Tag Archive for: Medicaid

House Advances Reconciliation Bill with Exemptions for American Indian and Alaska Native People from Community Engagement Requirements

On May 22, 2025, the House of Representatives voted 215-214-1 to pass a major reconciliation bill that would deliver the major elements of President Trump’s legislative agenda, including tax cuts, Medicaid reforms, and lifting the debt ceiling. The bill contains a health title, which includes Medicaid reform provisions, such as cost-sharing and provider tax changes. Importantly, the bill exempts American Indian and Alaska Native beneficiaries from the Medicaid community engagement requirements.

NCUIH Action

The National Council of Urban Indian Health (NCUIH) has worked with Urban Indian Organization (UIO) leaders and national partners, including the National Indian Health Board (NIHB) and the Medicaid Medicare Policy Committee (MMPC), to ensure that American Indian and Alaska Native Medicaid beneficiaries are protected from harmful policy changes. NCUIH participated in over 60 meetings with congressional offices.

Next Steps

The reconciliation package now goes to the Senate for consideration.

Analysis

Community Engagement Requirements for Certain Medicaid Beneficiaries

What it Does: States would be required to implement community engagement requirements for able-bodied adults without dependents. Compliance may be achieved through:

  • Working, volunteering, or participating in a work program for at least 80 hours/month; or
  • Enrolling in educational programs totaling 80 hours/month.

Impact on Indian Country: The bill exempts American Indian and Alaska Native beneficiaries from these requirements. Specifically, it states that “specified excluded individuals” include:

  • Indians and Urban Indians as defined in the Indian Health Care Improvement Act (IHCIA);
  • California Indians as described in Section 809(a) of the IHCIA;
  • Individuals determined eligible as an Indian for the Indian Health Service under regulations promulgated by the Secretary.

The work requirements go into effect on December 31, 2026.

Modifying Cost Sharing Requirements for Certain Expansion Individuals Under the Medicaid Program

What it Does: Requires states to impose cost sharing on Medicaid Expansion adults with incomes over 100 percent of the federal poverty level (FPL). This cost-sharing is capped at:

  • $35 per service.
  • May not exceed five percent of the individual’s income.

Impact on Indian Country: American Indian and Alaska Native beneficiaries are already exempted from cost-sharing provisions for those who receive a “service directly by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization or through referral under contract health services for which payment may be made under this subchapter.” This exemption will remain in place.

Moratorium on New or Increased Provider Taxes

What it Does: Prohibits states from implementing new provider taxes or increasing existing ones beyond their levels on the date of enactment.

Potential Impact on Urban Indian Organizations: UIOs are exempt from provider taxes due to their tax status and will not be affected by this provision.

Reduction in Expansion FMAP for States Covering Undocumented Immigrants

What it Does: Reduces by 10% the Federal Medical Assistance Percentage (FMAP) for Medicaid Expansion States who use their Medicaid infrastructure to provide health care coverage for undocumented immigrants under Medicaid or another state-based program.

Impact on States with Urban Indian Organizations: Seven states currently provide such coverage: California, Washington, Oregon, Minnesota, Illinois, New York, and Colorado, all of which have UIOs. States will have to individually decide on how and if they will adapt their programs to adjust to the potential decrease in federal funding,

Resource

Coalition for Tribal Sovereignty Reconciliation Letter (February 20, 2025)

NCUIH Contact: Meredith Raimondi, Vice President of Policy and Communications, mraimondi@ncuih.org

NCUIH 2025 Policy Priorities Released

NCUIH 2025 Policy Priorities

The National Council of Urban Indian Health (NCUIH) is pleased to announce the release of its 2025 Policy Priorities document, which outlines a summary of urban Indian organization (UIO) priorities for the Executive and Legislative branches of the government for 2025. These priorities were informed by NCUIH’s 2024 Policy Assessment.

NCUIH hosted five focus groups to identify UIO policy priorities for 2025, as they relate to Indian Health Service (IHS)- designated facility types (full ambulatory, limited ambulatory, outreach and referral, and outpatient and residential). NCUIH worked with UIOs to identify policy priorities in 2025 under eight themes:

  • Funding for Native Health Initiatives
  • Elevating Native Voices and Fostering Dialogue
  • Strengthening Health Outcomes: Addressing Social Determinants of Health
  • Honoring Promises to Native Veterans
  • Revitalizing Native Health: Embracing Traditional Healing and Behavioral Wellness
  • “Not One More’: Healing Generational Trauma and Protecting Native Lives
  • Addressing Workforce Recruitment and Retention Challenges
  • Improving the Indian Health Service

