Health and Health Care for American Indian or Alaska Native People: Key Issues

Introduction

Recent and forthcoming policy changes may have important implications for American Indian or Alaska Native (AIAN) people and could widen existing disparities in health and health care. This brief provides an overview of recent policies affecting health and health care for AIAN people and their potential impacts. It draws on data from KFF’s Key Data on Health and Health Care for American Indian or Alaska Native People and KFF analysis of recent laws and policy changes. AIAN people are identified as a racial and ethnic group. However, AIAN is also a political and legal classification. This status recognizes over 570 AIAN Tribes as sovereign nations, establishing a government-to-government relationship that dictates the federal government’s trust responsibility, including the provision of health care to AIAN people in federally recognized Tribes.  Key takeaways include the following:

• The 2025 reconciliation law makes large cutbacks in federal Medicaid spending that could negatively impact AIAN people and communities. The Congressional Budget Office (CBO) estimates that the law will reduce federal Medicaid spending over the next decade by an estimated $911 billion and increase the number of uninsured people by 10 million due to changes to Medicaid and other programs, including the ACA Marketplace. Medicaid is the primary source of health coverage for Native communities, with over one in three (35%) AIAN individuals under age 65 enrolled in Medicaid or the Children’s Health Insurance Program (CHIP), including 52% of AIAN children. Medicaid and CHIP are also the largest source of third-party funding for the Indian Health Service (IHS) and Tribal health facilities, and one of the main ways the federal government upholds its trust responsibility. To replace reductions in federal funding, states will need to increase spending or make program reductions, which could lead to eligibility and benefit cutbacks that might reduce coverage for low-income people overall, including AIAN people, and reduce funding available to IHS and other Tribal providers. Further, although the law provides exemptions for most AIAN people from new work requirements and more frequent eligibility determinations, AIAN people may face challenges documenting their eligibility for such exemptions and may experience coverage losses.
• Similarly, changes to the ACA Marketplace may erode coverage for AIAN people. Enhanced premium tax credits are set to expire at the end of 2025, which would make coverage unaffordable for many, including AIAN people. Estimates show that as many as 40% of AIAN people enrolled in the Marketplace with tax credits will lose their coverage if these credits expire.
• Continued underfunding of the IHS, broad reductions in federal funding and equity initiatives, and shifts in vaccination policy and attitudes may also negatively impact health and health care access for AIAN people. Despite proposed increases, FY 2026 funding for the IHS falls short of levels estimated to fully meet health care needs and fulfill the federal trust responsibility. Further, while Executive Orders focused on eliminating Diversity, Equity, and Inclusion (DEI) initiatives largely exempt Tribes, broader federal budget cuts and rollbacks to equity initiatives may reduce resources available to Tribal communities, including for data, public health surveillance, and outreach. Recent declines in vaccination rates, rising misinformation about vaccines, and shifts in federal vaccine policy may increase the risk of preventable disease outbreaks in AIAN communities, including recent measles outbreaks in the U.S.

Health Care for AIAN People

Under treaties and laws, the U.S. has a unique trust responsibility to provide health care to AIAN people. The IHS is the primary federal agency through which the federal government fulfills its trust responsibility for members of federally recognized Tribes, who make up approximately 2.8 million AIAN people from 574 federally recognized Tribes nationwide. Members of federally recognized Tribes, as well as certain other eligible AIAN individuals, can receive IHS-funded services through a network of IHS- and Tribally-run hospitals and clinics, along with Urban Indian Organizations (UIOs). AIAN people receiving services through IHS providers are not charged or billed for the cost of their services. However, the IHS has long been underfunded and lacks the resources needed to fully meet the health care needs of AIAN people. Services available through the IHS are primarily limited to primary care, although the IHS does provide some ancillary and specialty services. When care is not available within IHS or Tribal facilities, the Purchased/Referred Care (PRC) Program may fund services from outside providers. Yet, the funding for PRC has historically been insufficient and does not extend to UIOs. As a result, access to care through the IHS varies widely by location, and AIAN individuals who rely solely on the IHS often face significant barriers to obtaining needed services.

AIAN people can access health coverage through Medicaid, CHIP, and the Affordable Care Act (ACA) Marketplace, with certain unique benefits and protections. Tribal members enrolled in these programs can continue receiving care from IHS, Tribal, or UIO providers at no cost and additionally have access to a broader network of services than those available solely through IHS since they can access care through any provider participating in Medicaid and are covered by the comprehensive Medicaid benefit package. Medicaid offers specific protections for Tribal members, including exemptions from out-of-pocket costs. For the ACA Marketplace, Tribal members eligible for premium tax credits can enroll in zero or limited cost-sharing Marketplace plans and have other specific protections. For example, AIAN individuals with incomes between 100% and 300% of the federal poverty level who enroll in zero cost-sharing plans pay no out-of-pocket costs for covered services. Additionally, AIAN Marketplace enrollees have access to a Special Enrollment Period, allowing them to enroll in or switch plans once per month, beyond the standard open enrollment window that is available for other eligible people.

