By Arielle Zionts and Katheryn Houghton for KFF Health News.
Broadcast version by Kathleen Shannon for Greater Dakota News Service reporting for the KFF Health News-Public News Service Collaboration

When the Indian Health Service can't provide medical care to Native Americans, the federal agency can refer them elsewhere. But each year, it rejects tens of thousands of requests to fund those appointments, forcing patients to go without treatment or pay daunting medical bills out of their own pockets.

In theory, Native Americans are entitled to free health care when the Indian Health Service foots the bill at its facilities or sites managed by tribes. In reality, the agency is chronically underfunded and understaffed, leading to limited medical services and leaving vast swaths of the country without easy access to care.

Its Purchased/Referred Care program aims to fill gaps by paying outside providers for services patients might be unable to get through an agency-funded clinic or hospital, such as cancer treatment or pregnancy care. But resource shortages, complex rules, and administrative fumbles severely impede access to the referral program, according to patients, elected officials, and people who work with the agency.

The Indian Health Service, part of the Department of Health and Human Services, serves about 2.6 million Native Americans and Alaska Natives.

Native Americans qualify for the referred-care program if they live on tribal land - only 13% do - or within their nation's "delivery area," which usually includes surrounding counties. Those who live in another tribe's delivery area are eligible in limited cases, while Native Americans who live beyond such borders are excluded.

Eligible patients aren't guaranteed funding or timely help, however. Some of the Indian Health Service's 170 service units exhaust their annual pool of money or reserve it for the most serious medical concerns.

Referred-care programs denied or deferred nearly $552 million in spending for about 120,000 requests from eligible patients in fiscal year 2022.

As a result, Native Americans might forgo care, increasing the risk of death or serious illness for people with preventable or treatable medical conditions.

The problem isn't new. Federal watchdog agencies have reported concerns with the program for decades.

Connie Brushbreaker, a member of the Rosebud Sioux Tribe, has been denied or waitlisted for funding at least 14 times since 2018. She said it doesn't make sense that the agency sometimes refuses to pay for treatment that will later be approved once a health problem becomes more serious and expensive.

"We try to do this preventative stuff before something gets to the point where you need surgery," said Brushbreaker, who lives on her tribe's reservation in South Dakota.

Many Native Americans say the U.S. government is violating its treaties with tribal nations, which often promised to provide for the health and welfare of tribes in return for their land.

"I keep having my elders here saying, 'There's treaty rights that say they're supposed to be able to provide these services to us,'" said Lyle Rutherford, a council member for the Blackfeet Nation in northwestern Montana who said he also worked at the Indian Health Service for 11 years.

Native Americans have high rates of diseases compared with the general population, and a median age of death that's 14 years younger than that of white people. Researchers who have studied the issue say many problems stem from colonization and government policies such as forcing Indigenous people into boarding schools and isolated reservations and making them give up healthy traditions, including bison hunting and religious ceremonies. They also cite an ongoing lack of health funding.

Congress budgeted nearly $7 billion for the Indian Health Service this year, of which roughly $1 billion is set aside for the referred-care program. A committee of tribal health and government leaders has long made funding recommendations that far exceed the agency's budget. Its latest report says the Indian Health Service needs $63 billion to cover patients' needs for fiscal year 2026, including $10 billion for referred care.

Brendan White, an agency spokesperson, said improving the referred-care program is a top goal of the Indian Health Service. He said about 83% of the health units it manages have been able to approve all eligible funding requests this year.

White said the agency recently improved how referred-care programs prioritize such requests and it is tackling staff shortages that can slow down the process. An estimated third of positions within the referred-care program were unfilled as of June, he said.

The Indian Health Service also recently expanded some delivery areas to include more people and is studying whether it can afford to create statewide eligibility in the Dakotas.

Jonni Kroll of the Little Shell Tribe of Chippewa Indians of Montana doesn't qualify for the referred-care program because she lives in Deer Park, Washington, nearly 400 miles from her tribe's headquarters.

She said tying eligibility to tribal lands echoes old government policies meant to keep Indigenous people in one place, even if it means less access to jobs, education, and health care.

Kroll, 58, said she sometimes worries about the medical costs of aging. Moving to qualify for the program is unrealistic.

"We have people that live all across the nation," she said. "What do we do? Sell our homes, leave our families and our jobs?"

People applying for funding face a system so complicated that the Indian Health Service created flowcharts outlining the process.

Misty and Adam Heiden, of Mandan, North Dakota, experienced that firsthand. Their nearest Indian Health Service hospital no longer offers birthing services. So, late last year, Misty Heiden asked the referred-care program to pay for the delivery of their baby at an outside facility.

