California’s Medicaid Cuts Could Threaten Tribal Health

Native exemptions remain, but California’s Medicaid changes could weaken hospitals, behavioral health services, and specialty care used by California Tribal citizens.

Native Medicaid Exemptions Do Not Stop Systemwide Harm

Exemptions do not stop administrative harm. Right now, CMS guidance excludes qualifying American Indians, Alaska Natives, Urban Indians, California Indians, and people eligible for IHS services from the new Medicaid community engagement rules. Separate Medicaid renewal guidance keeps these individuals on 12-month renewals instead of six-month schedules. Correct eligibility coding remains essential.

The July 29, 2026 Health Affairs analysis reports that 66 percent of Medi-Cal losses during the COVID-19 unwinding were procedural. California projects about 1.3 million H.R. 1-related disenrollments by 2029 to 2030. UC Berkeley estimates almost 3 million additional uninsured Californians by 2028. Tribal citizens may retain legal protection, but still face mistaken notices, delayed appeals, or family coverage losses.

California Tribal Health Relies on Outside Hospitals

However, any changes to California’s care structure affects service for our California Tribal citizens. The California Area Indian Health Service works with 104 of California’s 109 federally recognized Tribes. Its network includes 34 Tribal health programs, 102 ambulatory clinics, 62 dental clinics, and nine Urban Indian health programs. In fiscal year 2025, Tribal programs reported 201,818 registered users and 86,381 active users. California lacks a full-service IHS hospital network comparable to other regions. So, Tribal citizens depend heavily on public and private hospitals for emergency, inpatient, maternity, specialty, laboratory, pharmacy, and radiology care.

Reduced Medi-Cal hospital financing or county behavioral health capacity could lengthen referrals, increase travel, pressure Purchased/Referred Care funds, and worsen clinician shortages.

California Medicaid Cuts Will Reach Other States

Across state lines, the consequences will travel. CalAIM has reached nearly 453,000 Medi-Cal members through Enhanced Care Management and more than 528,000 through Community Supports since 2022. Its current federal waiver authority ends December 31, 2026.

Nationwide Medicaid community engagement rules begin January 1, 2027. California’s decisions may influence implementation in Arizona, New Mexico, Oregon, Washington, Nevada, and other states serving Tribal and Urban Indian populations. Hospital contraction and workforce movement can also cross state borders. Tribal Nations should press for permanent Native exemption coding, advance notice before termination, Tribal data agreements, protected Indian health reimbursement, and continued CalAIM behavioral health and Traditional Health Care Practices.

Ellsworth is a Native owned small business and ISBEE certified staffing partner built for this exact moment. The company places culturally competent clinicians and Native practitioners inside IHS and Tribal 638 facilities across Arizona and New Mexico, supporting native health with genuine culture awareness. Every placement strengthens the workforce Indian Country relies on daily. Contact Ellsworth today to keep your clinic staffed and your community cared for.

Read more about the potential effects of federal Medicaid cuts at HealthAffairs.org