ASSOCIATED PRESS The longer the government shutdown continues, the more difficult it will be for small tribes in rural areas to get essential services like health care.

WASHINGTON ― Dr. Anpetu Luta Hoksila is a Native psychologist for the Indian Health Service. He pulls 10-hour shifts, four days a week, at an IHS medical facility in Arizona. And starting Friday, because of the partial government shutdown, he will stop getting a paycheck.

Anpetu Luta Hoksila, 35, doesn’t know how he’s going to pay his bills. He plans to lean on his credit card, but that won’t last long. He called his Toyota dealership to say he couldn’t make his car payment, and it agreed to let him tack the payment onto the end of his loan term. Worst case scenario, if the shutdown drags on beyond next week, he said he’s prepared to quit his job and work as a barista at a local coffee shop.

“On some level, it’s kind of pitiful. But I don’t care,” said Anpetu Luta Hoksila, who requested he be referred to by his given Indian name so he wouldn’t get in trouble at work. “Generally people know, if you’re up to date on current events, that this is fucked up, right?”

IHS health care providers all over the country are bracing for their first missed paychecks on Friday ― and the reality that they have to keep working anyway. That’s because employees like Anpetu Luta Hoksila are considered “excepted,” meaning they won’t get paid during the shutdown, but they are also considered “essential” because the care they provide is vital to IHS services. The agency provides health care to nearly 2 million American Indians and Alaska Natives through 45 hospitals and nearly 300 clinics in 35 states.

HuffPost tried to get an exact number for how many IHS health care providers will stop getting paid this week but are still expected to work. An IHS spokesman, who was working despite being furloughed, said he is trying to track down that information.

It’s too early to know how severely the IHS funding freeze will hurt health care services to tribes. But it’s already taking a toll. One urban IHS health care provider said morale has plummeted at her clinic in Michigan, where employees live paycheck to paycheck and are scared. A tribe of Chippewa Indians in Michigan’s Upper Peninsula is mulling its own furloughs and pared-back health services. A nonprofit based in Boston and Baltimore that contracts with IHS expects to run out of money this week, and is looking at layoffs and suspended medical and mental health services.

That IHS has even stopped sending money to tribes raises serious questions about the U.S. government not meeting its treaty obligations. The federal government is obligated to provide health care services to tribes because of treaties negotiated generations ago in exchange for huge swaths of land. IHS is funded by the Interior appropriations bill, though it is administered by the Department of Health and Human Services. As long as IHS funding is cut off, the government appears to be in violation of tribes’ treaty rights.

“In a roundabout way, they can say they are providing care. But the people that provide the health care are not getting paid to do so,” said one nurse practitioner who works at an IHS medical facility in Albuquerque, New Mexico, who requested anonymity in order to speak freely.

“We have psychologists, psychiatrists, a plethora of people who provide care,” she continued. “They can only maintain working without pay for a certain period. People will start dropping out. They’re going to have to find another job because they can’t pay rent. I have enough for two months. That’s it.”

ASSOCIATED PRESS Dr. LeeAnna Muzquiz of Ronan Tribal Health examines Mary Parker during a checkup in Ronan, Montana.

Several of the health care providers who talked to HuffPost said the shutdown marks another chapter in the government’s abysmal treatment of tribes. Native Americans suffer from many illnesses and diseases at rates several times higher than the overall U.S. population. IHS also has a long history of being underfunded. And the same federal policies that led to the creation of IHS ― disenfranchising marginalized and indigenous people ― are driving President Donald Trump’s insistence on building a wall along the border.

“They’re depressing our ability to provide health care to indigenous people while also trying to keep indigenous people out,” said Anpetu Luta Hoksila, who is an enrolled member of the Turtle Mountain Band of Chippewa Indians. “So it’s like, I’m a brown person trying to serve brown people while we’re also trying to cause harm to other brown people. On a number of levels, it’s really fucked up. That’s the only way I can put it.”

Dr. James McAuley, the clinical director of Whiteriver Indian Hospital in Arizona, said he expects his staff of about 40 nurses and physicians to work without pay for as long as they can because people in health care “are generally altruistic.” But he is bracing for low morale and stories of financial hardship. His hospital is on the Fort Apache Indian Reservation and serves about 17,000 Native Americans.

