How Tribes tap into California’s $233.6 million year one award to reshape rural health care
California received $233.6 million for the first year of a five-year effort to reshape rural health care. For Tribal Nations, the opportunity is substantial. Whether it strengthens Tribal health will depend on more than participation. It will depend on authority.
For many California Native American people in rural California, the distance between health coverage and health care is measured in hours. A specialist visit may require a long drive. A referral may stall because Purchased/Referred Care (PRC) funds are limited. For some patients, a prenatal appointment can mean spending most of the day away from home and family.
California’s Rural Health Transformation program, known as CalRHT, is a major attempt to address these connected barriers.
California received $233,639,308 for Federal Fiscal Year 2026 through the federal Rural Health Transformation Program, a $50 billion national investment over five years. The funding is intended to change how rural care is organized, staffed, connected, and sustained, rather than serve as a general supplement to Medicare or Medicaid payments.
For Tribal Nations, CalRHT creates an opening and a defining question: will Tribal health organizations help shape California’s new rural health system, or be asked to participate after its terms are set?
See a clear breakdown of how the Rural Health Transformation Program works, and what it means for Indian Country.
CalRHT in plain language
The California Department of Health Care Access and Information, or HCAI, leads CalRHT with oversight from the Centers for Medicare & Medicaid Services. The state’s plan has three connected parts:
Transformative Care Model: regional collaboratives linking hospitals, clinics, maternity providers, specialists, behavioral health providers, and other rural partners;
Technology and Tools: electronic health records, interoperability, telehealth, eConsults, remote monitoring, cybersecurity, and related infrastructure; and
Workforce Development: training, clinical placements, recruitment, and retention.
California is releasing funding in phases rather than through one grant. As of July 23, three opportunities are open: Accelerator Partners, Family Medicine Obstetrics Fellowship Subawards, and EHR Modernization Grants. A separate Workforce Development Recruitment and Retention opportunity is listed as coming soon, with an August 4 webinar announced.
These first awards will test approaches that may inform statewide expansion. As California begins choosing implementation partners, Tribal authority must be established before regional roles and funding relationships harden.
A hospital-centered model in a state without Tribal hospitals
The Transformative Care Model is the center of California’s strategy. It uses regional hub-and-spoke relationships, with hospitals or regional health systems positioned as hubs and local providers participating as spokes or partners.
Tribal health organizations in California enter that structure from a distinct position. There are no IHS or Tribally operated hospitals in the California Area. Tribal health programs therefore rely heavily on outside hospitals and specialists for care they cannot provide directly.
In practice, this means Tribal organizations could enter CalRHT collaboratives downstream from the hospital systems they already depend on.
Better referral pathways and specialist partnerships could reduce fragmentation and keep more care local. The risk lies in allowing the hub to control funding, data, performance measures, and the definition of regional need.
A seat at the table is meaningful only when it carries influence over the decisions being made there. Tribal Nations should be involved in setting priorities, defining success, determining how information is used, and deciding how resources move through the region.
Why specialty access & PRC belong at the center
Purchased/Referred Care, or PRC, may cover eligible services that an IHS or Tribal health program cannot provide directly, subject to eligibility, medical priority, and available funding. This is not exclusive to California but often includes inpatient and specialty care.
The available PRC funding is limited and does not always meet the need. In 2023 congressional testimony, Central Valley Indian Health CEO Carlo Villa-Montes explained that California’s PRC funding was insufficient for specialty care and that some patients were asked to go without higher-level care unless they had another source of coverage. California Area Tribal budget recommendations have also documented deferrals and denials, while cautioning that incomplete reporting likely understates the need.
CalRHT should therefore be evaluated by whether fewer patients must leave Tribal health systems to receive the care they need.
Regional specialist partnerships, eConsults, telehealth, remote diagnostics, and better referral coordination could allow more care to be delivered through or alongside Tribal health organizations. Local workforce investments could extend that capacity further. The relevant outcome is not the purchase of a platform or the signing of a partnership agreement. It is whether a patient receives appropriate care sooner, with less travel and fewer points of failure in a place where they feel comfortable and connected to their culture or community.
California’s consortium structure changes how decisions move
California’s Tribal health landscape includes organizations governed by several Tribal Nations. IHS profiles list health programs such as Lake County Tribal Health Consortium and Riverside-San Bernardino County Indian Health, each serving multiple Tribes across a shared system. CRIHB describes itself as a network of Tribal health programs controlled and sanctioned by Indian people and their Tribal governments.
