, created under the Biden administration during the covid-19 pandemic, expanded subsidized health coverage for millions of people. By late 2025, ACA plans saw about 24 million enrollees, more than twice the number of pre-pandemic annual sign-ups. The cost of coverage shot up for most of those people as the expanded subsidies expired, and enrollment so far has dropped by more than 1 million people, according to federal health officials.

The subsidies had also boosted tribal health insurance programs, like the one Bighorn is enrolled in. The programs pay the price of each person’s share of premiums after subsidies, and the coverage lowers patients’ treatment costs. Now that premium prices have ballooned, so have tribes’ costs.

Rae Jean Belgarde, who directs Fort Peck Tribes’ program, said the higher costs leave the tribes with one option at this point: “Start limiting who gets help.”

The tribes are helping people shift to other insurance options and, in some cases, find state programs to cover their premiums. Tribal leaders also sent a letter to Montana’s all-Republican congressional delegation asking them to support extending the subsidies.

“Our program is saving lives,” the letter read. Belgarde said she didn’t know whether the lawmakers responded.

Scrambling for Solutions

U.S. House members approved a temporary extension of the enhanced subsidies in January. But that measure stalled in the Senate. Lawmakers are scrambling for an alternative after President Donald Trump threatened to veto an extension if a bill reaches his desk. On Jan. 15, the president released an outline of a health care proposal that includes creating savings accounts for people to pay their health costs — an idea Senate Republicans previously floated as an alternative to the subsidies.

A.C. Locklear, CEO of the National Indian Health Board, a nonprofit that works to improve health in Native communities, said tribes are “looking at ways to cut back just as much as everyone else.”

Native Americans as a group continue to face disproportionately high rates of chronic diseases. Their median age at death is 14 years younger than that of white Americans.

“Reducing access to even just general primary care has a significant impact on those disparities,” Locklear said.

Tribal leaders have said letting the subsidies expire further undermines the federal government’s duty to ensure adequate care for Native Americans.

In exchange for taking tribal land through colonization, the U.S. government made long-standing promises to provide for the health and well-being of tribes. Native Americans are guaranteed free health care at clinics and hospitals operated or funded by the Indian Health Service. But that agency’s chronic underfunding has created massive blackouts in care. It sometimes pays for patients’ outside care through its Purchased/Referred Care program, but that’s limited too. Due to funding shortfalls, the agency prioritizes which treatments it will pay for.

To help fill the coverage gaps, some tribal nations have built their own health insurance programs. When tribes pay health premiums, clinics and hospitals in their areas can bill for services that might otherwise go unpaid. Some tribes have leveraged that money to expand services.

“I don’t see tribes getting rid of these programs,” Locklear said. “But it will drastically shift how much tribes can really put back in their community.”

For example, Tuba City Regional Health Care Corp., in northern Arizona within the Navajo Nation, is unique in providing comprehensive cancer treatment on a reservation, Locklear said. The corporation, he said, estimates its costs to cover patients this year are increasing by roughly 170% to nearly $38,000 per month without the enhanced subsidies.

One of the newer programs is on the Blackfeet reservation in northwestern Montana, where basic health services can be hard to find. Medical visits are often offered on a first-come, first-served basis, and services vanish when staff positions go unfilled, said Lyle Rutherford, a Blackfeet Nation council member.

“Some of it is just getting a regular eye appointment, or a primary care appointment,” Rutherford said.

The tribe has been slowly building its health insurance program since launching it in 2024. Rutherford said the enhanced subsidies made that possible. Fewer than 400 people are enrolled out of an estimated 3,000 who qualify. In January, the tribe paused the employer-sponsored coverage portion of its insurance program, which at the time included 52 people.

He said tribal leaders are seeking extra funding to keep the program afloat, and he hopes Congress finds a solution.

Lives on the Line

The impact goes beyond tribes’ insurance programs. The Urban Institute, a Washington, D.C.-based economic and social policy research nonprofit, estimates that 125,000 Native Americans will become uninsured in 2026 due to the higher costs.

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In 2024, the most recent year for which data for the population is available, Native American and Alaska Native people had the highest pregnancy-related mortality ratio among major demographic groups, according to the Centers for Disease Control and Prevention. 

According to a CDC analysis of 2021 data from 46 maternal mortality review committees, most, if not all, deaths among Native American and Alaska Native people were considered preventable. 

