ASTHO Addresses Insular Areas Health Equity Through Federal Engagement

March 09, 2021|3:46 p.m.| ASTHO Staff

List of ASTHO Members in the U.S. Territories and Freely Associated StatesAs the Association of State and Territorial Health Officials, ASTHO is committed to the T in our name. The health officials from the territories and Freely Associated States (FAS) are valued members and we are committed to advocating for the unique policy needs and priorities of the Pacific and Atlantic jurisdictions. Within ASTHO, the U.S. territories and Freely Associated States are collectively referred to as the insular areas.

The insular areas (IA) face unique challenges locally but also require a specific strategy here in Washington, D.C. Funding approaches and requirements set for states do not always translate to the unique context of the IA—for example, USAPI make use of foreign nationals for their workforce—and that sometimes additional constraints are placed on the IA despite immense need (such as caps on Medicaid reimbursement).

This year, as in years past, ASTHO provided an exclusive platform for ASTHO’s members and leaders from the IA to meet with strategically important Congressional committees and executive branch offices to further the goals of the IA Subcommittee during Washington Week 2021. This year, ASTHO arranged and hosted meetings with the Senate Finance Committee, Senate Energy and Natural Resources Committee, House Natural Resources Committee and House Energy and Commerce Committee and the U.S. Department of Interior and HHS. Primary emphasis was placed on the impending Medicaid financing cliff for the U.S. territories and the importance of renegotiating and fully-funding the Compacts of Free Association (COFA) Act for the freely associated states. A total of seven of the eight island jurisdictions have participated in meetings along with our partner the Pacific Island Health Officers' Association. The conversations are very productive and pave the way for future engagement and action on our priorities.

Washington Week 2021, ASTHO members meet with Stuart Portman, Health Policy Advisor at U.S. Senate Committee on Finance
ASTHO members meet with Stuart Portman Health Policy Advisor at U.S. Senate Committee on Finance

Medicaid Cliff
Three years ago, ASTHO worked diligently along with its members to raise the importance of developing a long-term solution to Medicaid financing for the U.S. territories as they faced drastic cuts. This effort secured a two-year fix for Medicaid funding for the U.S. territories. This year, these funds expire at the end of September and ASTHO is working with Congress to demonstrate the impact of these funds for some of the most vulnerable Americans. Earlier this year, ASTHO endorsed the Medicaid Parity Act which seeks to sunset limitations on Medicaid funding for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands (CNMI), and American Samoa beginning in fiscal year 2021 led by Congressman Kilili Camacho Sablan from CNMI. ASTHO will continue to provide Congress data and information to secure a long-term solution for Medicaid funding for these populations.

Compacts of Free Association
In addition to efforts on Medicaid, ASTHO continues to engage with key committees and executive agencies to provide data and insights on the impact of the Compacts of Free Association. Negotiations began in May 2020 and are set to expire in 2023 for the Marshall Islands and Micronesia and 2024 for Palau unless the U.S. and the FAS extend the agreements and Congress approves them through implementing legislation. One of the main interests for ASTHO members in these agreements is the economic assistance provided to the FAS. ASTHO is working to share the opportunities that exist for strategic investments in these jurisdictions. Recently the Biden Administration included in its Interim National Security Strategic Guidance that “recognizing the ties of shared history and sacrifice, we will reinforce our partnership with Pacific Island states.” Additionally, in 1985 Congress recognized the effect of legal and open migration from the FAS to U.S. territories and commonwealths in the Pacific and Hawaii. Congress also provides annual discretionary funding to offset the costs to education and social services programs since FAS citizens are not widely eligible for federal programs. In a recent Congressional Research Services report, Congressional funds only cover a fraction of the need and thus states and territories provide the difference in costs. In good news, however, included in the COVID-19 Emergency Supplemental Funding Package passed in Dec. 2020, was a provision that restores Medicaid access to individuals living in the U.S. from the FAS, reducing the cost of healthcare for these populations and improving healthcare access to these community members. ASTHO seeks to build on this but also working to improve the healthcare and public health infrastructure of these nations.

Our overarching theme is the importance of building comprehensive systems of care so that those who need preventive care and treatment services can be provided these supports without needing to travel to other jurisdictions—often at the hosting jurisdiction’s expense. Stable and consistent Medicaid and Compact funding provides the basics to help achieve this. ASTHO will continue to monitor the priorities and needs of our valued insular areas members.


Carolyn McCoy, MPH, is the senior director of federal government affairs