Health coverage improves access to care for AIAN people and strengthens Tribal health systems. Given the limitations of IHS funding and service availability, health coverage through Medicaid and the Marketplace enhances access to care for AIAN people since they can access covered care through a broader network of providers and have coverage for a comprehensive set of benefits. In addition to improving individual access to care, Medicaid is also an important source of funding for IHS and Tribal facilities and is one of the primary ways the federal government upholds its federal trust responsibility to provide health care to AIAN people. Medicaid is the largest third-party payer for the IHS, accounting for $1.3 billion out of the total almost $1.8 billion in third-party collections in fiscal year 2025. Further, unlike other Medicaid costs, which are typically shared between the federal government and states, the federal government covers 100% of the cost for services provided to AIAN Medicaid enrollees through the IHS or Tribally operated facilities whether operated directly by the IHS or on its behalf by a Tribe. Importantly, in contrast to IHS funding, Medicaid funding is not subject to annual appropriations and is provided on a continuous, claims-based basis throughout the year. As a result, Medicaid revenues are a vital funding stream that help facilities cover operational costs, pay providers, and invest in infrastructure development.

Due to a combination of lower coverage rates, additional access barriers, and historical and ongoing discrimination, AIAN people continue to face significant disparities in health and health care. AIAN people have shorter life expectancies relative to their White counterparts (70.1 vs 78.4 years at birth), higher rates of chronic diseases such as diabetes and asthma, and higher rates of suicide deaths and substance use disorder. About a quarter (26%) of AIAN adults report having fair or poor health status compared to 17% of White adults. Additionally, AIAN people face greater risks during pregnancy, including higher rates of preterm births and infant mortality. Among those under age 65, AIAN people are three times more likely to be uninsured (21%) compared to White people (7%).

Recent and Proposed Policies Related to AIAN Health and Health Care

Since President Trump took office in January 2025, the Administration and Congress have made significant health policy changes. While in some cases AIAN people have been specifically exempted or protected from new requirements or cutbacks, many changes may have significant impacts on health and health care for AIAN people that could exacerbate the large disparities they already face in health and health care.

Medicaid and ACA Marketplace Changes

The 2025 reconciliation legislation makes large cutbacks in federal Medicaid spending that could negatively impact low-income people overall, including AIAN people and communities. CBO estimates that the law will reduce federal Medicaid spending over the next decade by an estimated $911 billion and increase the number of uninsured people by 10 million due to changes to Medicaid and other programs, including the ACA Marketplace. Medicaid is the primary source of health coverage for Native communities with one in three (35%) AIAN individuals under age 65 enrolled in Medicaid or the Children’s Health Insurance Program (CHIP), including 52% of AIAN children. As noted, Medicaid is also the largest source of external funding for IHS and Tribal health facilities, accounting for roughly two-thirds of their third-party revenue and providing a stable funding source to support operations. To replace reductions in federal funding, states will need to increase spending or make program reductions, which could lead to broad eligibility and benefit cutbacks that might reduce coverage for low-income people overall, including AIAN people and reduce funding available to IHS and other Tribal providers.

The law imposes an array of new requirements on Medicaid enrollees but largely exempts AIAN people from these changes. The law will require more frequent Medicaid eligibility determinations (every six months), adds a new work requirement, and imposes increased cost sharing for adults enrolled in the ACA Medicaid expansion. The law exempts AIAN people from these new requirements. However, it is unclear how state Medicaid programs will verify AIAN people’s Tribal citizenship. Some AIAN people may face challenges documenting their exemption status. While states are required to use available data to verify exemption status, some AIAN people who need to document their Tribal citizenship may face challenges to submitting documents, including long distances to post offices and limited internet access, as seen during the recent unwinding of Medicaid continuous enrollment.

While the 2025 reconciliation law exempts AIAN people from changes to Marketplace coverage, the pending expiration of enhanced Marketplace subsidies could lead to declines in coverage for AIAN people. Without renewal of the enhanced tax credits, premium payments for individuals enrolled in the Marketplace are expected to more than double on average. Estimates suggest that a substantial share of AIAN people currently enrolled in a Marketplace plan could lose coverage if the enhanced premium tax credits expire, particularly in states that have not expanded Medicaid to adults.