In response, Native organizations, the CDC, and some states are working to boost Native American participation in state maternal mortality review committees, which investigate deaths that occur during pregnancy or within a year after birth. Native organizations are also considering ways tribes could create their own committees. 

Kim Moore-Salas, of the Arizona Maternal Mortality Review Committee, said tribal sovereignty, experience, and traditional knowledge are important factors to consider in developing tribal-led committees. 

“Our matriarchs, our moms, are what carries a nation forward,” she said. 

In 2024, Moore-Salas, a member of the Navajo Nation, became the first Native American co-chair of Arizona’s committee. Last year, she and other Native members of the committee developed guidelines for an American Indian/Alaska Native subcommittee and reviewed its first cases. 

The National Council of Urban Indian Health is also working to increase the participation of Urban Indian health organizations in state committee processes. As of 2025, the council had connected Urban Indian health organizations to state maternal mortality review committees in California, Kansas, Oklahoma, and South Dakota. 

Native leaders such as Moore-Salas find the efforts encouraging. 

“It shows that state and tribes can work together,” she said. 

After her stillbirth, Swaney had another complicated pregnancy. She went into labor about three months early, and doctors didn’t expect her son to survive. But he did, and Kelly Camel is now 48. He has severe cerebral palsy and profound deafness. He lives alone but has caregivers to help with cooking and other tasks, said Swaney, 73. 

He “has a good sense of humor,” she said. “He’s kind to other people. We couldn’t ask for a more complete child.”

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Then 25 years old and six months pregnant, she drove herself to the emergency room in Ronan, Montana, on the Flathead Indian Reservation, where an ambulance transferred her to a larger hospital 60 miles away in Missoula. Once she arrived, the staff couldn’t detect her baby’s heartbeat. Swaney began to bleed heavily. She delivered a stillborn baby and was hospitalized for several days. At one point, doctors told her to call her family. They didn’t expect her to survive.

“It certainly changed my life — the experience — but my life has not been a bad life,” she told KFF Health News.

Though her experiences were nearly 50 years ago, Swaney, a member of the Confederated Salish and Kootenai Tribes, said Native Americans continue to receive inadequate maternal care. The data appears to support that belief.

In 2024, the most recent year for which data for the population is available, Native American and Alaska Native people had the highest pregnancy-related mortality ratio among major demographic groups, according to the Centers for Disease Control and Prevention.

In response to this disparity, Native organizations, the CDC, and some states are working to boost tribal participation in state maternal mortality review committees to better track and address pregnancy-related deaths in their communities. Native organizations are also considering ways tribes could create their own committees.

State maternal mortality review committees investigate deaths that occur during pregnancy or within a year after pregnancy, analyze data, and issue policy recommendations to lower death rates.

According to 2021 CDC data, compiled from 46 maternal mortality review committees, 87% of maternal deaths in the U.S. were deemed preventable. Committees reported that most, if not all, deaths among Native American and Alaska Native people were considered preventable.

Our matriarchs, our moms, are what carries a nation forward.

Kim Moore-Salas

State committees have received federal money through the Preventing Maternal Deaths Act, which President Donald Trump signed in 2018.

But the money is scheduled to dry up on Jan. 31, when the short-term spending bill that ended the government shutdown expires.

Funding for the committees is included in the Labor, Health and Human Services, Education, and Related Agencies appropriations bill for fiscal year 2026. That bill must be approved by the House, Senate, and president to take effect.

Native American leaders said including members of their communities in maternal mortality review committee activities is an important step in addressing mortality disparities.

In 2023, tribal leaders and federal officials met to discuss four models: a mortality review committee for each tribe, a committee for each of the 12 Indian Health Service administrative regions, a national committee to review all Native American maternal deaths, and the addition of Native American subcommittees to state committees.

Whatever the model, tribal sovereignty, experience, and traditional knowledge are important factors, said Kim Moore-Salas, a co-chair of the Arizona Maternal Mortality Review Committee. She’s also the chairperson of the panel’s American Indian/Alaska Native mortality review subcommittee and a member of the Navajo Nation.

“Our matriarchs, our moms, are what carries a nation forward,” she said.

Mental health conditions and infection were the leading underlying causes of pregnancy-related death among Native American and Alaska Native women as of 2021, according to the CDC report analyzing data from 46 states.

The CDC found an estimated 68% of pregnancy-related deaths among Native American and Alaska Native people happened within a week of delivery to a year postpartum. The majority of those happened between 43 days and a year after birth.