“Generally, the public probably perceives physicians won’t suffer. But we have young people just out of residency, with big student loans ― they’ll have to make deferrals on those,” said McAuley. “More worrisome is what happens with support staff, who are making far less and supporting family members.”

“I think our local churches are anticipating a need to step in,” he added.

Small tribes in rural areas will be hit the hardest by the IHS funding freeze. Some rely entirely on federal funding for all of their services, and others don’t have a single clinic on their reservation. That requires people to commute, sometimes an hour or more, to a remote IHS facility that will now be struggling to operate because of the government shutdown.

I’m a brown person trying to serve brown people while we’re also trying to cause harm to other brown people. On a number of levels, it’s really fucked up. Dr. Anpetu Luta Hoksila

Monica Brady, the finance director for the Yomba Shoshone Tribe in northern Nevada, said that’s the situation with this tribe. It doesn’t have a clinic or generate its own income. Members of the community rely heavily on public transportation to get to their medical appointments.

“That’s my biggest concern: We need these programs back up and running to transport our elders to and from their appointments,” said Brady, who expressed frustration that there hasn’t been more news coverage of the shutdown’s effects on rural tribes. “Do people realize that not every reservation in the nation has a casino?”

Brady, whose husband is a member of the tribe, was the only person in the tribe’s administrative office when HuffPost called. It usually has 22 people in it. But she and all of her colleagues have been furloughed, and many are applying for unemployment.

“We’re just muddling along until we know what we can do,” she said. “I’m trying to make sure I’m here a few days a week, just to make sure someone is answering any calls.”

Paulette Jordan, a former Democratic candidate for governor and two-term state legislator, is a member of the Coeur d’Alene tribe in rural Idaho. She said her tribe’s health care services are fine for now because it relies less on federal money than some other tribes. But she’s worried about what a prolonged shutdown could mean.

“We live in health care deserts,” she said. “If our health clinics close up shop on reservations in rural communities, it poses a major threat to Native people who have been subject to governmental genocide for generations and are now left with increased demands for urgent and chronic care.”

Chuck Hoskin's Facebook page Cherokee Nation Secretary of State Chuck Hoskin said his tribe can weather the effects of the U.S. government shutdown for now. But not for too long.

Bigger tribes that generate significant money from casinos, like the Cherokee Nation, can pull from their general fund and get by for a longer period. The Cherokee Nation manages its own major hospital and eight health centers, and blends its own money with IHS money.

“For now, we’re able to protect the Cherokee people,” said Secretary of State Chuck Hoskin. “Not all tribes in the country are so blessed. We need to remember that. But even as strong as Cherokee Nation is, we’re not invulnerable to the effects of a long-term shutdown.”

Hoskin lamented that Congress has failed to carry out the most basic responsibilities of government, like balancing a budget and funding the government. It’s bad for the country, No. 1, he said, and it’s bad for tribes.

Despite Hoskin’s reassurances, some of his tribe’s members are scared about what the shutdown could mean for ailing family members. Amanda Clinton, his spokeswoman, tweeted that she’s afraid the freeze in IHS funding could affect care for her father, who began undergoing chemo to treat cancer.

My dad recently began chemo for lymphoma. We just found out he may also have congestive heart failure. Because @IHSgov is stupidly under @Interior & they’re #shutdown, can we stop talking about trash at parks & start talking about how ppl like my dad could die if this continues? — Amanda ♨️ (@Amanda_Clinton) January 5, 2019

For the moment, there are no signs of a deal for fully reopening the federal government. Trump and Democratic leaders continue to clash on the president’s demand for $5.7 billion to build his wall along the Mexican border.

In the meantime, for tribal health care providers trying to hang on without pay, it makes an already infuriating situation even worse when the president claims that affected workers support keeping the government closed until he gets his wall money.

“When I hear Trump say something like, ‘100 percent of federal workers not receiving a paycheck agree with my stance that we should have a resolution for wall funding,’ it really bothers me,” said Anpetu Luta Hoksila. “Because here we are, unfunded without a resolution for our budget appropriations for this year, and it kills me to hear that.”

“I don’t want your fucking wall and I want to get paid for my work,” he added.

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