2025 Policy Priorities:

FUNDING FOR NATIVE HEALTH INITIATIVES
Increasing Funding for Indian Health Service (IHS) and Urban Indian Health
  • Appropriate the Maximum Amount Possible for IHS and Fund Urban Indian Health at $100 million.
  • Support Participation and Continued Inclusion of Urban Indian Organizations in the IHS Budget Formulation Process.
Protecting Funding for Native Health from Political Disagreements
  • Maintain Advance Appropriations for IHS to Insulate the Indian Health System from Government Shutdowns
  • and to Protect Patient Lives.
  • Transition IHS from Discretionary to Mandatory Appropriations.
  • Transition Contract Support Costs and 105 (l) Leases to Mandatory Appropriations.
Meeting the Trust Obligation for IHS-Medicaid Beneficiaries Receiving at Urban Indian Organizations (UIOs)
  • Pass the Urban Indian Health Parity Act to Ensure Permanent Full (100%) Federal Medical Assistance
  • Percentage (FMAP) for Services Provided at UIOs (100% FMAP for UIOs).
  • Ensure that All American Indian and Alaska Native People are Exempt from Medicaid Work Requirements.
  • Allow for Audio-Only Telehealth Services for Medicare Beneficiaries at UIOs through the Telehealth for Tribal Communities Act.
Transforming Health Care Resources in Indian Country and Beyond
  • Decrease Competition and Reduce Barriers to Access to Ensure Equitable Distribution of Grant Funding.
ELEVATING NATIVE VOICES AND FOSTERING DIALOUGE
Inclusion of Urban Native Communities in Resource Allocation
  • Ensure Critical Resource and Funding Opportunities are Inclusive of Urban Native Communities and the Urban Indian Organizations that Help Serve Them.
STRENGTHENING HEALTH OUTCOMES: ADDRESSING SOCIAL DETERMINANTS OF HEALTH
Improving Native Maternal and Infant Health
  • Strengthen the Ability of the Advisory Committee on Infant and Maternal Mortality to Address Native Maternal and Infant Health.
  • Improve Funding Access for Urban Indian Organizations to expand Housing Services.
Improving Food Security for Urban American Indian and Alaska Native People
  • Increase Access to U.S. Department of Agriculture (USDA) Resources and Funding Opportunities for Urban American Indian and Alaska Native Communities and the Urban Indian Organizations that Serve Them.
  • Increase Urban Indian Organization Access to Fresh and Traditional Foods Through Increased Funding for the IHS Produce Prescription Pilot Program.
  • Permanently Reauthorize and Increase Funding for the Special Diabetes Program for Indians (SDPI) at a Minimum of $250 Million Annually
Including Urban American Indian and Alaska Native People in Preparing and Protecting Their Communities
  • Increase Emergency Preparedness through the Passage of the CDC Tribal Public Health Security and Preparedness Act.
HONORING THE PROMISES TO NATIVE VETERANS
Improving American Indian and Alaska Native Veteran Health Outcomes
  • Engage with Urban Indian Organizations to Successfully Implement the Interagency Initiative to Address Homelessness for Urban American Indians and Alaska Native Veterans.
REVITALIZING NATIVE HEALTH: EMBRACING TRADITIONAL HEALING AND BEHAVIORAL WELLNESS
Improving Behavioral Health for All American Indian and Alaska Native People
  • Increase Funding for Behavioral Health and Substance Use Disorder Resources for American Indian and Alaska Native People.
  • Respond to the Significant Increase in Overdose Deaths in Indian Country.
  • Pass the Comprehensive Addiction Resources Emergency (CARE) Act.
Improving Health Outcomes Through Traditional Healing and Culturally Based Practices
  • Improve Funding Access for Urban Indian Organizations to Expand Traditional Healing and Culturally Based Practices.
“NOT ONE MORE”: HEALING GENERATIONAL TRAUMA AND PROTECTING NATIVE LIVES
Healing from Federal Boarding Schools
  • Support Federal Initiatives to Allow the Indian Health Service to Support Healing from Boarding School Policies.
Ending the Epidemic of Missing or Murdered Indigenous Peoples (MMIP)
  • Pass the Bridging Agency Data Gaps and Ensuring Safety (BADGES) for Native Communities Act.
  • Honor Executive Order 14053: Improving Public Safety and Criminal Justice for Native Americans and
  • Addressing the Crisis of Missing or Murdered Indigenous People by Including Urban Indian Organizations in Prevention and Intervention Efforts.
ADDRESSING WORKFORCE RECRUITMENT AND RETENTION CHALLENGES
Improving the Indian Health Workforce
  • Include Urban Indian Organizations in the national Community Health Aide Program (CHAP).
  • Improve the Indian Health Workforce through the Placement of Residents at Urban Indian Organizations through the Department of Veterans Affairs Pilot Program on Graduate Medical Education and Residency Program (PPGMER).
  • Enable Urban Indian Organizations to Fill Critical Workforce Needs through University Partnerships by Passing the Medical Student Education Authorization Act.
  • Extend Federal Health Benefits to Urban Indian Organizations.
  • Improve Recruitment and Retention of Physicians at Urban Indian Organizations by Reintroducing the IHS Workforce Parity Act.
  • Increase Tax Fairness for Loan Repayment for Urban Indian Organization Staff by Reintroducing the Indian Health Service Health Professions Tax Fairness Act.
  • Permit U.S. Public Health Service Commissioned Officers to be Detailed to Urban Indian Organizations.
  • Improve Community Health Worker Coverage at Urban Indian Organizations through the Introduction of the Community Health Workers Access Act.
Accurately Account for Provider Shortages
  • Engage with the Health Resources and Services Administration (HRSA) so that Urban Indian Organizations receive Health Professional Shortage Area (HPSA) Scores that Accurately Reflect the Level of Provider Shortage for Urban Indian Organization Service Areas.
IMPROVING THE INDIAN HEALTH SERVICE
Bridging the Gap: Enhancing Patient Care by Advancing Health Information Technology
  • Improve Health Information Technology, Including Electronic Health Records Systems.
Elevate the Health Care Needs of American Indian and Alaska Native People Within the Federal Government
  • Pass the Stronger Engagement for Indian Health Needs Act to elevate the IHS Director to Assistant Secretary for Indian Health.