The federal government has a responsibility under signed treaties to provide health care to the 575 federally recognized tribes in the U.S. through the Indian Health Service. Tribal members can receive limited services at no cost, but the agency is underfunded and understaffed.

A study published in 2024 that analyzed data from 2016 to 2020 found that approximately 75% of Native American and Alaska Native pregnant people didn’t have access to care through the Indian Health Service around the time of giving birth, meaning many likely sought care elsewhere. More than 90% of Native American and Alaska Native births occur outside of IHS facilities, according to the agency. For those who did deliver at IHS facilities, a 2020 report from the Department of Health and Human Services’ Office of Inspector General found that 56% of labor and delivery patients received care that did not follow national clinical guidelines.

The 2024 study’s authors also found that members of the population were less likely to have stable insurance coverage and more likely to have a lapse in coverage during the period close to birth than non-Hispanic white people.

Cindy Gamble, who is Tlingit and a tribal community health consultant for the American Indian Health Commission in Washington, has been a member of the state’s maternal mortality review panel for about eight years. In the time she’s been on the state panel, she said, its composition has broadened to include more people of color and community members.

The panel also began to include suicide, overdose, and homicide deaths in its data analysis and added racism and discrimination to the risk factors considered during its case review process.

Solutions need to be tailored to the tribe’s identity and needs, Gamble said.

“It’s not a one-size-fits-all,” Gamble said, “because of all the beliefs and different cultures and languages that different tribes have.”

Gamble’s tenure on the state committee is distinctive. Few states have tribal representation on maternal mortality review committees, according to the National Indian Health Board, a nonprofit organization that advocates for tribal health.

The National Council of Urban Indian Health is also working to increase the participation of Urban Indian health organizations, which provide care for Native American people who live outside of reservations, in state maternal mortality review processes. As of 2025, the council had connected Urban Indian health organizations to state review committees in California, Kansas, Oklahoma, and South Dakota.

Native leaders such as Moore-Salas find the current efforts encouraging.

“It shows that state and tribes can work together,” she said.

In March 2024, Moore-Salas became the first Native American co-chair of Arizona’s Maternal Mortality Review Committee. In 2025 she and other Native American members of the committee developed guidelines for the American Indian/Alaska Native subcommittee and reviewed the group’s first cases.

The subcommittee is exploring ways to make the data collection and analysis process more culturally relevant to their population, Moore-Salas said.

But it takes time for policy changes to create widespread change in the health of a population, Gamble said. Despite efforts around the country, other factors may hinder the pace of progress. For example, maternity care deserts are growing nationally, caused by rapid hospital and labor and delivery unit closures. Health experts have raised concerns that upcoming cuts to Medicaid will hasten these closures.

Despite her experience and the ongoing crisis among Native American and Alaska Native people, Swaney hopes for change.

She had a second complicated pregnancy soon after her stillbirth. She went into labor about three months early, and the doctors said her son wouldn’t live to the next morning. But he did, and he was transferred about 525 miles away from Missoula to the nearest advanced neonatal unit, in Salt Lake City.

Her son, Kelly Camel, is now 48. He has severe cerebral palsy and profound deafness. He lives alone but has caregivers to help with cooking and other tasks, said Swaney, 73.

He “has a good sense of humor. He’s kind to other people. We couldn’t ask for a more complete child.”

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Federally recognized tribes can’t directly apply for a share of the rural health fund — only states can. And states aren’t required to consider tribes’ needs. But state applications for the five-year payout show some states with significant Native American populations did so anyway.

Workforce development, technology upgrades, and traditional healing are a few of the initiatives specifically aimed at Native American communities that some states included in their applications, which were due to the Centers for Medicare & Medicaid Services on Nov. 5. The fund was a late addition to the One Big Beautiful Bill Act in response to worries about the harm the spending reductions in Republicans’ bill would have on rural hospitals’ finances.

Some states, including Idaho, Nevada, and Oregon, are also considering setting aside 3% to 10% of their federal payouts to distribute among tribes. Washington proposed setting aside $20 million per year.

Federally recognized tribes have direct relationships with the U.S. government, but state governments also allocate resources to tribes and can create policies that support tribal priorities. States and tribes share concerns about the effect that the massive GOP budget bill, which President Donald Trump signed into law in July, will have on the U.S. health system. The law is expected to reduce federal Medicaid spending by nearly $1 trillion and increase the number of uninsured by approximately 10 million people, according to KFF, a health information nonprofit that includes KFF Health News.

