The end of enhanced Affordable Care Act (ACA) subsidies on December 31 has plunged Native American communities into a severe public health and financial crisis, dismantling a successful model of health care that was beginning to close long-standing gaps in medical access. These pandemic-era subsidies were the financial cornerstone of innovative, tribally sponsored health insurance programs that provided comprehensive coverage to thousands of citizens. With this critical federal support now gone, a dramatic surge in premium costs is jeopardizing this vital lifeline, threatening to unravel years of progress and exacerbate the profound health disparities that have plagued these populations for generations. The termination of this policy is not an abstract economic shift but a tangible and immediate threat to the well-being of a vulnerable population, forcing tribal leaders into impossible choices between financial solvency and the health of their people.
A Legacy of Neglect and an Innovative Response
The U.S. government’s treaty obligation to provide health care to Native Americans in exchange for tribal lands has been systematically unfulfilled, leaving a legacy of underfunded and inadequate services through the Indian Health Service (IHS). For decades, this chronic lack of resources has created a two-tiered system where tribal members face significant delays for specialty treatments, have limited access to preventative screenings, and often see serious medical conditions go undiagnosed until they reach a critical stage. The IHS system, stretched thin and overburdened, frequently cannot provide the comprehensive or timely care necessary to manage chronic diseases or address complex health issues, leaving many with no option but to wait as their conditions worsen. This gap in care has contributed directly to the stark health disparities seen in Native communities, where life expectancies are significantly lower and rates of chronic illness are disproportionately high.
In response to this systemic failure, many tribes developed their own health insurance programs, demonstrating remarkable ingenuity and self-determination. These initiatives creatively leveraged the framework of the Affordable Care Act by enrolling tribal members in marketplace health plans. The key to their success was the enhanced federal subsidies, which dramatically lowered premium costs. Tribes were then able to cover the remaining, much smaller, share of the premiums for their citizens. This innovative model provided thousands of Native Americans with robust health coverage for the first time, opening doors to a level of consistent, specialized, and preventative medical care that the IHS system could rarely offer. These programs were not just a stopgap; they were a transformative solution that empowered tribes to take control of their communities’ health and well-being.
The Human Cost of a Policy Reversal
The profound, life-saving impact of these tribally sponsored programs is powerfully illustrated by the personal story of Leonard Bighorn, a 65-year-old game warden on the Fort Peck Reservation. He carries the painful memory of watching his mother suffer for two years with severe stomach pain, unable to secure an adequate diagnosis through the limited local health services. By the time she was finally able to see a specialist, her condition had progressed to stage 4 colon cancer, and she passed away shortly thereafter. Her tragic experience is a testament to the dire consequences of delayed care within the under-resourced IHS system, a reality familiar to countless Native families. Her story highlights the systemic barriers that prevent timely diagnosis and treatment, turning manageable conditions into fatal illnesses and perpetuating a cycle of preventable loss within the community.
In stark contrast, Mr. Bighorn’s own health journey has been reshaped by the Fort Peck Tribes’ health insurance program, which was established in 2016. Through this coverage, he has access to the regular cancer screenings his mother desperately needed but never received. The program proved instrumental when he required two necessary hip replacements, complex procedures that are often designated as a low priority by the IHS and can involve years-long waits. Even more critically, routine pre-surgery testing led to the diagnosis of lifelong, untreated asthma and sleep apnea, which were identified as the root cause of his dangerously high blood pressure. He firmly believes that without the tribe’s comprehensive insurance program, he would have faced a similar fate as his mother, waiting years for such essential care and likely receiving it only after his health had deteriorated to a point of crisis.
An Unsustainable Financial Burden
The expiration of the enhanced ACA subsidies has triggered an immediate and existential financial crisis for the tribal health programs that depended on them. The premium costs that tribes must now cover for their enrolled members have ballooned to unsustainable levels, forcing a rapid and painful reassessment of these vital initiatives. At the Fort Peck Reservation, program director Rae Jean Belgarde has stated that with the sudden cost increase, the tribe’s only viable option is to “start limiting who gets help,” a devastating choice that means revoking a lifeline for many. This situation is mirrored across the country. The Blackfeet Nation, whose similar health program was launched in 2024 and made possible entirely by the enhanced subsidies, has already been forced to halt all new enrollments. A tribal council member warned that its funding will run out before the end of the year, as premiums have skyrocketed by over 100 percent.
This immense financial pressure is creating a destructive feedback loop that threatens the entire health care infrastructure in these communities. A key benefit of the tribally sponsored insurance plans was that local clinics and hospitals could bill for services provided to Native American patients, generating a crucial revenue stream. Many tribes leveraged this income to expand their own health services, from hiring more staff to purchasing new equipment and offering specialized care on-reservation. Now, as tribes are forced to cut back or eliminate their insurance programs, that revenue is disappearing. A.C. Locklear, CEO of the National Indian Health Board, explained that this will “drastically shift how much tribes can really put back in their community.” The Tuba City Regional Health Care Corp. in the Navajo Nation, for instance, provides comprehensive cancer treatment and estimates its costs to cover patients will increase by approximately 170% without the subsidies, a staggering rise that threatens its ability to continue providing such essential, life-saving care.
A System on the Brink of Collapse
The termination of these subsidies marked a significant step backward in public health for Native Americans, a population that already faces disproportionately high rates of chronic disease and a median age at death that is 14 years younger than that of white Americans. The social policy research nonprofit, the Urban Institute, projected that 125,000 Native Americans will become uninsured by 2026 due to the higher costs, a reality that will inevitably push more people back into the already overburdened IHS system. This influx will place immense strain on critical IHS programs like the Purchased/Referred Care system, which is the mechanism used to pay for medical services that IHS facilities cannot provide directly. The program is already chronically underfunded, forcing officials to make difficult decisions about who receives care.
With an increased patient load and no additional funding, the bar for receiving outside care will be raised even higher. Jerilyn Church, CEO of the Oyate Health Center in South Dakota, warned that officials will be forced to tighten eligibility, approving referrals only for the most critically ill patients. This political impasse, with a measure to extend the subsidies passing the House only to stall in the Senate, has been viewed by tribal leaders as another profound betrayal of the federal government’s treaty-mandated duty to ensure adequate health care. Leaders from Fort Peck wrote to their congressional delegation to plead for an extension, emphasizing that their program was “saving lives.” The failure to act has left tribes scrambling and has dismantled a successful health care model, with the grim conclusion that people will not get the care they need. This policy failure could, as Church starkly concluded, translate directly to “people losing their lives.”