Heiden, 40, is a member of the Sisseton-Wahpeton Oyate, a South Dakota-based tribe, but lives within the Standing Rock Sioux Tribe's delivery area. Native Americans who live in another tribe's area, as she does, are eligible if they have close ties. Even though she is married to a Standing Rock tribal member, Heiden was deemed ineligible by hospital staff.

Now, the family has had to cut into its grocery budget to help pay off more than $1,000 in medical debt.

"It was kind of a slap in the face," Adam Heiden said.

White, the Indian Health Service spokesperson, said many providers offer educational materials to help patients understand eligibility. But the Standing Rock rules, for example, aren't fully explained in its brochure.

When patients are eligible, their needs are ranked using a medical priority list.

Connie Brushbreaker's doctor at the Indian Health Service hospital in Rosebud, South Dakota, said she needed to see an orthopedic surgeon. But hospital staffers said the unit covers only patients at imminent risk of dying.

She said that, at one point, a worker at the referred-care program told her she could handle her pain, which was so intense she had to limit work duties and rely on her husband to put her hair in a ponytail.

"I feel like I am being tossed aside, like I do not matter," Brushbreaker wrote in an appeal letter. "I am begging you to reconsider."

The 55-year-old was eventually approved for funding and had surgery this July, two years after injuring her shoulder and four months after her referral.

Patients said they sometimes have trouble reaching referred-care departments due to staffing problems.

Patti Conica, a member of the Standing Rock Sioux Tribe, needed emergency care after developing a serious infection in June 2023. She said she applied for funding to cover the cost but has yet to receive a decision on her case despite repeated phone calls to referred-care staffers and in-person visits.

"I've been given the runaround," said Conica, 58, who lives in Fort Yates, North Dakota, her tribe's headquarters.

She now faces more than $1,500 in medical bills, some of which have been turned over to a collection agency.

Tyler Tordsen, a Republican state lawmaker and member of the Sisseton-Wahpeton Oyate in South Dakota, says the referred-care program needs more funding but officials could also do a "better job managing their finances."

Some service units have large amounts of leftover funding. But it's unclear how much of this money is unspent dollars versus earmarked for approved cases going through billing.

Meanwhile, more tribes are managing their health care facilities - an arrangement that still uses agency money - to try new ways to improve services.

Many also try to help patients receive outside care in other ways. That can include offering free transportation to appointments, arranging for specialists to visit reservations, or creating tribal health insurance programs.

For Brushbreaker, begging for funding "felt like I had to sell my soul to the IHS gods."

"I'm just tired of fighting the system," she said.


Arielle Zionts and Katheryn Houghton wrote this story for KFF Health News.


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By Robert Bordeaux for Arts Midwest.
Broadcast version by Mike Moen for Wisconsin News Connection reporting for the Arts Midwest-Public News Service Collaboration

Language is the center-point of any culture. For Indigenous people, keeping and carrying forward their language becomes a decolonial act — a reclamation of space. 

This has been Laura C. Red Eagle’s journey. A writer and language enthusiast, Red Eagle is a member of the Ho-Chunk Nation, whose traditional territories include land in Wisconsin, Minnesota, Iowa, and Illinois.

Red Eagle grew up in rural Wisconsin with her non-native mother, away from her Ho-chunk communities in the area. During this time, she had trouble navigating her identity, culture, and community. Her father’s family were fluent Ho-chunk speakers, but they spoke to her in English when they shared space. In high school, Red Eagle decided to start learning her traditional language. She joined a language camp offered by the Ho-chunk community in Black River Falls. This lit the fire to her language-learning journey.

Over the years, she noticed a deep yearning to create community around language learning. Post-secondary education didn’t offer what she was hoping for. Determined, she decided to gather her own resources. 

These resources were few and far between — common for many Indigenous languages. As oral languages, resources weren’t created until colonial contact. Made by non-speakers, non-native individuals and organizations, complications arose around the control of translations and learning methods, and access to these materials. 

A Space to Share

Red Eagle tracked down a tape that offered Ho-chunk for colors, numbers, and animals, but she craved to dive deeper.

Then, a timely interaction set the stage for her next chapter of language-learning. At her father’s funeral, she heard Jon Greendeer (current president of Ho-Chunk Nation) speak in Ho-Chunk. After a conversation, he offered resources and other community members to connect with around the language. The importance of community learning spaces kept surfacing for Red Eagle. 

“Learning the language in a judgment-free zone opens doors into learning about history, the ways of thinking, and being, and what is important, and so much more,” she says.

Her perseverance led to the Indigenous Language Table at the Wisconsin Institute for Discovery (WID) in Madison. It’s a space for active language practice beyond the classroom. The Indigenous Language Table is a communal gathering that meets once a week. It emphasizes the importance of using the language in everyday conversations.

