Indigenous Affairs Trump takes a hard line on tribal health care Yes, tribal nations are sovereign, but the U.S. still has obligations for their wellbeing.

Indian Country News is a weekly note from High Country News, as we continue to broaden our coverage of tribal affairs across the West.

This week, the Trump administration made the remarkable step of asserting that tribal citizens should be required to have a job before receiving tribal health care assistance. Several states are seeking to force the requirement on tribal health care systems that have always operated within their sovereign nations. The Trump administration contends that tribal members should be considered a race, not a political class, as courts have always viewed them, and should not be exempted from state regulations, Politico reported on Sunday.

The administration has repeatedly denied requests from tribes — sovereign nations that oversee their own health care systems — that they be exempt from the Medicaid work requirement, which would force potential recipients of government health coverage to work or look for work. (For similar reasons of sovereignty, Native Americans are exempt from paying penalties for not having health coverage.)

Kentucky, Indiana and Arkansas have been given federal permission to implement work requirement rules for Medicaid. Ten other states have made similar requests. More than 600,000 Native Americans live in those 13 states.

Indigenous communities already face higher than average rates of unemployment and poor health, as well as a severe lack of job opportunities, and adding a work requirement for medical treatment on tribal lands could potentially exacerbate those pressing issues. Nevertheless, Trump’s Health and Human Services administrator, Seema Verma, suggested in an April 4 tweet that making patients work can be one way doctors can help them: “Doctors know that helping individuals rise out of poverty can be the best medicine!”

Olivia Vanni/Native News Project/University of Montana

The Trump administration’s racial approach to tribes is “a remarkable departure from U.S. history, U.S. policy, and U.S. law,” Taiawagi Helton, a professor at the Oklahoma College of Law, told me this week. According to the Supreme Court, tribal citizenship is not a racial classification, it is a political one. When it comes to tribal members, the U.S. government is dealing with the citizens of another nation.

All three branches of the government have affirmed the sovereignty of tribes since the founding of the country. In 1886, the Supreme Court affirmed the right of Congress to decide how to deal with tribal nations, giving the federal government enormous power over the hundreds of nation states within its borders. At the same time, the U.S. government has long recognized that generations of conquest have left those nations dependent on the federal government, and the U.S. has made explicit legal promises to provide assistance.

“Providing care through the Indian Health Service has been a part of the responsibilities that the United States voluntarily undertook,” Helton told me. “So it would be extraordinary to claim that this is a racial classification, when it isn't, and (deny) the commitment that we undertook, sometimes explicitly in a treaty and sometimes based on the guardian and ward relationship between the U.S. government and tribal governments.”

In an interview with Politico, Mary Smith, a member of the Cherokee Nation who was acting head of the Indian Health Service under the Obama administration, underlined the federal government’s responsibility to uphold commitments made to the tribes it had once sought to destroy. Medicaid, she said, is “the largest prepaid health system in the world — they’ve paid through land and massacres — and now you’re going to take away health care and add a work requirement?”

It’s complicated, but broadly speaking, tribes are individual nations that have entered into treaties with the United States, under which the U.S. government promised to provide assistance to them. “To reject both of those things is contrary to both law and the moral standing of the United States,” Helton said.

Even with Medicaid, citizens of sovereign tribal nations still face more challenges accessing health care than the average American. Reducing or eliminating any of those funds could leave thousands of Native Americans with even less health care options.

“Officially Medicaid represents 13 percent of the Indian Health Service’s $6.1 billion budget (just under $800 million),” writes Mark Trahant, editor-in-chief of Indian Country Today. And many of those states depend heavily on federal funding to provide health care to underserved areas. Trahant points out that in Alaska, for example, “40 percent of its $1.8 billion Medicaid budget is spent on Alaska Native patients.”

Creating stricter rules for access, such as adding work requirements, will mean “fewer people will sign up for Medicaid, and the Indian Health Service — already significantly underfunded — will have to pick up the extra costs from existing appropriations,” Trahant writes. “That will result in less money, and fewer healthcare services, across the board.”

The assertion that tribal nations are a racial distinction and not a political classification also highlights the Trump administration’s troubling lack of understanding about tribal sovereignty. It is unsurprising that the current administration would hold such a misguided view on Native identity. In 1993, Donald Trump testified before a House subcommittee and noted that certain tribal casino operators “Don’t look like Indians to me,” indicating he views tribal membership on outward appearances, such as skin color or dress.

The president, in other words, seems to have no interest in understanding Indian Country. That is unfortunate for the millions of Native Americans who belong to arguably the country’s most invisible minority. Given that tribal nations once flourished across this continent, only to be decimated by colonization, upholding the treaties to care for the survivors and their descendants through a functioning health care system is the very least the U.S. could do.

Wado.

Note: A previous version of this story incorrectly referred to survivors of colonization and their ancestors, instead of their descendants.

Graham Lee Brewer is a contributing editor at High Country News and a member of the Cherokee Nation. Follow @grahambrewer

Get our Indigenous Affairs newsletter ↓