On May 22, 2025, the House of Representatives passed H.R. 1, the One Big Beautiful Bill Act, which advances the budget reconciliation process. The legislation includes an exemption for American Indian and Alaska Native (AI/AN) individuals eligible for services through the Indian health system from Medicaid community engagement/work requirements protecting the federal trust and treaty obligations. Medicaid work requirements without an AI/AN exemption would likely cause many AI/ANs to lose coverage and would place additional strain on the Indian health system resources. Additionally, the bill protects existing cost sharing exemptions for IHS eligible beneficiaries. NIHB and our Tribal partners helped secure this important exemption.
The legislation passed by the House also amends retroactive coverage under Medicaid and CHIP programs. Currently, eligible beneficiaries can receive retroactive coverage for three months prior to submitting an application for coverage. If signed into law, this bill would reduce that window to one month, limiting retroactivity.
In addition, the bill includes a moratorium on the implementation of the minimum staffing standard for long-term care facilities. This will reverse a rule published by the Centers for Medicare & Medicaid Services (CMS) on May 10, 2024 and requires minimum nurse staffing requirements at Medicare and Medicaid certified long-term facilities. This rule could prove catastrophic for keeping facilities open and meeting the trust and treaty obligations in healthcare because of the difficulty of staffing in Indian Country. Long-term care facility closures like this in Tribal communities do not just remove jobs but break cultural bonds and remove Elders from our communities. CMS TTAG submitted comments opposing the rule when it was out for comment.
Finally, the bill includes critical reforms and oversight on pharmacy benefit managers. Most importantly, it bans PBM spread pricing in the Medicaid program. This reform will ensure our IHS and Tribal providers are reimbursed fairly and patients can access the medications they need.
The 215-214 vote completed weeks of negotiations among House leaders and finalized a major step in the budget reconciliation process. The bill will now head to the Senate, where it will likely face major hurdles and possible edits. The National Indian Health Board will continue to advocate to ensure that the trust and treaty obligations in health are upheld. For more information on getting involved, see our advocacy resources here.