To young Indigenous people and new language learners, Red Eagle says: find a class, build a community, and create spaces for language use. 

Red Eagle remains steadfast in creating a supportive community for language learners, even with the struggles of language revitalization work. “Language is ultimately about connecting as human beings and creating a sense of belonging,” she says. She envisions more Indigenous Language Tables across Wisconsin and beyond. Her story is a testament to the resilience and dedication required to revive and sustain Indigenous languages. Her efforts with the Indigenous Language Table offer a blueprint for creating vibrant language communities.


Robert Bordeaux wrote this story for Arts Midwest.


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Montana's largest Indigenous rights group is hosting a series of events around the state to empower Native voters as the election draws closer. The next event begins today in Fort Belknap.

The events in the Snag Dat Vote Tour are about more than just registering and encouraging all Indigenous people to vote.

Western Native Voice Communications Director Tracie Garfield said there's a special focus on educating young people.

"They're brand new voters, so this might be the first time they're voting," said Garfield. "But I believe that if we can get them to vote in this election, the likelihood of them voting in more elections is pretty high."

In addition to the Fort Belknap event that starts today, she said Western Native Voice is holding outreach events in Crow Agency, Lame Deer, Polson, and Poplar through early October.

Garfield said educating Indigenous people about the importance of their voices in elections is a critical part of the democratic process, especially in Indian country.

"Not just this election, but in the city, state, local county elections," said Garfield. "We want to make sure voting becomes a family tradition - because Native people haven't been voting that long, and making it a family tradition is something that we would really like to see."

Western Native Voice also launched an online voter guide, called Ballot Builder, to help educate voters about the candidates and issues before they head to the polls.

By Taylar Dawn Stagner for Grist.
Broadcast version by Mark Richardson for Louisiana News Connection, reporting for the Solutions Journalism Network-Public News Service Collaboration

Allie "Nokko" Johnson is a member of the Coushatta Tribe of Louisiana, and they love teaching young tribal members about recycling. Johnson helps them make Christmas ornaments out of things that were going to be thrown away, or melts down small crayons to make bigger ones.

"In its own way, recycling is a form of decolonization for tribal members," Johnson said. "We have to decolonize our present to make a better future for tomorrow."

The Coushatta Reservation, in southern Louisiana, is small, consisting of about 300 tribal members on or nearby the reservation, and rural - the nearest Walmart is 40 minutes away. Recycling hasn't been popular in the area, but as the risks from climate change have grown, so has the tribe's interest. In 2014, the tribe took action and started gathering materials from tribal offices and departments, created recycling competitions for the community, and started teaching kids about recycling.

Recently, federal grant money has been made available to tribes to help start and grow recycling programs. Last fall, the Coushatta received $565,000 from the Environmental Protection Agency for its small operation. The funds will be used to repair repair a storage shed, build a facility for the community to use, and continue educational outreach. But it may not be enough to serve the area's 3,000 residents of Native and non-Native recyclers for the long haul.

Typically, small tribes don't have the resources to run recycling programs because the operations have to be financially successful. Federal funding can offset heavy equipment costs and some labor, but educating people on how to recycle, coupled with long distances from processing facilities, make operation difficult.

But that hasn't deterred the Coushatta Tribe.

In 2021, the European Union banned single-use plastics like straws, bottles, cutlery, and shopping bags. Germany recycles 69 percent of its municipal waste thanks to laws that enforce recycling habits. South Korea enforces strict fees for violations of the nation's recycling protocols and even offers rewards to report violators, resulting in a 60 percent recycling and composting rate.

But those figures don't truly illuminate the scale of the world's recycling product. Around 8.3 billion metric tons of plastic have been manufactured since the 1950's and researchers estimate that 91 percent of it isn't recycled. In the United States, the Department of Energy finds that only 5 percent is recycled, while aluminum, used in packaging has a recycling rate of about 35 percent. The recycling rate for paper products, including books, mail, containers, and packaging, is about 68 percent.

There are no nationwide recycling laws in the U.S., leaving the task up to states, and only a handful of states take it seriously: Ten have "bottle bills," which allow individuals to redeem empty containers for cash, while Maine, California, Colorado, and Oregon have passed laws that hold corporations and manufacturers accountable for wasteful packaging by requiring them to help pay for recycling efforts. In the 1960s, the U.S. recycling rate across all materials - including plastic, paper, and glass - was only 7 percent. Now, it's 32 percent. The EPA aims to increase that number to 50 percent nationwide by 2030, but other than one law targeted at rural recycling moving through Congress, there are no overarching national recycling requirements to help make that happen.

