As Congress mulls potentially massive cuts to federal Medicaid funding, health centers that serve Native American communities, such as the Oneida Community Health Center near Green Bay, Wisconsin, are bracing for catastrophe.
That鈥檚 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.
鈥淚t would be a tremendous hit,鈥 she said.
The facility provides a range of services to most of the Oneida Nation鈥檚 17,000 people, including ambulatory care, internal medicine, family practice, and obstetrics. The tribe is one of two in Wisconsin that have an 鈥渙pen-door policy,鈥 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 of third-party revenue for tribal health providers, creating financial stability and helping facilities pay operational costs. Native Americans enrolled in Medicaid or the closely related Children鈥檚 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.
鈥淢edicaid is one of the ways in which the federal government meets its trust and treaty obligations to provide health care to us,鈥 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 . Malerba is a citizen of the Mohegan Tribe.
鈥淪o we view any disruption or cut to Medicaid as an abrogation of that responsibility,鈥 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 鈥 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, in February organized by the Georgetown University Center for Children and Families and the National Council of Urban Indian Health.
The increased revenue was 鈥渋nstrumental,鈥 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鈥檚 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 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 杨贵妃传媒視頻 Health News.
A Georgetown Center for Children and Families 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鈥檚 executive orders. In late February, Department of Health and Human Services acting general counsel Sean Keveney clarified that tribal health programs would by 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 .
HHS Secretary Robert F. Kennedy Jr. also of more than 900 IHS employees in February just hours after they鈥檇 received termination notices. During Kennedy鈥檚 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鈥檚 White House, said exemptions won鈥檛 be enough.
鈥淛ust because Native Americans are exempt doesn鈥檛 mean that they won鈥檛 feel the impact of cuts that are made throughout the rest of the program,鈥 she said.
State leaders are also 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 about Medicaid cuts, saying in an interview on Fox News in February that Medicaid and Medicare wouldn鈥檛 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 over the next decade. The possibility of cuts to the program that, together with CHIP, provides insurance to has from national and state organizations.
The federal government reimburses IHS and tribal health facilities 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鈥檛 be a matter of replacing the money but operating with less.
鈥淲hen you鈥檙e talking about somewhere between 30% to 60% of a facility鈥檚 budget is made up by Medicaid dollars, that鈥檚 a very difficult hole to try and backfill,鈥 said Winn Davis, congressional relations director for the National Indian Health Board.
Congress isn鈥檛 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 this fiscal year, which represents less than half of 1% of overall federal spending on Medicaid.
鈥淲e are saving more lives,鈥 Malerba said of the additional services Medicaid covers in tribal health care. 鈥淚t brings us closer to a level of 21st century care that we should all have access to but don鈥檛 always.鈥
This article was published with the support of the Journalism & Women Symposium (JAWS) Health Journalism Fellowship, assisted by grants from The Commonwealth Fund.
