Island Areas Public Health Policies in 2024

April 15, 2024 | Jessica Bissett

The U.S. territories and freely associated states—collectively referred to as Island Areas—do not fall under the category of a state or federal district, and while they share many common concerns, they often face challenges that are different from those faced by other island jurisdictions and the continental states. The Federated States of Micronesia, Republic of the Marshall Islands, and Republic of Palau are sovereign nations with a Compact of Free Association with the federal government. American Samoa, Guam, Northern Marina Islands, Puerto Rico, and U.S. Virgin Islands have American sovereignty but do not have voting representation in Congress. Further, their eligibility for key programs (e.g., Medicaid, Medicare, and Supplemental Security Income) does not match other states. Combined with the history of colonialism and significant distances from the continental United States, island areas are generally underserved.

Some public health legislation introduced during the Island Areas’ most recent legislative sessions seeks to address substance misuse, tobacco and vaping, access to care, and sexual abuse prevention. While federal datasets do not broadly capture the prevalence of inequities of behavioral health issues in Island Areas, these policies should apply to all people within each jurisdiction, including those residing on remote atolls, indigenous populations, mothers, children, migrants, and other underserved populations. In addition, policy proposals should include provisions to increase access to opioid reversal medication, reduce access to and use of tobacco, enhance sexual abuse prevention education, and improve infrastructure for providing health services.

Substance Misuse

Although limited data suggest the opioid crisis is generally less pronounced in island jurisdictions, officials are nonetheless taking policy actions to prevent overdoses and other health consequences from substance use. Opioid reversal medication, like naloxone, can prevent death by reversing the effects of an opioid overdose. Efforts to expand access to naloxone in the United States are ongoing, and on March 29, 2023, FDA approved the first over-the-counter naloxone nasal spray.

Legislatures in the Island Areas have recently considered at least three bills related to opioid reversal medication. The Commonwealth of the Northern Mariana Islands (CNMI) considered HB 23-23, which would authorize and mandate first responders to possess opioid overdose reversal medication—and provide limited immunity for dispensing them—and authorize standing orders for the medication. CNMI also considered HB 23-25, which would amend their Good Samaritan law to include administering opioid overdose reversal medications. In Guam, the legislature is considering Bill No. 10-37 (COR), which expands access to opioid antagonists (such as naloxone) and grants immunity from criminal or civil liability to people administering opioid antagonists.

Island Areas also considered legislation to reduce the use of other harmful substances. CNMI is considering two bills related to the use of betelnut (i.e., areca nut), which is wrapped in a leaf with afok or bweesch, a powdered limestone mixture, and chewed, often with tobacco. The betelnut itself has stimulant properties and is classified as a carcinogen by the World Health Organization and has harmful effects. CNMI HB 23-41 would establish an excise tax for betelnut and afok and bweesch, and SB 23-54 would regulate afok and bweesch under CNMI’s Pure Food and Drug Control Act.

Tobacco Product Use

Tobacco continues to be the leading cause of preventable death in the United States. While cigarette smoking among adults has declined from 20.9% in 2005 to 11.5% in 2021, some Island Areas may have a higher percentage of cigarette smokers than the U.S. average. For example, in 2019, Guam had a 23.4% rate of adult cigarette use, while Puerto Rico had a rate of 9.6%.

Guam recently enacted two bills related to tobacco use. Bill No. 186-37 (LS) redistributes tobacco fees and penalties to more directly fund government programs that administer tobacco and nicotine education and prevention services; it also establishes the Youth Tobacco Education and Prevention Fund as a revolving fund. Bill No. 187-37 (LS) prohibits the sale of all tobacco products, including e-cigarettes, through vending machines. Guam’s legislature is considering three additional bills:

• Bill No. 195-37 (LS) would prohibit advertising or marketing tobacco products, including within six feet of a point of sale (e.g., the cash register).
• Bill No. 197-37 (LS) would require wholesale and retail licensing for e-cigarette products, as well as establish an excise tax of 40% on e-cigarette products.
• Bill No. 229-37 (COR) would prohibit the sale of flavored tobacco products (e.g., all tobacco products inclusive of e-cigarettes).

In 2023, the Republic of Palau enacted HB No. 11-67-7S, which prohibits manufacturing, importing, using, possessing, and selling e-cigarettes.

Sexual Abuse Prevention

Preventing sexual violence includes strategies such as promoting social norms protecting against violence, teaching skills like health, safe dating, and intimate relationships to adolescents, and educating professionals about sexual abuse.

Puerto Rico recently introduced two resolutions related to sexual abuse education. Joint Resolution No. 7 - 2023 directs Puerto Rico’s health agency to require nursing professionals to meet continuing education requirements about sexual violence and abuse. Joint Resolution No. 61-2023 directs the territory’s public safety agency to provide a course on sexual abuse issues in the Academic Program for Cadets of the Puerto Rico Policy Bureau.

Access to Care

Because of their location and infrastructure, accessing care in Island Areas can be difficult, leading to a higher risk of chronic disease and premature death. Increasing options for Island residents, such as mobile integrated healthcare and telehealth, can provide the support needed for increased health.

Two of the island jurisdictions recently enacted legislation supporting mobile integrated healthcare and telehealth. CNMI enacted HB 23-47, which requires health insurers to cover and reimburse telehealth providers of mental health services at the same rate as an in-person provider. It also prohibits insurers from denying coverage or imposing unique conditions for mental health services provided by telehealth providers.

The U.S. Virgin Islands (USVI) enacted Bill No. 35-0119, which directs the Department of Health to develop and approve mobile integrated healthcare programs and establishes criteria for program approval. USVI is also considering Bill No. 35-0224, which would increase access to behavioral health services by establishing a Psychiatric Emergency Response Team to provide mobile crisis intervention services and facilitate the 988 telecommunication system.

ASTHO is committed to supporting the work of the Island Areas to improve population health and health equity in the Island Areas and will continue to track and share legislative proposals that will help yield positive health outcomes for their residents.