While Congress considers potentially massive cuts to federal Medicaid funding, tribal health leaders are bracing for a crisis.

Indian Country has a unique relationship to Medicaid, because the program helps tribes cover chronic funding shortfalls left by the Indian Health Service, the federal agency responsible for providing health care to Native Americans.

With the related Children’s Health Insurance Program, Medicaid provides coverage to more than a million Native Americans. The joint state-federal program also accounts for about two-thirds of non-IHS revenue for tribal health providers. That income helps create financial stability and covers some operational costs for tribal hospitals and clinics. Tribal leaders want an exemption from any cuts and are preparing for a fight to preserve their access.

“Medicaid is one of the ways in which the federal government meets its trust and treaty obligations to provide health care to us,” said Liz Malerba, director of policy and legislative affairs for the United South and Eastern Tribes Sovereignty Protection Fund, a nonprofit advocacy organization for 33 tribes spanning from Texas to Maine. Malerba is a citizen of the Mohegan Tribe.

“So we view any disruption or cut to Medicaid as an abrogation of that responsibility,” she said.

Last month, the House approved a budget resolution that requires lawmakers to cut spending to offset tax breaks. The House Committee on Energy and Commerce, which oversees spending on Medicaid, is instructed to slash $880 billion over the next decade.

The IHS projects that it will bill Medicaid about $1.3 billion this fiscal year, which represents less than half of 1% of overall federal spending on Medicaid.

If Congress makes big cuts to the program, tribal health facilities will likely need to scale back services for a population that experiences severe health disparities, a high incidence of chronic illness, and a shorter life expectancy.

“When you’re talking about somewhere between 30% to 60% of a facility’s budget is made up by Medicaid dollars, that’s a very difficult hole to try and backfill,” said Winn Davis, congressional relations director for the National Indian Health Board.

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