This structure builds shared capacity while preserving each Nation’s authority. It also means a regional partnership cannot rest on one executive sponsor or one letter of support.
A proposal that works for one location may affect member Tribes differently. A technology agreement may raise questions about control of data. A service plan may produce uneven access across a large geography. Executive leadership can advance the work, but governing boards and the Tribal Nations represented on them must have enough information and time to evaluate the consequences.
Those conversations belong at the beginning of regional design, before roles and budgets harden.
CRIHB connects Tribal health programs across California, represents them in national Indian health advocacy, and supports information-sharing, training, and policy work.
The new Rural Health Policy Council includes two Tribal representatives: Orvin Hanson, CEO of Indian Health Council, Inc., and Virginia Hedrick, CEO of CRIHB. The Council advises HCAI but does not have decision-making authority over program administration.
That representation provides an important public channel for Tribal expertise. It cannot replace direct engagement in each region. California’s Tribes, consortia, and service areas are not interchangeable.
The five-percent commitment is meaningful, but incomplete
The approved Project Narrative also commits at least five percent of the overall program budget to support Tribal clinics and health centers participating in the Transformative Care Model.
The commitment recognizes that Tribal participation requires dedicated resources. Its value will ultimately depend on how the funding is structured:
- How much will reach Tribal organizations directly?
- Can Tribal Health Programs lead or co-lead regional work?
- What authority will Tribal partners hold over governance, data, performance measures, and service design?
- Will smaller and remote programs receive enough implementation support to participate on equal footing?
Grant rules, subaward arrangements, and regional agreements will answer these questions. The percentage deserves attention, but so do the terms attached to it.
Funding is only one part of readiness
CalRHT is arriving alongside facility expansion, behavioral health investment, workforce initiatives, and changes in Medi-Cal. Indigenous Pact’s reading of the California market is that operational capacity is becoming as consequential as access to funding.
An award does not hire a workforce, create referral protocols, configure an EHR, negotiate data-sharing terms, enroll providers, or establish durable governance. Tribal health organizations must do that work while continuing to operate today’s services.
The timeline adds pressure. According to HCAI’s July 1 program FAQ, Budget Period 1 funds awarded to subrecipients must be used by September 30, 2027. A credible project needs enough ambition to improve care and enough operational discipline to move within that window.
Readiness includes governance, implementation staff, viable partnerships, a realistic workplan, and a plan to sustain the work when transformation funding ends.
Six questions Tribal leaders can ask now
1. What problem should CalRHT solve for our people? Start with the lived barrier. Where are patients traveling? Which referrals fail? Which services consume limited PRC resources? Which vacancies restrict care? The funding category should follow the need.
2. What authority would we hold? Clarify who will control funds, set priorities, make performance decisions, and speak for the region. Participation, co-leadership, and leadership are different arrangements.
3. How would this strengthen care within our system? Look for a concrete gain in local capability, specialty access, or referral reliability. A partnership should leave the Tribal health system stronger than it found it.
4. What happens to Tribal data? Address access, stewardship, consent, secondary use, and control before systems connect. Technical interoperability cannot become assumed permission.
5. Can we implement this within the funding window? Account for Tribal approvals, contracting, procurement, hiring, credentialing, technology deployment, training, and reporting. A realistic scope protects both the award and the organization.
6. What remains when the funding ends? Transformation should leave behind trained people, stronger operations, dependable care pathways, and greater Tribal control. Otherwise, the result is a temporary project.
What CalRHT should be held accountable to deliver
CalRHT arrives amid workforce shortages, limited specialty access, fragile referral pathways, and rising need. The investment may flow most easily toward institutions with the largest administrative teams unless program design accounts for unequal capacity.
Tribal Nations should not have to fit their priorities into a regional model built without them. This is the time to shape the model itself.
Success will be visible in the experience of care: a patient seen sooner, a family traveling less, a referral completed, scarce PRC resources used more effectively, and a Native health worker able to build a career in their own community. It will also be visible in who holds power when the funding is gone.
That is the standard CalRHT should be held accountable to meet.
CalRHT can strengthen care across California, but lasting transformation will require Tribal Nations to shape it from the beginning. Indigenous Pact works alongside Tribal leaders to design and build healthcare delivery through CalRHT that reflects the priorities of your Nation and the needs of your people.
Program details may change. This article reflects publicly available information as of July 23, 2026. Program facts are drawn from primary CMS, HCAI, IHS, congressional, and Tribal health sources. Statements about the implications of CalRHT for governance, regional power, and operational capacity are Indigenous Pact’s analysis.
