Transcripts For CSPAN3 Hearing On Medicaid Programs In Puerto Rico And U.S. Territories 20240714

The day he will take questions from the house intelligence committee. Both open sessions. Mr. Muellers report into russian interference in the 2016 election will air live on cspan3 online at cspan. Org or listen with the free cspan radio app. Much of puerto ricos medicaid funding conspires at the end of september. Puerto rico and other u. S. Territories are on a separate medicaid system nan the rest of the u. S. Congress funds them through block grants. So when the territories are hit by hurricane they go through funds faster and deplete the grants early. The House Natural Resources Committee held a hearing on why states get continuous medicaid coverage while the territories do not. The committees meeting today today to hear testimony on the impact of the end of medicaid funding for the insular areas under the Affordable Care act also known as the insular areas medicaid cliff. And the Committee Rule 4 f any oral Opening Statements at hearings are limited to the chairman and the ranking minority member. Therefore i ask you unanimous consent that all other members Opening Statements be made part of the hearing record if ner submitted to the clerk by 5 00 p. M. Today. I ask unanimous consent that the gentlewoman from the u. S. Virgin islands miss plaskett be allowed to sit and question the witnesses no objection. No objection, so ordered. Good morning again, everyone. And the Mariana Islands which i represent and the four other u. S. Areasry ep face a medicaid ending this year. Supplemental med kald including in the Patient Protection and Affordable Care act or obamacare as we like to call it conspires this year. And i can just recall as if it was onlyyesterday when we enlisted the help of the Congressional Hispanic Caucus and met the president on this issue. And, the senator from new jersey joined us and i think from that meeting we were able to get money because we were not included in the Affordable Care act under the reconciliation process. But, most of that funding puts Healthcare Delivery at risk, not just for medicaid recipients in our islands were for the population at large. This hearing is meant to shine a light on that imminent crisis. I want to thank the directors of the Medicaid Programs for being here as witnesses. Your programs are already short of cash and the cost of coming to washington was not taken lightly. I think we could ask no better spokespeople describe how truly dire the situation is a. I hope we will be able to learn from you what the loss of medicaid funds will mean to the people you serve. Real people. Our people who simply have no other means of getting basic healthcare. Also invited to testify today is the chief executive officer of the Commonwealth Healthcare Corporation. They run the one only hospital in the Mariana Islands and that depends on medicaid for one quarter of its revenue. I hope miss william will be able to tell us what the loss of medicaid funding will mean to the hospitals ability to deliver services and how that will impact not only medicaid patients but all her patients. I think ms. Munez description will help us understand how losing medicaid revenues will hurt Healthcare Providers and private practice as well. So, we are all working from the common set of facts. Let me quickly review the situation. In the state and the district of columbia medicaid is an entitlement program. There is a need for services and to the extent that the state can provide local matching funds, federal medicaid funds are always available. In the five areas this is not the case, up until 2011, we each received a fixed block grant. That block grant i am sorry to say is unrelated to the needs of our areas. It seems to have been set rather arbitrarily decades ago. And the local access to that block grant was set 5050. 5050 is the same matching rate as the wealthiest states, while states swear only matched the rate of 24 federal, i mean 24 local, 76 federal. Obama care provided some relief an extra 7. 3 billion into every medicaid funding and a permanent change in the match 45 federal, 55 local. But the obama care money is no longer available after this year. And all the ancillary areas will revert to their block grants. Using 2018 data means going from 20 million in federal funding to 12 million. For guam from 56 to 18 million. For the marianas from 25 million to 7 million. For the u. S. Virgin islands from 70 million to 18 million. And for puerto rico from 2. 