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On July 3, 2025, the House of Representatives passed H.R. 1, the One Big Beautiful Bill Act, making substantial changes to Medicaid, Medicare, SNAP, and many other social services programs. In a vote of 218-214, Republicans were able to secure enough votes to pass the bill. Although this bill will have significant impacts on public safety nets, including critical healthcare programs, it includes several key provisions that will protect and exempt American Indians and Alaska Natives from the most harmful cuts to Medicaid and SNAP. A list of key provisions that will impact Tribes can be found below.
The bill will now be sent to the President’s desk to be signed into law. While most provisions will not start to be implemented until 2026 or beyond, NIHB will focus efforts on ensuring Tribes are directly involved in the policy and regulation making process to limit the impacts of this legislation on the federal trust and treaty obligations.
Key Provisions to Know:
- Medicaid Work Requirements:
- American Indians and Alaska Natives are exempted from community engagement and work requirements.
- Provision would prohibit states from using 1115 waivers to avoid implementing work requirements.
- SNAP Work Requirements:
- American Indians and Alaska Natives are exempted from SNAP work requirements.
- Existing cost-sharing protections for American Indians and Alaska Natives in Medicaid were preserved. There will be no new cost sharing.
- Medicaid Redetermination:
- There is a provision in the Senate bill to amend the Medicaid expansion redetermination window from one-year to 6-months. However, American Indians and Alaska Natives are exempted from this provision, keeping our redeterminations on a 12-month cycle.
- Rural Healthcare Transformation Payments:
- The bill provides for up to $50 billion over five years to states to support rural health care providers, and as written would allow Tribal programs to participate if they meet the generally applicable requirement.
- Medicaid PBM Spread Pricing Prohibition:
- While the original House version included a provision to prohibit the use of spread pricing by PBMs participating in the Medicaid program, it was removed by the Senate. NIHB will continue advocacy to Congress to ban PBM spread pricing in the future.
Why this matters:
Medicaid is a critical funding source for our Indian health system. While this bill makes harmful cuts to this important program, the exemptions the bill provides will continue to secure access to this important program for American Indians and Alaska Natives.
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