In 2021, Louisiana had a recycling rate of 2.9 percent, save for cities like New Orleans, where containers are available for free for residents to use to recycle everything from glass bottles to electronics to Mardi Gras beads. In rural areas, access to recycling facilities is scarce if it exists at all, leaving it up to local communities or tribal governments to provide it. There is little data on how many tribes operate recycling programs, and the EPA tracks neither the number of tribal recycling programs nationwide, nor tribal recycling rates.

"Tribal members see the state of the world presently, and they want to make a change," said Skyler Bourque, who works on the tribe's recycling program. "Ultimately, as a tribe, it's up to us to give them the tools to do that."

But the number one issue facing small programs is still funding. Cody Marshall, chief system optimization officer for The Recycling Partnership, a nonprofit, said that many rural communities and tribal nations across the country would be happy to recycle more if they had the funds to do so, but running a recycling program is more expensive than using the landfill that might be next door.

"Many landfills are in rural areas and many of the processing sites that manage recyclables are in urban areas, and the driving costs alone can sometimes be what makes a recycling program unfeasible," he said.

The Recycling Partnership also provides grants for tribes and other communities to help with the cost of recycling. The EPA received 91 applications and selected 59 tribal recycling programs at various stages of development for this year, including one run by the Muscogee (Creek) Nation in Oklahoma, which began its recycling program in 2010. Today, it collects nearly 50 metric tons of material a year - material that would have otherwise ended up in a landfill.

"Once you start small, you can get people on board with you," said James Williams, director of the Muscogee (Creek) Nation's Environmental Services. He is optimistic about the future of recycling in tribal communities. "Now I see blue bins all through the nation," he said, referring to the recycling containers used by tribal citizens.

Williams' department has cleaned up a dozen open dumps in the last two years, as well as two lagoons - an issue on tribal lands in Oklahoma and beyond. Illegal dumping can be a symptom of lack of resources due to waste management being historically underfunded. Those dumping on tribal land have also faced inadequate consequences.

"We still have the issue of illegal dumping on rural roads," he said, adding that his goal is to clean up as many as possible. "If you dump something, it's going to hit a waterway."

According to Williams, tribes in Oklahoma with recycling programs work together to address problems like long-distance transportation of materials and how to serve tribal communities in rural areas, as well as funding issues specific to tribes, like putting together grant applications and getting tribal governments to make recycling a priority. The Choctaw Nation in Oklahoma also partners with Durant, a nearby town. Durant couldn't afford a recycling program of their own, so they directed recycling needs to the tribe.

This year's EPA grant to the Muscogee program purchases a $225,000 semitruck, an $80,000 truck for cardboard boxes, and a $200,000 truck that shreds documents. Muscogee was also able to purchase a $70,000 horizontal compactor, which helps with squishing down materials to help store them, and two $5,000 trailers for hauling. Williams' recycling program operates in conjunction with the Muscogee solid waste program, so they share some of their resources.

Returns on recycled material aren't high. In California, for instance, one ton of plastic can fetch $167, while aluminum can go for $1,230. Corrugated cardboard can also vary wildly from $20 to $210 a ton. Prices for all recycled materials fluctuate regularly, and unless you're dealing in huge amounts, the business can be hard. Those who can't sell their material might have to sit on it until they can find a buyer, or throw it away.

Last year, Muscogee Creek made about $100,000 reselling the materials it collected, but the program cost $250,000 to run. The difference is made up by profits from the Muscogee Creek Nation's casino, which helps keep the recycling program free for the 101,252 tribal members who live on the reservation. The profits also help non-Natives who want to recycle.

The Coushatta Tribe serves 3,000 people, Native and non-Native, and they have been rejected by 12 different recycling brokers - individuals that act as intermediaries between operations and buyers - due to the distance materials would have to travel.

Skyler Bourque said she couldn't find a broker that was close enough, or that was willing to travel to the Coushatta Tribe to pick up their recycling. "We either bite the cost," she said, "or commute and have to pay extra in gas. It's exhausting."

Currently, the only place near them that's buying recyclables is St. Landry Parish Recycling Center, which only pays $0.01 per pound of cardboard. A truck bed full of aluminum cans only yields $20 from the nearest center, 90 minutes away. That's how much the tribe expects to make for now.

Still, the Coushatta Tribe of Louisiana is not giving up.

With this new injection of federal money, they will eventually be able to store more materials, and hopefully, make money back on their communities' recyclables. Much like the Muscogee Creek Nation, they see the recycling program as an amenity, but they still have hopes to turn it into a thriving business.

In the meantime, the Coushatta keep up their educational programming, teaching children the value of taking care of the Earth, even when it's hard.

"It's about maintaining the land," Johnson said.


Taylar Dawn Stagner wrote this article for Grist.


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