By Jazmin Orozco Rodriguez for KFF Health News.
Broadcast version by Alex Gonzalez for Nevada News Service reporting for the KFF Health News-Public News Service Collaboration

A few years before the covid-19 pandemic, Dale Rice lost a toe to infection.

But because he was uninsured at the time, the surgery at a Reno, Nevada, hospital led to years of anguish. He said he owes the hospital more than $20,000 for the procedure and still gets calls from collection agencies.

“It can cause a lot of anxiety,” Rice said. “I can’t give you what I don’t have.”

Rice, 62, was born and has spent his life in Nevada. He said he fell through a gap in the tribal health care system because he lives 1,500 miles from the Prairie Band Potawatomi Nation home area in eastern Kansas, where he’s an enrolled member.

He receives primary care at the Reno-Sparks Indian Colony tribal health clinic in Nevada, but structural barriers in the federal Indian Health Service left him without coverage for specialty care outside of the clinic. Rice might have been eligible for specialty services referred by his tribe’s health system in Kansas, but he lives too far from the tribe’s delivery area to utilize the tribal health program that helps pay for services outside of the IHS.

“I shouldn’t need to move to Kansas City to be fully covered,” Rice said.

A new tribal sponsorship program rolled out last year in Nevada is aimed at getting tribal citizens like Rice covered and protecting them from incurring debt for uninsured care. It allows tribes to buy health insurance through the state’s Affordable Care Act marketplace for people living in their service area, including Native Americans from other tribes.

Tribal leaders and Nevada officials say the sponsorship model increases access to coverage and care for tribal citizens and their families by allowing them to seek medical care outside the tribal health care system.

A few dozen tribes have moved to set up the insurance programs since the ACA authorized them more than a decade ago.

“It’s not widespread,” said Yvonne Myers, an ACA and Medicaid consultant for Citizen Potawatomi Nation Health Services in Oklahoma.

Native American adults are enrolled in Medicaid at higher rates than their white counterparts and have long faced worse health outcomes, higher incidences of chronic disease, and shorter life expectancy. Many rely on the IHS, a division within the Department of Health and Human Services responsible for providing care to Native Americans, but the agency is chronically underfunded.

In Nevada, tribes can sponsor their community members’ health coverage through aggregated billing, a method for paying the premiums for multiple individuals in a single monthly payment to the insurer. Another part of the program includes collaboration between Nevada Health Link, the state health insurance marketplace, and tribes to certify staffers at tribal health clinics so they can enroll community members in health plans. Program officials also said they are committed to providing further education to tribes about the accommodations available to them under the ACA.

Health agencies in Washington state and Nevada have helped set up tribal sponsorship programs. Independently, tribes in Alaska, Wisconsin, Idaho, Michigan, Montana, and South Dakota have rolled out individual programs, as well.

It’s already making a difference for Native American patients in Nevada, said Angie Wilson, tribal health director for the Reno-Sparks Indian Colony and an enrolled member of the Pit River Tribe in California. Wilson said patients have shown up at her office in tears because they couldn’t afford services they needed outside of the tribal clinic and were not eligible for those services to be covered by the IHS Purchased/Referred Care program.

The Reno-Sparks Indian Colony, with more than 1,330 members in 2023, is one of two tribes that participate in Nevada’s tribal sponsorship program and aggregated billing. Russell Cook, executive director of Nevada Health Link, said he expects more tribes to come aboard as the agency works to build community trust in tribes often wary of government and corporate entities.

The Fort McDermitt Paiute and Shoshone Tribe, with a reservation that spans Nevada’s northwestern border, was the first tribe to pilot the program. There are about 125 households on the reservation.

As of December, 30 tribal members had been enrolled into qualified health plans through Nevada Health Link as part of the tribal sponsorship program, according to state officials, and more than 700 of those enrolled through the state marketplace self-reported American Indian and/or Alaska Native status for last year.

Through sponsorship, tribes may use their federal health care funding to pay the premium costs for each participating person. That, combined with cost-sharing protections in the ACA for American Indian and Alaska Natives enrolled in marketplace health plans, means beneficiaries face very low to no costs to receive care outside of tribal clinics. The American Rescue Plan also expanded eligibility for premium tax credits, making purchasing a health plan more affordable.

Because sponsorship in some tribes isn’t limited to enrolled tribal citizens, it can help the whole community, said Jim Roberts, senior executive liaison for intergovernmental affairs with the Alaska Native Tribal Health Consortium and an enrolled member of the Hopi Tribe in Arizona.

Since Alaska first allowed sponsorship in 2013, Roberts said, it has not only increased the access to care for Native Americans but also significantly lowered the costs of care, “which is equally as important, if not for some tribes more important.”

In Washington state, where sponsorship in ACA plans began in 2014, 12 of 29 tribes participate.

Cook said the state exchange is seeing interest in the part of the sponsorship program that trains staff at tribal clinics to become certified exchange representatives, a role similar to that of a navigator who helps inform people about health coverage options.

He said the agency is working on a marketing campaign to spread awareness among Native Americans in the state about the sponsorship program. It will include translating resource guides and other materials from the agency into Native languages spoken in the state, such as Northern and Southern Paiute, Washoe, and Western Shoshone.

Cook said he’s surprised more states haven’t taken the initiative to create sponsorship programs in collaboration with tribes.

Nevada Health Link patterned its approach by looking at Washington state’s program, Cook said. Since launching its own program, the Nevada agency has been approached by officials in California who are exploring the option.