Catherine Howden, a CMS spokesperson, said that states are required to develop their applications in collaboration with key stakeholders, including the state governments’ tribal affairs offices or tribal liaisons, as well as “Indian health care providers, as applicable.” But these entities do not include tribal governments or official tribal representatives.

Tribes can apply for Rural Health Transformation Fund subgrants through their states. But during a recent call with federal health officials, tribal leaders expressed frustration about being regarded as just another stakeholder in the issue rather than sovereign nations. Tribal sovereignty guides most government-to-government consultations over proposed federal actions that would have a substantial effect on tribes.

“Even in a scenario where tribal consultation is required, the quality and quantity of that tribal consultation on a state-by-state basis is all over the place,” said Liz Malerba, director of policy and legislative affairs for the United South and Eastern Tribes Sovereignty Protection Fund, which advocates for tribal nations from Texas to Maine. Malerba is a citizen of the Mohegan Tribe.

Federal policy works better when tribal nations are directly eligible for funding that supports essential services in their communities, Malerba said, adding that tribal leaders are concerned that the reach of the program into their communities will vary considerably.

There are 574 federally recognized tribes and more than 7 million Native American and Alaska Native people in the U.S. The population faces a lower life expectancy and among the poorest health outcomes when compared with other demographics. The Indian Health Service, the federal agency responsible for providing health care to Native Americans and Alaska Natives, has been historically underfunded by Congress.

KFF Health News analyzed how 12 states with significant Native American populations took tribes into account as they developed plans for the pot of federal money.

Idaho, Washington, Montana, and Arizona were among the states that held tribal consultations or listening sessions ahead of the Nov. 5 application deadline.

In states that did not initiate input from tribes, some Native American leaders made sure their voices were heard in other public hearings. Jerilyn Church, CEO of the Great Plains Tribal Leaders’ Health Board, said she attended an October public meeting in South Dakota because she felt it was important for state leaders to consider how they could use the program’s resources on reservations. There are nine federally recognized tribes in the state, and Native American people make up 9% of the population.

“I felt like we needed to help be that advocate,” said Church, a citizen of the Cheyenne River Sioux Tribe.

In the proposed initiatives included in its rural fund application, South Dakota identified tribal community needs such as improved telehealth and funding for doula programs. It also said the state will continue meeting with the Great Plains tribal health board throughout the five-year funding cycle.

In Oklahoma — where more than 14% of the population is Native American, a higher share than in most other states — tribal representatives were invited to weigh in with the rest of the public when the state was gathering information for its application, the details of which have not been publicly released.

“We’ve welcomed input from any Oklahoman,” said state health department spokesperson Erica Rankin-Riley.

North Dakota identified tribes in its state as partners in the Rural Health Transformation Program and included initiatives such as expanding physician residency slots with tribal-specific rotations and opportunities for farm-to-table food distributions. But lawmakers there declined to support a proposal that would have pledged 5% of its federal allotment to tribes. There are five federally recognized tribes in the state, and Native Americans make up nearly 5% of the population.

Some states did include proposals to fund high-priority initiatives for tribes.

Washington’s application for the rural fund included an initiative focused on improving health among Native American communities. Its goals include investing in workforce development for tribes, better care coordination between tribes and rural hospitals, and $2.4 million annually to support Washington State University’s rural health education programs, including its Indigenous health program.

Alaska’s proposal included integrating Indigenous traditional healing in Alaska Native village clinics. It would include offering traditional-healing house calls, hands-on training for healers, and traditional-medicine training for health care providers and staff, according to the application.

One of Oregon’s five initiatives would support the state’s nine federally recognized tribes in improving health outcomes. The state estimates the initiative would require $20 million per year, or 10% of the Rural Health Transformation Program award.

Whether or not states identified funding for tribes or included tribal priorities in their proposals, tribes will be eligible to apply to their states for subgrants of the Rural Health Transformation Program money. While larger tribes that have more resources, such as grant writers and staff to implement programs, could benefit, smaller tribes may struggle to produce competitive applications.

Church said that the Great Plains Tribal Leaders’ Health Board will know the fruits of its labor when states are notified of their rural health fund allotments by the end of the year.

“Hopefully the work that we did, the advocacy that we did, and the outreach,” Church said, “will result in resources getting to our tribes.”

KFF Health News South Dakota correspondent Arielle Zionts contributed to this report.

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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.

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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