The reservation of the Kashia Pomo Tribe, based in Sonoma County, Calif., is nearly two hours away from the nearest hospital or center providing critical medical services.
Reno Keoni Franklin, chairman emeritus of the Kashia Pomo Tribe, says the long commute is just one of several inconveniences impacting American Indians, whose medical care is funded by federal dollars. Funding for Indian Health Service (IHS), the agency that provides Native Americans with medical care, is under threat by slashes to national spending imposed by the Department of Government Efficiency (DOGE), which tribal leaders say could worsen their situation.
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“These cuts are jeopardizing a system that’s working. The notion by DOGE is that it’s of no real value… They don’t know what these workers do to provide essential services,” says Ron Allen, chairman of the Jamestown S’Klallam Tribe. “They’re an essential pipeline to help the community. We do what we can to make a difference. And we’re still struggling.”
Tribal reliance on federal funds for medical care is part of the existing legal trust obligation to provide certain services, including health care, to Native Americans because the government took over Indigenous land.
But looming DOGE cuts could upend the already-underfunded IHS. For fiscal year 2025, IHS received a budget of some $8 billion, far below its estimated need. The IHS National Tribal Budget Formulation Workgroup recommended the agency receive $73 billion—nine times the amount allotted to the agency. Administrators for tribal public health boards are able to supplement lack of funding by applying for federal grants—which are also being gutted by DOGE—and other third-party revenue reimbursements from Medicare and Medicaid. While President Trump has said that Medicaid and Medicare will not be cut, Congressional Republicans have pledged to make massive cuts to their budget, and constituents fear the two programs will be affected.
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The medical care system for American Indians is complex. Tribes can opt in to receive direct services from IHS—meaning the agency runs and oversees the clinics and services they provide tribes—or they can take the funds that would have been allotted to them and assume responsibility for the management of their own health care, typically through a tribal public-health board.
“DOGE is starting to look at all of these inefficiencies across Indian Country, closing down facilities or limiting the amount of staff that can be hired at each one. It sounds like this is going to be a trickle-down effect; it’s not. It’s a tidal-wave effect. It happens instantly,” says Franklin, who is also the chair of the California Rural Indian Health Board.
DOGE has shut down at least 12IHS offices or facilitiesin the U.S. At least two of these locations provided essential services, including water and sewage inspection, and inspection of kitchen facilities where food is prepared for local nutrition programs, according to Franklin. “Our drinking water system is in need. Our wastewater system is in need of updating and modernization. And those field offices, those engineers, were working to get that done for us,” he says.
Neither the White House nor IHS responded to TIME’s request for comment regarding the closure of these offices.
Health care leaders argue that the lack of funding for the IHS limits improvement to medical tools and systems, which affects the quality of care. “It’s about making sure that the facilities are up to date, making sure that we have the latest equipment,” says Locklear. “So much changes in the medical field that it’s hard for facilities to keep up, so that’s probably one of the biggest barriers and burdens.”
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The IHS funding gap also deters people from becoming health care workers or staying in these jobs. The vacancy rate for IHS professionals stands at about 30%, and 36% for physicians, according to the NIHB. The U.S. at large is already experiencing a physician shortage.
“What’s Sec. [Kennedy’s] proposal in terms of how will he address the trust and treaty trust obligations with our sovereign nations, if he has less people to do more work?” says Allen. “How would that not be a breach of trust responsibilities?”
Current DOGE cuts put IHS at imminent risk of losing some 2,500 employees, A.C. Locklear, interim CEO of the National Indian Health Board (NIHB), told Native News Online. IHS clinics and facilities, even those that are self-run by tribes, already only provide basic services. Tribal leaders in Sonoma County and the Great Plains say that their facilities—and those of other tribes—are not open overnight. Many elsewhere do not offer any emergency aid, meaning American Indians and Alaska Native must travel to the nearest hospital when in need of urgent care. Several tribes also do not provide any local obstetric care, limiting the access to maternal health and wellness services. “One percent [in funding] can make an extreme difference in the ability to provide care,” says Locklear. “It can make the difference between having one physician to two physicians.”
American Indian and Alaska Natives, who account for more than 11 million people in the U.S., face serious health risks. These groups have the lowest life expectancy at birth when compared to all other racial and ethnic groups in the U.S., according to the Department of Health and Human Services Office of Minority Health. Nearly a fifth of the American Indian and Alaska Native population reported being in fair or poor health in 2023.
The future of the IHS is also threatened by a federal hiring freeze. While IHS medical professionals are exempt, hospital administrators have been affected by budget cuts. Because tribes rely so heavily on third-party revenue, administrators play a big role in ensuring the clinics receive money in exchange for the services provided. An estimated 31.5% of American Indians and Alaska Natives are enrolled in Medicaid, with another 12.8% enrolled in Medicare, according to the NIHB.
Still, some tribal leaders who have participated in meetings with IHS officials and other government leadership are hopeful that Trump Administration officials will listen to their concerns.
U.S. Department of Health and Human Services Secretary Robert F. Kennedy Jr. previously spoke about his commitment to the Indigenous community and met with tribal leaders in late February, promising to make “Indian Country a priority.”Some tribal leaders are hopeful. Franklin notes that his tribe upgraded from a well system to a septic system thanks to legislation introduced by Kennedy’s late uncle, the former President John F. Kennedy, after he visited the reservation.
“Secretary Kennedy is aware and understands the [legal] trust responsibility to American Indian tribes from the federal government,” says Franklin. “Now, is he going to be able to act on it or advise the President and his budget to include these increases that are needed? I’m hoping so.”
But fears from a potential impact still loom over officials. A January memo from the Office of Management and Budget (OMB) directed agencies to pause any federal financial assistance programs, on which many tribal public health boards rely.
“We have an agreement with the federal government to provide these public health services and implement these grants to provide services to relatives in the Great Plains area,” says Jerilyn Church, president and CEO for the Great Plains Tribal Leaders Health Board. The potential impact of the OMB memo, without a court order, could have been devastating for the Oyate Health Center, which she runs. “It would have brought to halt all of the services and programs that we were providing through our grants.”
In the Great Plains, tribal leaders are able to fund care for substance abuse—a problem that Native Americans have historically faced—and food assistance programs.
HHS recently issued a memo offering employees a $25,000 buyout for early retirement. Church identified at least 22 employees—including administrators—who received a letter from HHS offering the early retirement buyout, which she says would cause the Oyate Health Center to lose the most-experienced nurses and employees. In total, the hospital has some 20 providers that care for 24,000 patients. At least one individual confirmed to Church that they will be leaving the clinic due to the buyout. “We also know that typically the voluntary employment offer is rolled out ahead of involuntary, so we’re concerned about that,” says Church.
While leaders remain optimistic, they still feel wary about what could come next, and believe DOGE should act with better caution before they act. “There are administrative costs to the Indian Health Service that I think need to be looked at first before just doing a blanket invitation to leave the health system to reduce the workforce,” says Church.
“Tribes paid in full with their land, with their resources, and entered into agreements with the government to provide for health, among other things,” says Locklear. “There is a history of broken treaties that has been acknowledged time and time again.”
“We want to make sure that they are aware that shutdowns and appropriations decisions and funding decisions can have substantial impacts to the lives of American Indian and Alaska Nativepeople and their ability to be healthy.”