3 billion just under 160 million. We cannot suffer cuts like that and continue to deliver services. The fast or the path forward is unclear. More money is needed at an equitable matching rate. But theres also need for each of the ancillary areas to deliver capacity of care because ultimately the goal is not just to have the same funding as states. What we want is medical care for those who need it in the ancillary areas to be every bit as good as medical care in the state. I look forward to hearing from the witnesses for their advice and experiences. Lastly i want to report that one of the meetings we do right arranged for the directors will advise the time in washington, some of you already know this prior to coming here. But you met yesterday with staff of the Senate Finance committee and the house Commerce Committee, we also met for you to arrange with cms centers. You asked them of the meeting for obama care section 1323 money to be used in fiscal year 2020 be used before you use the section 11 or eighth annual block grant. I received word last night that they have decided to do what you ask. It will make more money available that otherwise would have been lost. So if we are able to do nothing else i would like to say we will get Something Else done here. I really do believe that todays hearing will have positive results, and i now recognize my colleague, the gentle lady from puerto rico on Opening Statement. Thank you vice chairman and i really appreciate this hearing taking place. I want to thank all for being here today. To discuss one of the most important and Critical Issues currently affecting all the u. S. Territories. The impending expiration of medicaid funding, funds granted by the Affordable Care act and the instability of our healthcare infrastructure, in 2017, 1. 6 million americans living in the territories were enrolled in medicaid. That breaks down to 79 of the population of American Samoa, 21 of the population of guam. 33 of the population of northern Mariana Islands and 37 of the population of rico and 16 of the population of u. S. Virgin islands. The National Average enrollment for the state and the district of columbia was 21 . During the same year the Medicaid Program spent an average of about 1800 dollars a year per territory in relief, in contrast to the National Average excluding the territories that was more than 7000 per relief. Medicaid in the territories is subject to federal matching percentage. What we call fmap, and it varies relatively to each state per capita income. The fmap for the territories is completely different. We are permanently capped, by law to 55 . If the formula used to determine the fmap for the states were applied to puerto rico , the federal funding match chair will be increasing up to 83 for the maximum. But if the state and the district of columbia, medicaid provides a guarantee of federal matching payments with no precept limits. And this is the main difference between the treatment to the territories and the rest of the states. However, annual federal funding for medicaid in the territories is subject to this cap. Once a territory exhausts its cap federal funds, it will no longer receive federal Financial Support for the Medicaid Program during that fiscal year. In 2011, the Affordable Care act granted the territories an additional 8. 25 dollars billion in federal funds, for the Medicaid Programs, in lieu of establishing a healthcare insurance marketplace. The additional funding for each territory reached from 100. 2 million for the northern marianas, 6. 3 billion for puerto rico, and was available to be drawn down between july 2011 and december 2019. Since then, the spending and puerto rico has. These funds were depleted in february of last year. The last congress, the President Trump acted to avert this crisis and puerto rico Medicaid Program with a temporary increase to 296 million for the fiscal year 18 19. Moreover, as a result, you can see in 2017 again increase the federal cap to 4. 8 billion for the first time 100 federal cost here to the fiscal year 19 to keep puerto ricos Medicaid Program operational. All these additional sources of federal funding for puerto rico and Medicaid Programs will expire september of this year. For my island, medicaid and the fiscal year 2020 will be approximately 375 million. With no additional source of federal funding available. This means that puerto rico will exhaust its federal medicaid allotment in the first three months of fiscal year 2020. And will bear the expense and express excess of 85 of the federal program placing additional pressure on Territory Resources i know this is going to be happening all territories as well. Issues affected by this treatment and equable treatment in healthcare funding in their own way. However, all of the Medicaid Programs are currently conceived are unsustainable. This underfunding contributes to larger problems including lower provided rates and provider shortages. To correct this challenge i have introduced hr 2306, the puerto rico medicaid ask, which seeks to strengthen the Medicaid Program on the island by increasing the cap and removing a subsidiary fmap limitation. Im also the regional cosponsor of hr 1354 the territories held in equity act. This was introduced by the congressman of the Virgin Islands that will face the problem for all tear five territories. Those bills are under the jurisdiction of the energy and Commerce Committee and i will continue to work with my fellow delegates and the members of that committee to advocate for the advancement of those bills. I trust that todays testimony will help my colleagues understand the urgent need of action if we fail to act with the expediency that the situation requires, the provision of healthcare in all