Leonard Bighorn recounted that his mother struggled for a two-year period to obtain medical assistance for debilitating abdominal discomfort, given the restricted healthcare amenities available in proximity to her residence on the Fort Peck Reservation in northeastern Montana.
Following an eventual consultation with a medical specialist in Glasgow, a journey of approximately one hour, his mother received a diagnosis of stage 4 colon cancer, Bighorn reported.
Now, sixteen years subsequent to his mother’s passing, Bighorn has gained access to routine cancer screenings and other specialized medical attention that were unavailable to her, courtesy of a healthcare insurance initiative established by the Fort Peck Tribes in 2016. This initiative, which underwrites the majority of expenses for the approximately 1,000 enrolled tribal citizens, represents one of an increasing number of health insurance programs sponsored by tribes.
While these programs exhibit variations among different tribes, their fundamental purpose involves identifying and enrolling individuals residing within tribal territories into plans offered on the Affordable Care Act marketplace. They afford participating Native Americans the liberty to seek care from external physicians and medical facilities when services from the Indian Health Service (IHS) are not accessible.
“Absent this provision, I would find myself in a precarious situation,” stated Bighorn, a 65-year-old tribal game warden and a member of the Dakota community.
However, the Fort Peck Tribes have recently instituted limitations on eligibility for this coverage. Approximately 400 miles to the west, the Blackfeet Nation has ceased new enrollments in a comparable initiative, issuing a cautionary statement regarding the depletion of funding before the close of the current year. Other tribal organizations providing similar healthcare coverage to Native Americans are also grappling with escalating expenditures.
The fiscal strain commenced when congressional legislators permitted the expiration of enhanced subsidies under the Affordable Care Act on December 31st. These tax credits, introduced by the Biden administration during the COVID-19 pandemic, broadened subsidized health coverage for millions of individuals. By late 2025, ACA plans had garnered around 24 million enrollees, more than double the pre-pandemic annual sign-up figures. The cost of coverage surged for the majority of these individuals as the expanded subsidies lapsed, and federal health officials indicate a decrease in enrollment exceeding one million people thus far.
The subsidies had also provided a significant boost to tribal health insurance programs, such as the one Bighorn is part of. These programs cover the portion of an individual’s premium payments that remain after subsidies are applied, and this coverage subsequently reduces patients’ out-of-pocket treatment expenses. With the contemporary surge in premium prices, tribal expenditures have correspondingly escalated.
Rae Jean Belgarde, who supervises the Fort Peck Tribes’ program, articulated that the increased costs leave the tribes with a solitary recourse at this juncture: “to commence restricting who receives assistance.”
The tribes are facilitating beneficiaries’ transitions to alternative insurance options and, in certain instances, identifying state programs to cover their premiums. Tribal leadership has also dispatched a formal communication to Montana’s entirely Republican congressional delegation, urging their endorsement for an extension of the subsidies.
“Our program is instrumental in preserving lives,” the correspondence asserted. Belgarde expressed uncertainty regarding any response from the lawmakers.
Scrambling for solutions
Members of the U.S. House of Representatives gave their approval to a temporary extension of the enhanced subsidies in January. Nonetheless, this legislative measure encountered an impasse in the Senate. Lawmakers are now in a state of urgency, endeavoring to devise an alternative strategy, particularly after President Donald Trump’s threat to veto any extension bill that reaches his desk. On January 15th, the President unveiled a framework for a healthcare proposal that incorporates the establishment of savings accounts to facilitate individuals in managing their medical expenses—a concept previously advocated by Senate Republicans as a substitute for the subsidies.
A.C. Locklear, the Chief Executive Officer of the National Indian Health Board, a non-profit organization dedicated to advancing healthcare within Native communities, observed that tribes are “exploring avenues for reductions, much like everyone else.”
Native Americans, as a demographic cohort, continue to experience disproportionately elevated incidences of chronic illnesses. Their median age at mortality is fourteen years lower than that of white Americans.
“A curtailment in access, even to basic primary care, exerts a substantial adverse effect on these existing disparities,” Locklear commented.