Funding for IHS

Congressional appropriations bills for Fiscal Year (FY) 2026 increase funding for the IHS compared to prior years but still fall far short of the funding levels to fulfill the federal trust responsibility to AIAN communities. In late July 2025, both the House and Senate Appropriations Committees passed their respective FY 2026 bills, each proposing increased funding for the IHS. The House bill allocates $8.41 billion, while the Senate bill allocates $8.1 billion, both above the FY 2025 enacted level of $6.96 billion. These increases are expected to support expanded primary care, behavioral health, and preventive services, as well as help offset inflationary pressures that threaten to erode service capacity. The House bill also includes $105.99 million for Urban Indian Health and $6.05 billion in advance appropriations for FY 2027. Following the most recent government shutdown, the deadline to pass FY 2026 appropriations bills has been extended through the end of January, during which time IHS continues to operate at FY 2025 funding levels. While these bills increase funding, they fall short of estimated needs. The Tribal Budget Formulation Work Group, led by Tribal leaders across all IHS regions, has recommended full funding at $73 billion for the IHS and $1.09 billion for Urban Indian Health to meet health care needs and fill service gaps. The group has identified several areas that would benefit from increased funding including workforce shortages, Infrastructure improvement, and targeted public health initiatives, such as mental health, substance use and opioid treatment programs, efforts to eliminate HIV and hepatitis C, and culturally tailored chronic disease management through the Special Diabetes Program for Indians.

Federal Cutbacks to Staff, Diversity Initiatives, Data, and Research

Although Tribes have largely been exempted from recent reductions in DEI initiatives, broader federal program and budget cutbacks that eliminate staff and programs focused on health equity may still undermine efforts to address longstanding disparities affecting AIAN communities. While Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. has suspended layoffs at IHS, Tribal leaders caution that deep cuts at other federal health agencies are causing widespread disruption. These reductions are impacting many programs Tribal communities rely on, including public health surveillance, data systems, and community outreach efforts. Tribes report that staffing losses in key federal health agencies have led to gaps in data collection, weakened communication, and delayed implementation of essential programs. Maintaining strong health data infrastructure and partnerships with Tribal communities is key for tracking health inequities and targeting resources effectively. One notable loss is the Centers for Disease Control and Prevention’s (CDC) Healthy Tribes Program, which previously provided roughly $32.5 million annually to support culturally grounded approaches, such as community gardens and incorporation of traditional wellness practices, but has now been effectively dismantled. Broader restructuring across the HHS has also affected Indian country. Tribal representatives, including the National Indian Health Board, have expressed concerns that dismantling equity-focused initiatives threatens to reverse gains addressing disparities affecting AIAN people.

Changes in Vaccine Policy

Shifts in vaccine policy, misinformation about vaccine safety, and declines in childhood vaccination rates may lead to a rise in outbreaks of once eradicated diseases with disproportionate impacts for AIAN people. HHS Secretary Kennedy, known for his longstanding opposition to vaccines and for spreading vaccine misinformation, has recently spearheaded initiatives to review the federal childhood vaccination schedule, overhaul the membership of the Advisory Committee on Immunization Practices (ACIP), and limit both COVID-19 vaccines and mRNA vaccine research. Additionally, the Trump administration has released a report advocating for a new vaccine policy framework, which includes revisiting the childhood vaccine schedule and focusing on vaccine-related injuries. Since the COVID-19 pandemic, childhood vaccination coverage has declined nationwide. Gaps in immunization are higher in AIAN communities, increasing their susceptibility to disease resurgence. Among children born in 2020, only 57% of AIAN children were fully immunized by age two, compared to 71% of non-Hispanic White children. Additionally, roughly 76% of AIAN children have received their first MMR dose, falling short of the 95% coverage required to achieve herd immunity. AIAN adults were also 30% less likely to receive a flu shot than their non-Hispanic White counterparts during the 2023–2024 season. These declines have contributed to the most severe measles outbreak in the U.S. in more than three decades. Recent measles clusters in Tribal communities, especially in the Northern Plains and Southwest, have disrupted health care access and led to temporary clinic closures. In response, IHS, Tribal, and Urban health facilities have implemented mobile vaccination units, walk-in clinics, and multilingual public health campaigns tailored to meet local needs.

At the same time, misinformation about vaccine safety continues to circulate widely. KFF polling data shows that a majority of Americans have read or heard the false claim that the MMR vaccine causes autism in children. About one-third have heard that getting the measles vaccine is more dangerous than becoming infected with measles, and 34% believe the debunked claim that MMR vaccines cause autism. Among parents, about one in ten (9%) believe the MMR vaccine can cause autism, and roughly one in six (16%) say they have ever skipped or delayed at least one childhood vaccine for any of their children. Additionally, while formally supportive of the MMR vaccine’s effectiveness, Senator Kennedy has amplified anti-vaccine narratives including debunked claims linking the MMR vaccine to autism, creating confusion and reducing clarity on vaccine safety. Beyond the existing mistrust of the health care system due to historical trauma and abuse, some Tribal leaders warn that skepticism and mistrust of the health care system among AIAN people is increasing. Together, the increased skepticism among the public about the safety and effectiveness of measles vaccines and a decline in trust of health authorities in general, have contributed to lower vaccination rates and complicated outreach and communication efforts to combat preventable disease outbreaks.