Paul Hamby, Billings Gazette, Jul. 14 2025
The hospital in Crow Agency isn’t hurting for patients.
The campus of the Indian Health Service hospital, located among the collection of buildings housing the government offices for the Crow Tribe, has a parking lot that’s consistently full. As a full-service hospital, it offers some of the most comprehensive health care that members of the Crow and Northern Cheyenne can receive outside of Billings.
Despite the boon the hospital and its staff have been to the wellbeing of its Native American patients — who are among the most vulnerable in the country to chronic diseases — IHS has received a fraction of the funding required to meet the needs of its patients.
“Growing up, the IHS was all I’d ever known,” said Levi Black Eagle, secretary for the Crow Tribe’s executive branch. Black Eagle joined two other representatives in surveying Montana tribal members, with their efforts contributing to the latest budget recommendation for IHS from the perspective of Indigenous people.
“It was never really taught to me that IHS was a trust responsibility negotiated in treaties with the United States government. It wasn’t something where the government said, ‘We’re going to do all these Indigenous folks a solid and just provide free health care.’ It was something that was negotiated through our ancestors.”
Indian tribes in the United States have a unique status in that they’re one of just three sovereign entities recognized by law, the other two being the federal government and the states.
In the 1970s, watershed legislation bolstered the federal government’s obligation to improve those tribes’ access to health care. On the tribes’ end, they had the obligation to advocate for those health care policies and programs that best suited their needs. The Indian Health Service is the federal organization tasked with meeting those needs. Roughly two-thirds of Native Americans in the U.S. receive treatment through IHS, a population of about 2.8 million people.
Prior to the establishment of IHS in 1955, Indigenous health care was in the hands of the Bureau of Indian Affairs, then known as the Office of Indian Affairs. Until those major reforms in the fallout of the American Indian Movement during the latter half of the 1900s, federal policies and attitudes toward Native Americans were centered on assimilation. In the words of one U.S. Army officer in the late 1800s, that policy rested on killing the Indian, but saving the man.
Indigenous health care through 1950 dovetailed with this policy of assimilation. As infectious diseases like smallpox and tuberculosis were razing tribes, according to the National Library of Medicine, solutions imposed by the government typically involved removing those infected off reservations for treatment instead of sending physicians to them or constructing hospitals within Indigenous communities. With the passage of the Indian Self-Determination and Education Assistance Act and the Indian Health Care Improvement Act in the 1970s,
The effectiveness of the outcomes for IHS patients varies from tribe to tribe, but underfunding and understaffing has dogged the organization since its creation. With this dearth in quality health care, Native Americans have consistently been some of the most vulnerable people in the country to preventable illnesses, with some of the highest rates of diabetes and heart disease. Indigenous people also have a substantially higher rate of suicide when compared to white people in the United States.
Earlier this year, the National Indian Health Board published its recommendation for federal funding of IHS. To piece together its recommendation, the report’s authors leaned on representatives from 12 designated areas across the United States who surveyed Indigenous people on their health needs. The results of those surveys were weighted to result in regional and national priorities.
To facilitate nationwide priorities of expanding IHS’s campuses, adding staff for clinical programs and supplementing treatment on reservations with referred care vouchers, the report came with a recommendation of $73 billion for IHS in the fiscal year of 2027.
In May, the White House published the President’s Discretionary Budget for the fiscal year of 2026. While affording a small boost in funds to IHS, President Donald Trump’s proposal cut spending for the Bureau of Indian Affairs and other agencies under the Department of the Interior. Those agencies have a direct coordination with Indigenous communities, and culling support for them would result in millions of dollars lost for tribal programs, according to reporting from Tribal Business News. Even with that boost, the White House slated $8.1 billion for IHS in 2026. While still more annual funding when compared to the $6.6 billion the agency received in 2022, the president's budget is still only about 11% of what Indigenous health experts have requested.
“We do what we can with what we have,” Black Eagle said.
Some major successes in recent years for
Tribal health on the reservation, Black Eagle said, have been access to dental care, transportation to and from Billings and hiring locals to staff some positions at the hospital. Black Eagle said the tribe had also tried hard to lobby for the preservation of Medicaid access. On the Crow Reservation, tribal members enrolled in Medicaid can take advantage of more preventative care, such as cancer screenings and tests for diabetes, while the IHS receives revenue from those Medicaid patients.
Earlier this month, Congress passed the One Big Beautiful Bill, a fraught bit of legislation sold to voters as a comprehensive streamlining of government spending, combined with cutting $4.5 trillion in tax revenue over the next decade. A last-minute stipulation shielded Native Americans from work requirements being added to Medicaid and SNAP benefits. Even with the provisions protecting coverage for Indigenous people, the nonpartisan Congressional Budget Office estimated that the cuts to Medicaid would result in more than 10 million people nationwide losing health insurance by 2034.
For the Billings area, which includes all the tribes in Montana along with the Wind River Indian Reservation in Wyoming, the survey’s results prioritized mental health care. The survey noted that Native Americans in the United States die by suicide at higher rates than any other ethnic group. In Montana, the Indigenous people ages 11 to 24 die by suicide at nearly five times the rate of the statewide average, according to one study from the Montana Budget and Policy Center.
To combat these grim figures, the survey showed prioritizing long-term mental health programs on reservations and upping the compensation for mental health professionals. A critical part of improving mental health services for the Crow Tribe, Black Eagle said, was removing any stigma attached to asking for help.
“I know what to do if my knee hurts, or if I roll my ankle or if I’m sick. I don’t know what to do if I have a sickness up here,” Black Eagle said, pointing to his temple.
When Congress has attempted to supply IHS with an influx of funds, according to data from the National Institute of Health, economic realities have made those efforts moot. For example, in the 1990s, Congress increased appropriations for IHS by 8% over a five-year period. However, inflation and increases in the national Natives American population resulted in a net decrease in the per capita appropriation by IHS.
As such, Public Health Director for the Crow Tribe LeeAnn Bruised Head said the funding hasn’t necessarily dropped. For decades, it’s just stagnated.
“The IHS system is really old,” said Bruised Head, who has spent more than 30 years in the public health field working with tribes across the state.
“It didn’t evolve, so even their (electronic health records) system is antiquated. The other thing is that their system on hiring is just a really complex, difficult system. It might take six months to two years to hire a professional.”
One positive that Bruised Head has seen emerge in health care for Indigenous people in Montana has been IHS’s and other providers’ trauma-informed approach to treatment. That is, becoming historically and culturally knowledgeable.
For the Crow Tribe, she said that could mean doctors allowing for a friend to accompany a patient to translate treatment plans into the Apsáalooke language. It could also mean doctors understanding that patients in Wyola or St. Xavier may have missed their appointments because they didn’t have access to a vehicle.
While she has poured much of her career into lobbying for funds through grant writing and building partnerships with organizations outside of the Crow Nation, Bruised Head said when she needs stability, she looks inward.
“Money comes and goes,” she said. “Funding comes and goes, but what is still here is the people and the culture. That will always be here.”
MBPC is a nonprofit organization focused on providing credible and timely research and analysis on budget, tax, and economic issues that impact low- and moderate-income Montana families.