Tribal leaders have contended that the cessation of subsidies further erodes the federal government’s obligation to ensure adequate healthcare provisions for Native Americans.
In recompense for the acquisition of tribal lands through colonization, the U.S. government made enduring commitments to uphold the health and welfare of tribal nations. Native Americans are assured of complimentary healthcare services at clinics and hospitals that are either operated by or receive funding from the Indian Health Service. However, the persistent underfunding of this agency has resulted in significant deficiencies in care provision. Occasionally, it finances external patient treatments through its Purchased/Referred Care program, but this avenue is also subject to limitations. Due to funding shortfalls, the agency exercises discretion in prioritizing which medical interventions will be covered.
To assist in bridging these coverage voids, a number of tribal sovereign nations have established their own health insurance programs. When tribes contribute to health premiums, local clinics and hospitals are empowered to bill for services that might otherwise remain unreimbursed. Certain tribes have capitalized on these financial resources to expand their service offerings.
“I do not foresee tribes discontinuing these programs,” Locklear stated. “However, it will profoundly alter the extent to which tribes can reinvest in their communities.”
For instance, Tuba City Regional Health Care Corp., situated in northern Arizona within the Navajo Nation, is distinguished for its provision of comprehensive cancer treatment on a reservation, Locklear noted. This corporation, he added, estimates that its expenses for patient care this year are projected to escalate by approximately 170%, reaching close to $38,000 per month in the absence of the enhanced subsidies.
One of the more recently established programs is located on the Blackfeet reservation in northwestern Montana, where access to fundamental healthcare services can be challenging. Medical appointments are frequently administered on a first-come, first-served basis, and services become unavailable when vacant staff positions are not filled, according to Lyle Rutherford, a council member of the Blackfeet Nation.
“Some of it simply involves securing a routine eye examination or a primary care appointment,” Rutherford remarked.
The tribe has been incrementally developing its health insurance program since its inception in 2024. Rutherford indicated that the enhanced subsidies were instrumental in making this endeavor feasible. Fewer than 400 individuals are currently enrolled out of an estimated 3,000 who are eligible. The tribe suspended new enrollments approximately two months ago due to the impending expiration of subsidies, and reallocated its healthier members to more cost-effective plans.
“At this current juncture, we are compelled to pause operations,” Rutherford stated. “Premiums have experienced an escalation exceeding 100%.”
He mentioned that tribal leaders are actively seeking supplementary financial resources to sustain the program, and he expressed hope for a resolution from Congress.
Lives on the line
The ramifications extend beyond the scope of tribal insurance programs. The Urban Institute, a nonprofit organization based in Washington, D.C., specializing in economic and social policy research, projects that 125,000 Native Americans will become uninsured in 2026 as a consequence of escalating costs.
Patients receiving care at the Oyate Health Center in Rapid City, South Dakota, are already reporting substantial increases in premiums for ACA plans. CEO Jerilyn Church stated that it is too early to ascertain the precise number who will opt out of coverage. However, she cautioned that an increase in uninsured patients would further strain the IHS Purchased/Referred Care program—with officials raising the threshold for the severity of illness required for coverage of care outside of tribal health facilities.
“Individuals will be unable to obtain the medical attention they require,” Church stated, adding that this situation could translate to “people losing their lives.”
Bighorn, the game warden residing on the Fort Peck Reservation, is among those who continue to benefit from the tribes’ insurance program. He has utilized its provisions.
Shortly after enrolling, Bighorn required two hip replacement surgeries, procedures that necessitate care beyond the reservation and are classified as low-priority by the Indian Health Service. Bighorn reported that during pre-operative testing, specialists identified the underlying cause of his long-standing, dangerously elevated blood pressure. The diagnosis: untreated lifelong asthma and sleep apnea.
“I was a profoundly unwell individual, perpetually fatigued,” he expressed.
Without the tribe’s coverage, Bighorn might have eventually received these diagnoses, but he acknowledged that it would likely have taken years to secure assistance through the Indian Health Service. This would have meant experiencing a significant deterioration in his health before receiving care.
