End of enhanced Obamacare subsidies puts tribal health lifeline at risk
By Katheryn Houghton, Jazmin Orozco Rodriguez, KFF Health News
Leonard Bighorn said his mother tried for two years to get help for severe stomach pain through the limited health services available near her home on the Fort Peck Reservation in northeastern Montana.
After his mom finally saw a specialist in Glasgow, about an hour away, she was diagnosed with stage 4 colon cancer, Bighorn said.
Now, 16 years after his mother’s death, Bighorn has access to regular screenings for cancer and other specialty care that she didn’t have, through a health insurance program the Fort Peck Tribes created in 2016. The program, which covers most of the costs for the roughly 1,000 tribal citizens enrolled, is among a growing number of tribally sponsored health insurance programs.
Such programs vary by tribe, but they essentially screen and enroll people living within tribal boundaries in Affordable Care Act marketplace plans. They allow participating Native Americans flexibility to go to outside doctors and clinics when care through the Indian Health Service is unavailable.
“I’d be in a bind otherwise,” said Bighorn, a 65-year-old tribal game warden and member of the Dakota community.
But the Fort Peck Tribes now limit who has access to that coverage. Nearly 400 miles to the west, the Blackfeet Nation recently stopped enrolling people in a similar program, warning that funding will run out before the end of the year. Other tribal organizations that offer Native Americans similar coverage are struggling with rising costs, too.
The financial crunch began when congressional lawmakers allowed enhanced subsidies under the Affordable Care Act to expire on Dec. 31. Those tax credits, created under the Biden administration during the covid-19 pandemic, expanded subsidized health coverage for millions of people. By late 2025, ACA plans saw about 24 million enrollees, more than twice the number of pre-pandemic annual sign-ups. The cost of coverage shot up for most of those people as the expanded subsidies expired, and enrollment so far has dropped by more than 1 million people, according to federal health officials.
The subsidies had also boosted tribal health insurance programs, like the one Bighorn is enrolled in. The programs pay the price of each person’s share of premiums after subsidies, and the coverage lowers patients’ treatment costs. Now that premium prices have ballooned, so have tribes’ costs.
Rae Jean Belgarde, who directs Fort Peck Tribes’ program, said the higher costs leave the tribes with one option at this point: “Start limiting who gets help.”
The tribes are helping people shift to other insurance options and, in some cases, find state programs to cover their premiums. Tribal leaders also sent a letter to Montana’s all-Republican congressional delegation asking them to support extending the subsidies.
“Our program is saving lives,” the letter read. Belgarde said she didn’t know whether the lawmakers responded.
Scrambling for Solutions
U.S. House members approved a temporary extension of the enhanced subsidies in January. But that measure stalled in the Senate. Lawmakers are scrambling for an alternative after President Donald Trump threatened to veto an extension if a bill reaches his desk. On Jan. 15, the president released an outline of a health care proposal that includes creating savings accounts for people to pay their health costs — an idea Senate Republicans previously floated as an alternative to the subsidies.
A.C. Locklear, CEO of the National Indian Health Board, a nonprofit that works to improve health in Native communities, said tribes are “looking at ways to cut back just as much as everyone else.”
Native Americans as a group continue to face disproportionately high rates of chronic diseases. Their median age at death is 14 years younger than that of white Americans.
“Reducing access to even just general primary care has a significant impact on those disparities,” Locklear said.
Tribal leaders have said letting the subsidies expire further undermines the federal government’s duty to ensure adequate care for Native Americans.
In exchange for taking tribal land through colonization, the U.S. government made long-standing promises to provide for the health and well-being of tribes. Native Americans are guaranteed free health care at clinics and hospitals operated or funded by the Indian Health Service. But that agency’s chronic underfunding has created massive blackouts in care. It sometimes pays for patients’ outside care through its Purchased/Referred Care program, but that’s limited too. Due to funding shortfalls, the agency prioritizes which treatments it will pay for.
To help fill the coverage gaps, some tribal nations have built their own health insurance programs. When tribes pay health premiums, clinics and hospitals in their areas can bill for services that might otherwise go unpaid. Some tribes have leveraged that money to expand services.
“I don’t see tribes getting rid of these programs,” Locklear said. “But it will drastically shift how much tribes can really put back in their community.”
For example, Tuba City Regional Health Care Corp., in northern Arizona within the Navajo Nation, is unique in providing comprehensive cancer treatment on a reservation, Locklear said. The corporation, he said, estimates its costs to cover patients this year are increasing by roughly 170% to nearly $38,000 per month without the enhanced subsidies.
One of the newer programs is on the Blackfeet reservation in northwestern Montana, where basic health services can be hard to find. Medical visits are often offered on a first-come, first-served basis, and services vanish when staff positions go unfilled, said Lyle Rutherford, a Blackfeet Nation council member.
“Some of it is just getting a regular eye appointment, or a primary care appointment,” Rutherford said.
The tribe has been slowly building its health insurance program since launching it in 2024. Rutherford said the enhanced subsidies made that possible. Fewer than 400 people are enrolled out of an estimated 3,000 who qualify. The tribe halted new enrollments about two months ago because of the pending expiration of subsidies and shifted its healthier members to lower-cost plans.
“At this point in time, we just have to hold off,” Rutherford said. “Premiums have increased by 100-plus percent.”
He said tribal leaders are seeking extra funding to keep the program afloat, and he hopes Congress finds a solution.
Lives on the Line
The impact goes beyond tribes’ insurance programs. The Urban Institute, a Washington, D.C.-based economic and social policy research nonprofit, estimates that 125,000 Native Americans will become uninsured in 2026 due to the higher costs.
Patients at the Oyate Health Center in Rapid City, South Dakota, are already reporting sky-high premium increases for ACA plans. CEO Jerilyn Church said it’s too soon to know how many will forgo coverage. But she said more uninsured patients would further strain the IHS Purchased/Referred Care program — with officials raising the bar for how sick patients must be to cover care outside of tribal health sites.
“There will be people that will not be able to get the care they need,” Church said, adding that could translate to “people losing their lives.”
Bighorn, the game warden on the Fort Peck Reservation, is among those still covered by the tribes’ insurance program. He has put it to use.
Soon after enrolling, Bighorn needed two hip replacements, surgeries that require off-reservation care and are ranked as low-priority procedures by the Indian Health Service. Bighorn said that in pre-surgery tests, specialists found the cause for his long-standing, dangerously high blood pressure. The diagnosis: untreated lifelong asthma and sleep apnea.
“I was a miserable man, tired all the time,” he said.
Without the tribe’s coverage, Bighorn may have eventually gotten those diagnoses but said it would have likely taken years to get help through the Indian Health Service. That would have meant getting much sicker before receiving care.
KFF Health News correspondent Arielle Zionts contributed to this report.
©2026 KFF Health News. Distributed by Tribune Content Agency, LLC.