territories will be severely affected by far reach and repercussion for our nation. Although i recognize that this is not the committee with jurisdiction, i would like to thank the vice chairman and members of this committee for this important hearing. Having the witnesses to testify and to be on the record on the impact of the medicaid cliff that will undoubtedly help us as we continue working for a long Term Solution of this issue. Thank you chairman. I thank gentle lady for the Opening Statement and recognize the chairman. Thank you so much. No Opening Statement just a thank you for organizing the meeting. I think an excellent panel and i am here to learn something and which direction legislative we are going to go in in terms of dealing with the issue. Thank you so much for this i appreciate it. I was just coming over here, you know when you are chairman of the full committee mr. Gregorio sablan you are conscious, whether people say are not of a possible coup when power is removed and youre thrown off the chair. And having said that mr. Gregorio sablan , of all the people mr. Gregorio sablan i just cant believe it. [ laughter ] with that i yield back. Thank you, tu i for those, i will analyze those comments, but i think he meant well. [ laughter ] thank you i would now like to introduce our witnesses. Ms. Esther muna who is the chief executive officer for the commonwealth of the northern mariana healthcare corporation. Ms. Muna runs our only hospital in the marianas. And, whose revenue is about one quarter, if not more comes from medicaid patients. Ms. Helen sablan who is the director of the commonwealth of the northern Mariana Islands. State Medicaid Agency. Welcome to you. I am going to go ahead and also acknowledge ms. Teresa arcangel, did i say that right . Arcangel. Okay. Who is also the chief administrator of the Guam Division of Public Welfare which runs the Medicaid Programs. And, i would like to ask ms. To introduce her witness. Ms. Aumua amata radewagen to introduce her witness. Thank you mr. Chairman. Our medicaid director and ceo is sandra and she came into the position of ceo and director of medicaid, she has been there for most of the time that the aca funds have been there and she has been working very hard on it. And i want to welcome her to, and her delegation, to town. Thank you. I now recognize the Ranking Member for introduction of her. Thank you mr. Gregorio sablan i would like to introduce ms. Angie abelard she is the executive director of the Puerto Rico Health insurance administration. She is about providing the data related to Health Care System, and coronation with the secretary of health and puerto rico. Alright. Ms. Stacey plaskett, i recognize ms. Stacey plaskett to recognize that the witness from the United States Virgin Islands. Thank you mr. Chairman. It is an honor and a pleasure to be here under your leadership. I called the leadership of the subcommittee for mr. Gregorio sablan so please be careful. [ laughter ] this is a really important issue, and i am really grateful to have ms. Rhymer browne who is the assistant commissioner of the United States Virgin Islands department of Human Services , which does tremendous work and is managing this issue as well. I do note that the governor has his chief of staff here as well as other members of the administration are here, as our governor albert recognizes what a tremendously important issue and the need for this funding is to the people of the Virgin Islands. Thank you. Thank you everyone and, again witnesses are welcome. But under Committee Rules, oral statements are limited to five minutes. But your entire statement will appear in the hearing record. Right in front of you, the microphone will turn yellow when there is one minute left, and then red when you time has expired. I like to keep timeframe. We may, if necessary do two rounds of questioning. But, at the moment we will start with ms. Esther muna. Chairman raul grijalva, vicechairman Gregorio Sablan and testing which Committee Members , thank you for the opportunity to appear before you today. As chief executive officer, i oversee the work of the Commonwealth Healthcare Corporation known as chcc a. Chcc is responsible for seeing over my hospital, dialysis services, Mental Health or Public Health services in several outpatient clinics. As one born and raised on taipan i relied on our Healthcare Services long before i became responsible for them. I have seen how begin a remote location poses a host of challenges for our population. For example, in the 1990s a baby with a congenital Heart Disease had to take a total of eight hours and flight time to receive care costing 1 million accumulated in a year. Several residents that are my neighbors, my relatives, and my friends, are unable to return home because we do not have an oncologist on the island to manage their complex cancer treatment. A gentleman with a neurological injury waited for days before being transported off the island because the cheapest and safest way for him to receive treatment for his injury was at a hospital in the philippines. And like many u. S. Citizens, he did not own a u. S. Passport. Patients with complex medical issues like this issue are often flown to guam, hawaii, the philippines, and taiwan to receive care. In addition to the challenges with access to care, delivering Health Services in a Remote Island is more costly with high cost of shipping and we are competing with u. S. Hospitals for the same workforce. 