Dozens of tribal leaders and representatives testified last week before lawmakers, urging them to fully fund the long-neglected Indian Health Service.
The United States government has a treaty and trust responsibility to uphold tribal sovereignty and provide services to Native nations, such as healthcare, public safety, education, and more.
In a House Appropriations Interior, Environment, and Related Agencies Subcommittee hearing, tribal leaders emphasized that programs serving Indian Country have never been fully funded, effectively violating those treaty obligations. The outcomes are disastrous, with Native Americans facing some of the highest rates of heart disease, diabetes, cancer, mental illness, substance use disorders, and maternal and infant mortality.
The Indian Health Service is tasked with providing healthcare to more than 3 million Native people across 12 service areas. Its federal budget for FY 2026 is $8.05 billion, with $5.3 billion in advance appropriations for next year. The funds are tens of billions short of the $73 billion needed to fully fund the service, according to the Tribal Budget Formulation Workgroup. The agency’s vacancy rate has historically sat around 25%.
Tribal leaders spoke at last week’s hearing about skeleton staffs, shuttered departments, and deteriorating facilities.
Abigail Echo-Hawk, executive vice president of the Seattle Indian Health Board and director of the Urban Indian Health Institute, told lawmakers about an elder in hospice who was raped in a program she heads. The perpatrator was still in the building. Echo-Hawk was with the elder as they waited hours for the police to show up.
“We only had size 5x for a small, dainty little elder,” Echo-Hwk said. “I remember pulling the string of those 5x sweatpants to make sure when we brought them to her, we could slide them up her legs and tie them tightly around her waist so after a rape, she could wear clean clothes.”
Without the full funding of the Indian Health Service, you’re going to see providers like myself, other people, taking 5X sweatpants and attempting to pull the string so we can just fit them up the legs of a rape victim.”
Tohono O’odham Nation Chairman Berlin Jose said its hospital in Sells, Ariz., is one of the oldest IHS facilities in the country. A replacement facility has been on the IHS facilities priority list for over 30 years, yet it continues to receive only limited funding. Jose also testified that IHS’s Phoenix Indian Medical Center shuttered its labor and delivery services in 2020. The services have yet to resume.
“Congress must do better to fulfill the trust obligation to provide health care to Native Americans, Joe said.
Pueblo of Acoma Governor Charles Riley said his tribe was essentially forced to take over the operations of its IHS facility in October 2025. The building was in a state of deterioration and lacked hot water; the tribe spent its own funds to make the repairs.
“We are asking for some funding dedicated to the Acoma Health Center so that we can rebuild and move forward and improve our health care system for our people,” Riley said.
The IHS’s maintenance backlog is substantial and dates back more than 30 years.
National Indian Health Board CEO AC Locklear (Lumbee) put it into perspective for lawmakers.
“IHS estimates more than $26 billion is required to address facilities construction needs,” Locklear said. “At current funding levels, that will take over 200 years.”
Repairs are just the beginning; modernizing the IHS system will take billions. Locklear said the NIHB requests Congress to fully fund the implementation of a modern electronic health records system, estimated to cost $6.2 billion — just $2 billion short of the agency’s entire 2026 budget.
Federal spending on the IHS is around $4,000 per person — less than half the per-person Medicaid spending.
Tribal leaders spoke of their fear around the nearly $1 trillion in sweeping Medicaid cuts set to begin later this year.
IHS depends heavily on Medicaid, billing $1.3 billion to the joint federal-state program in 2025 alone.
“We’ve gotten very dependant on having tribal members be covered by Medicaid, and I don’t know how we should be thinking about that in this year’s appropriations cycle, but if there’s ways we could write some language in there to help protect that, whatever we can do to sort of prevent disaster when there’s suddenly a huge pool of unfunded people,” Rep. Chellie Pingree of Maine, ranking member of the subcommittee, said.
IHS funding is discretionary, meaning it is subject to policy changes and must be voted on each year. Indian Country has long called for the agency’s funding to be made mandatory.
2023 was the first year advance appropriations were rolled into the IHS budget, adding a layer of protection from lapses in appropriation.
Chairman of the House Committee on Appropriations Senator Tom Cole (R-Okla.), a member of the Chickasaw Nation, noted that the IHS is older than all federal programs that receive mandatory funding.
“It was one of the few areas the federal government actually had an obligation to provide health care because of treaty and trust responsibilities, before Medicaid, Medicare, and all those programs, so it never got pulled into the system,” Cole said.
