The Trump administration is touting its $50 billion Rural Health Transformation Program as the largest investment in rural health care in U.S. history. But the government made minimal mention of Indian tribes, who live in sparsely populated areas and need vastly improved access to health care.
Federally recognized tribes cannot directly claim a share of the rural health care fund—only states can. And states are not required to consider the needs of tribes. But state applications for five-year payments show that some states with significant Native American populations did so anyway.
Workforce development, technology upgrades and traditional healing are just some of the initiatives specifically aimed at Native American communities that some states included in their applications submitted by the Centers for Medicare and Medicaid Services on Nov. 5. The fund was a late addition to the One Big Beautiful Bill Act in response to concerns about the harm that spending cuts in the Republican bill would have on rural hospital finances.
Some states including IdahoNevada, and Oregonare also considering setting aside 3% to 10% of their federal payments for distribution to tribes. Washington proposed to allocate $20 million a year.
Federally recognized tribes have a direct relationship with the U.S. government, but state governments also allocate resources to tribes and can create policies that support tribal priorities. States and tribes divide concerns about the effect that the sweeping GOP budget bill that President Donald Trump signed into law in July will address the U.S. health care system. The legislation is expected to cut federal Medicaid spending by nearly $1 trillion and increase the number of uninsured people. about 10 million peopleaccording to KFF, a nonprofit health information organization that includes KFF Health News.
Katherine Howden, a CMS spokeswoman, said states should develop their applications in collaboration with key stakeholders, including state government tribal affairs offices or tribal liaisons and “Indian health care providers, as appropriate.” But these entities do not include tribal governments or tribal officials.
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 at being seen as just another stakeholder in the issue rather than as sovereign states. Tribal sovereignty guides most intergovernmental consultations on proposed federal actions that will have a significant impact on tribes.
“Even in a scenario where consultation among tribes is required, the quality and quantity of that consultation varies from state to state,” said Liz Malerba, director of policy and legislative affairs for the United Southern and Eastern Tribes Sovereignty Defense Fund, which defends tribal nations from Texas to Maine. Malherba is a citizen of the Mohegan Tribe.
Federal policies work best when tribal nations have direct eligibility for funding that supports essential services in their communities, Malerba said, adding that tribal leaders are concerned that program coverage in their communities will vary significantly.
Eat 574 federally recognized tribes And more than 7 million Native Americans and Alaska Natives in the United States Populations face lower life expectancy and among the worst health indicators compared to other demographic groups. The Indian Health Service, the federal agency responsible for providing health care to Native Americans and Alaska Natives, was historically underfunded Congress.
KFF Health News analyzed how 12 states with significant Native American populations considered tribes when developing plans to receive federal money.
Idaho, Washington, MontanaAnd Arizona were among the states that held tribal consultations or hearings before the Nov. 5 filing deadline.
In states that did not initiate tribal participation, some Native American leaders made sure their voices were heard at other public hearings. Jerilyn Church, CEO of the Great Plains Tribal Chiefs' Health Council, said she attended the October public meeting in South Dakota because she felt it was important for state leaders to think about how they could use the program's resources on reservations. The state is home to nine federally recognized tribes, and Native Americans make up 9% of the population.
“I felt like we needed to help become those advocates,” said Church, a citizen of the Cheyenne River Sioux Tribe.
In proposed initiatives included in the Rural Fund Application, South Dakota identified needs of the tribal community such as improving telemedicine and funding for doula programs. It also says the state will continue to meet 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 percentage than most other states, tribal members were asked to voice their opinions along with the rest of the public as the state gathered information for its application, the details of which were not made public.
“We welcome the input of any Oklahoman,” state health department spokeswoman Erica Rankin-Riley said.
North Dakota identified tribes in his state as partners in the Rural Health Transformation Program and included initiatives such as expanding tribal resident physician slots and farm-to-table food distribution opportunities. But local legislators refused to support the proposal it would transfer 5% of federal appropriations to tribes. The state is home to five federally recognized tribes, and Native Americans make up nearly 5% of the population.
Some states have included proposals to fund high-priority initiatives for tribes.
Washington statement The Rural Fund included an initiative aimed at improving the health of Native American communities. Its goals include investing in workforce development for tribes, improving care coordination between tribes and rural hospitals, and providing $2.4 million a year to support UW's rural health education programs, including its Indigenous health program.
Alaska proposal included the integration of traditional Native healing into Alaska Native village clinics. According to the application, this will include traditional healing house calls, hands-on training for healers and traditional medicine training for health workers and staff.
One of Five Oregon Initiatives will support the state's nine federally recognized tribes in improving health outcomes. The state estimates the initiative will require $20 million annually, or 10% of the amount allocated to the Rural Health Transformation Program.
Regardless of whether states have identified funding for tribes or included tribal priorities in their proposals, tribes will be eligible to apply to their states for subgrants under the Rural Health Transformation Program. While larger tribes that have more resources, such as grant writers and staff to implement programs, may benefit, smaller tribes may have difficulty generating competitive proposals.
Church said the Great Plains Tribal Chiefs' Health Council will learn the fruits of its labor when states are notified of rural health fund allocations by the end of the year.
“Hopefully the work we've done, the advocacy we've done and the outreach we've done,” Church said, “will result in resources getting to our tribes.”
KFF Health News South Dakota reporter Arielle Zionts contributed to this report.