Tribal Leaders Highlight the Importance of Medicaid at Hearing

On April 4, 2025, the House Natural Resources Subcommittee on Indian and Insular Affairs held a hearing on “Examining 50 Years of the Indian Self-Determination and Education Assistance Act in Indian Country” in Oklahoma City, Oklahoma. The Subcommittee on Indian and Insular Affairs members asked Tribal leaders about the impacts of self-determination contracts. In the hearing, Tribal leaders expressed the successes of self-governance agreements in areas of agriculture, healthcare, and Department of Justice programs, as well as the need for additional funding and support for these contracts. In terms of healthcare, it was highlighted that Medicaid is an essential funding source that funds healthcare related self-governance agreements, and that any cuts to Medicaid would impact Tribes’ ability to manage their health systems.

During the hearing, Rep. Leger Fernandez (D-NM-3), Ranking Member of the Subcommittee on Indian and Insular Affairs, noted the connection between Medicaid and self-determination, “I am very concerned about the Medicaid cuts because we know that Indian self-determination does not exist in a vacuum, that when I was helping set up those clinics and when you were setting up your own clinics, you were relying on third party funding. Everybody’s shaking their head because it’s simply true, you’re relying on those Medicaid dollars to come in so that you could increase services because, sadly, we underfund IHS. We’ve had hearings on that and it breaks my heart every time we read the numbers of how every other agency for their healthcare gets paid so much more.

If you cut Medicaid funding, tribes might have to cut services, they might have to cut staff. And this is a — is a major problem. So a $880 billion cut to Medicaid doesn’t just hurt other communities, it hurts this amazing goal and promise of Indian self-determination.”

In response to questions regarding the implications of cuts to Medicaid, Martin Harvier, President of Salt River Pima-Maricopa Indian Community, shared, “We face a stark reality, residents in our community, on average, die more than 30 years younger than residents of Scottsdale, only a few miles away. It will be a challenge to meet our five-and-five goal. if there are significant cuts to Medicaid. IHS only funds about 65 percent of our operational budgets so we, like other tribes, rely on third party revenue to supplement our programing.

And the vast majority comes from Medicaid. Any cut to Medicaid would, significantly, reduce the budget of our health system. And without an equal increase in IHS funds, we would have limited capacity to expand programs and facilities that are needed. A cut to Medicaid would make it nearly impossible to keep up with the demand for service.”

Medicaid’s Importance for AI/AN Communities and UIOs

In 2023, approximately 2.7 million American Indian and Alaska Native (AI/AN) people were enrolled in Medicaid across the United States, according to American Community Service data. Medicaid is a major source of health care funding, particularly for Urban Indian Organizations (UIOs), which provide essential healthcare services to AI/AN people living in urban areas. The proposed Medicaid cuts would threaten the ability of UIOs to sustain necessary service offerings, potentially reducing access to essential health care services for urban AI/AN people.

Read NCUIH’s comprehensive overview highlighting the crucial role Medicaid plays in providing health care to AI/AN communities.

Budget Reconciliation and Medicaid

On April 5, 2025, the Senate passed their budget resolution. The resolution will allow Congressional Republicans craft their budget reconciliation aimed at extending the 2017 Trump tax cuts and instituting new spending cuts. The resolution also allows for $1.5 trillion in new tax cuts over a decade and $5 trillion increase to the federal borrowing limit to avoid hitting the debt ceiling. The House version passed on February 25, 2025, allows $4.5 trillion in tax breaks and $2 trillion in spending cuts, including $880 billion from the Energy and Commerce Committee which has jurisdiction over the Medicare and Medicaid programs. An analysis by the nonpartisan Congressional Budget Office (CBO) shows that budget goals outlined in the House plan cannot be reached without reducing spending on Medicaid

Resources