But leaders like Wilson are concerned that under the Trump administration the enhanced tax credits for ACA marketplace enrollees implemented during the pandemic will end. The credits are set to expire at the end of this year if Congress doesn’t act to extend them. Without the credits, nearly all people enrolled through the marketplace will see steep increases in their premium payments next year.

If tribal citizens or other community members become ineligible for the premium tax credits, that could jeopardize the tribe’s financial ability to continue sponsoring health plans, Roberts said.

“Whatever side of the fence people fall on, it does not take away that there’s a federal trust responsibility by the United States of America to its First Nations people,” Wilson said.

Wilson, who has been an advocate for sponsorship since the ACA was approved in 2010 and led the effort to establish the program in Nevada, said she is happy with the tribal sponsorship program but wishes it would have happened sooner.

“We’ve lost so much in Indian Country over time,” she said. “How many more Indian people could have gotten access to care? How much more of a difference could that have made in sustaining health care for tribes?”


Jazmin Orozco Rodriguez wrote this story for KFF Health News.


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Voter turnout from tribal communities in Wisconsin has increased in recent years, with historic numbers for the state Supreme Court election this month.

The Menominee reservation turnout increased by more than 80% from the spring 2023 election and both the Red Cliff and Bad River Bands of Lake Superior Chippewa saw turnout jump more than 60%, according to Wisconsin Conservation Voices, which works with tribal communities through its Wisconsin Native Vote program.

Maria Haskins, native regional tribal organizer for the group, said listening sessions, roundtables and regional dinners have been crucial in building relationships and getting people to the polls.

"With people seeing their peers being more active in the polls and becoming more informed about a lot of these issues, is what is really motivating them to go out and cast their ballot," Haskins observed. "Because I think that people are realizing their vote is their voice."

Haskins noted communities shared concerns at the events about issues like the opioid epidemic, which is severely affecting tribal communities, while drawing the connections of voting to their goal of tribal sovereignty.

The Menominee community has seen some of the most dramatic jumps in voter turnout. In 2023, community voting increased by 75% and has seen a 220% increase since 2019. Haskins believes the influx reflects the increase tribes are also seeing in representation, with more Native Americans running for office.

"I think that it's a huge movement," Haskins emphasized. "It's just something saying, 'Our people deserve to have a voice in what is happening, and we deserve to have the ability to be involved.'"

At a time when the country is seeing the rapid-fire dismantling of DEI initiatives and priorities, Haskins thinks it has never been more important to stay connected and involved.

"I'm super thankful for every community that we work in and I just can't express the importance enough of being in community and leaning on community right now," Haskins added. "I think that it's really important for all of us to have those connections and continue moving forward."


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The Jackson-based group Native American Jump Start has been providing grants to Native students, interns and young workers for decades and this year, has added an ambassador program.

Nine ambassadors across the country will help spread the word on Native American Jump Start opportunities, up to 100 microgrants per year to help, among others, students at any level of higher education.

Wicahpi Chaddlesone-Yankton, grant and operations coordinator for the group, said they want to highlight more student voices and half of ambassadors in the first cohort are current students.

"We wanted to have our ambassadors work with their Native student centers or organizations on their campus and just help bring NAJS's voice into a bigger light," Chaddlesone-Yankton explained.

The group is funded by private donations and therefore will be directly affected by cuts from the Trump administration. Meanwhile, the Native American Rights fund in March sued the U.S. Interior Department and the Office of Indian Affairs over the federal administration's cuts to the Bureau of Indian Education.

O'Shay Birdinground comes from the Great Apsaalooke Nation and will graduate this spring from the University of Montana. He first used Jump Start funding to attend a conference. Now as an ambassador, Birdinground encouraged "future Indigenous leaders" to take advantage of educational opportunities.

"There are a lot of opportunities out there for education and leadership development," Birdinground emphasized. "I wouldn't hesitate to jump on any one of those opportunities that is provided to you."

The application period for Native American Jump Start's education grant funding for this fall opens April 1.

Support for this reporting was provided by Lumina Foundation.

Indigenous people have made great contributions to the state of Wisconsin yet the alarming rates of violence against them remains a public health crisis.

A new study showed intimate partner violence disproportionately impacts Indigenous women more than any other ethnic or racial group in the U.S. The murder rate for Native American women and girls is up to 10 times higher than the national average, according to the U.S. Department of Justice, yet they account for less than 1% of the population.

Desiree Tody, outreach program coordinator at the Center Against Sexual and Domestic Abuse and a member of the Red Cliff Band of Lake Superior Chippewa, said violence against Native women is underreported and unaddressed.

"There's jurisdictional issues that come into play as to how things are investigated, how things are tried, and there's always racism," Tody observed. "There's less attention paid to the individuals that some of these things happen to."

The Wisconsin Department of Justice created a task force to combat violence against Native women across the state after legislation which would have addressed the issues failed to pass. There are currently no upcoming task force meetings listed on the newly updated DOJ website.

Poor tracking and data collection are among the many issues contributing to the epidemic among Indigenous women. During a multistate march last month, Tody read a list of names of Indigenous people from Minnesota who had died from domestic violence. No such list currently exists for Wisconsin and Tody noted she is working to change it.

She emphasized the great need to address the systems in place, which continue to fail Native people.

"I have three daughters that I want them to grow up as strong Native women and I want them to grow up safely as strong Native women," Tody explained. "This is their futures on the line. This is their ability to walk down a street safely."

Research shows Indigenous women also face significant barriers when seeking help after experiencing domestic violence. A survivor of domestic violence herself, Tody works with the Center Against Sexual and Domestic Abuse to provide resources for those affected in Bayfield and Ashland counties. Gov. Tony Evers has proposed a $20 million funding increase for domestic abuse services in his current executive budget.


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