By james art 
A few years before the COVID-19 pandemic, Dale Rice lost his toe to an infection.
But because he was uninsured at the time, the surgery at a hospital in Reno, Nevada, led to years of anguish. He said he owes the hospital more than $20,000 for the procedure and is still getting 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 spent his life in Nevada. He said he fell into a gap in the tribal health care system because he lives 1,500 miles from the Prairie Band Potawatomi Nation’s home area in eastern Kansas, where he is an enrolled member.
He receives primary care at the Reno-Sparks Indian Colony Tribal Health Clinic in Nevada, but structural barriers at the federal Indian Health Service (IHS) have left him without coverage for specialty care outside the clinic. Rice may have been eligible for special services recommended by his Kansas tribe’s health system, but he lives too far from the tribe’s delivery area to use the tribal health program, which helps pay for services outside of IHS.
“I don’t have to move to Kansas City to be fully covered,” Rice said.
A new tribal sponsorship program introduced last year in Nevada aims to provide coverage to tribal citizens like Rice and protect them from taking on debt for uninsured care. It allows tribes to buy health insurance through the state’s Affordable Care Act (ACA) marketplace for people living in their service area, including Indians 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 of the tribal health care system.
Several dozen tribes have moved to create 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 with 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 poorer health outcomes, higher incidence of chronic disease, and shorter life expectancy. Many rely on the IHS, a department 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 health insurance for members of their community through bundled billing, a method of paying premiums for multiple individuals in one monthly payment to the insurer. Another part of the program involves a collaboration between Nevada Health Link, the state’s health insurance marketplace, and tribes to certify employees at tribal health clinics so they can enroll community members in health plans. Program officials also said they are committed to providing additional education to tribes about the accommodations available to them under the ACA.
Health agencies in Washington state and Nevada helped establish tribal sponsorship programs. Independently, tribes in Alaska, Wisconsin, Idaho, Michigan, Montana and South Dakota have also implemented individual programs.
That already has implications for Native American patients in Nevada, said Angie Wilson, tribal health director for the Reno-Sparks Indian Colony and a member of the Pitt River Tribe in California. Wilson said patients have come to her office in tears because they couldn’t afford services they needed outside of the tribal clinic and weren’t eligible to have those services 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 participating in Nevada’s Tribal Sponsorship and Bundled Billing Program. Russell Cook, executive director of Nevada Health Link, said he expects more tribes to get involved as the agency works to build community trust in tribes that are often wary of government and corporate organizations.
The Fort McDermitt Paiute and Shoshone Tribe, with a reservation that straddles Nevada’s northwestern border, was the first tribe to pilot the program. There are about 125 households in the reserve.
As of December, 30 tribal members were enrolled in 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 reported being American Indian and/or or Last year’s Alaska Native Status.
Through sponsorship, tribes can use their federal health care funding to pay the premium costs for each participating individual. This, combined with the cost-sharing protections in the ACA for American Indians and Alaska Natives enrolled in marketplace health plans, means that beneficiaries face very low to no costs for receiving care outside of tribal clinics. America’s Rescue Plan also expanded eligibility for premium tax credits, making purchasing a health plan more affordable.
Because sponsorship in some tribes is not limited to enrolled tribal citizens, it can help the entire community, said Jim Roberts, senior executive officer for intergovernmental affairs at the Alaska Native Tribal Health Consortium and a member of the Hopi Tribe of Arizona.
Since Alaska first allowed sponsorship in 2013, Roberts said, it has not only increased access to care for Native Americans, but also significantly reduced the cost of care, “which is just as important, if not more important for some tribes “.
In Washington state, where sponsorship in ACA plans began in 2014, 12 of 29 tribes participate.
Cook said the state exchange is interested 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 Indians in the state about the sponsorship programme. This will include translating resource guides and other agency materials into the indigenous 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 cooperation with tribes.
Nevada Health Link modeled its approach by looking at Washington state’s program, Cook said. Since launching its own program, the Nevada agency has reached out to officials in California exploring that option.
But leaders like Wilson are concerned that under a Donald Trump administration, enhanced tax credits for ACA enrollees put in place during the pandemic will be phased out. The credits expire at the end of this year unless Congress acts to extend them. Without the credits, nearly all people enrolled through the marketplace would see a sharp increase in their premium payments next year.
If tribal citizens or other community members become ineligible for premium tax credits, it could jeopardize the tribe’s financial ability to continue sponsoring health plans, Roberts said.
“Whichever side of the fence people fall on, it doesn’t take away from the fact that there is a federal responsibility of the United States of America to First Nations people,” Wilson said.
Wilson, who has been an advocate for sponsorships since the ACA was approved in 2010. and led efforts to establish the program in Nevada, said she is pleased with the tribal sponsorship program but wishes it had happened sooner.
“We’ve lost so much in Native American country over time,” she said. “How many more Indians could get access to care? How much more of a difference could that make in maintaining tribal health care?”
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