15 years ago, with only the inadequate medicaid funding and the undergoing a Major Economic crisis due to several global and u. S. Policy shifts, hospital struggled to hold and stock medical supplies and recruit healthcare workers. The 2007 survey revealed many problems. With no funding improvements, paydays were missed and doctors and nurses left the island. In september 2012, cms issued a termination notice to our hospital. It was clear without Adequate Funding the chcc cannot sustain life saving services, much less in the healthcare needs of our residences. The 100 million available to supplement the medicaid funding in 2011 gave us the chance to deliver a little more than basic Healthcare Services that our people deserve it. Prior to 2011, we were receiving the left over crumbs of the capped funding and the insufficient medicaid funding was desperately needed and was utilized to save the lives going off island. With the supplemental medicaid funding, the chcc accepted a Payment Methodology that allowed the hospital to be paid at . 55 of its one dollar cost because the government declining economy cannot afford to make the amount of the . 45. It wasnt the most ideal funding, however, if it were not for that boost in medicaid funding that supplemented the statutory cap, we may have lost our hospital. And i wouldnt be here before you today. Thanks to the study steady medicaid reimbursement, my team has brought the hospital operations to the highest level that has ever been. With increased revenue, and a record system, a quality issued was unit, telemedicine services, and Specialty Services such as podiatry, emt, orthopedic surgery and as of this month oncology. We have tripled our medical staff, nearly doubling since 2013. We have cut our admission rate in half, far below the National Average. We do this by maximizing efficiency and innovation to maintain u. S. Hospital standards in our remote, rule environment. Rural environment. During two of the worst is typhoons in u. S. History, we were able to bring medical attention directly to the villages that were hit hard by the storm. The reliable monthly reimbursement for medicaid protected chccs cash flow and enabled our staff to do their job. We took full advantage of the opportunity presented to us in 2011 to stabilize our Healthcare System. Belinelli face another crisis. Our Medicaid Program is unable to sustain the needs of our Healthcare System. Earlier this program exhausted the medical funds made available in 2011. We returned to the low statutory cap, and the low federal share, and endangers the very system of our Healthcare System, threatens our economy and put at risk the health and wellbeing of our people. Help us maintain our progress and a return or avoid a return to those dark days. Stabilize our medicaid funding and provide healthcare to the u. S. Citizens. Great timing ms. Muna. Thank you for that. We are trying to get our witnesses testimony, and then, because some members need to run to vote, but ms. Sablan you are recognized for five minutes. Members of the committee on natural resources, thank you sm thank you so much for holding a hearing on the insular areas medicaid and for providing the commonwealth on the Mariana Islands the opportunity to present information on what the fiscal cliff means for the u. S. Citizens. We recognize we are the smallest of the u. S. Territories in terms of population and geographic size. Nevertheless, the u. S. Citizens value the uterus citizenship in the Medicaid Program. U. S. Citizenship in the Medicaid Program. The medicaid underneath section 08 budget caps are totally inadequate, they recognize the problem and temporally adjusted a budget cap. The federal medicare medical assistant prevented was also adjusted to 45 45th 35 45 . In fiscal year 2018 the Medicaid Program expended over 53 million to provide healthcare for the 51,000 eligible medicaid populations. Today the number of enrolled medicaid beneficiaries has increased to 62,000, 206 following the two typhoons in 2018 and the category five. In march 2019 the Medicaid Program exhausted its medicaid funding, program funding, in the final amounts made available. This is not a physical cliff, but it is in a freefall. For fiscal year 2020 region nine has been informed or that has informed us that our allotment will be 11. 2. This is not much of a change in the cap and means of the shortfall between the actual medicaid expenditures for fiscal year 2018 and cms fiscal year allotments will be allowed at 50 million. It will be around 80 million with the accounts payable for 2018 and fiscal year 2019 are accumulated. The Median Income for a family of four based on data divided by u. S. Census in 2010 shows that the family earns 19,958 in the same year the average u. S. Family arent 61,564 if we just at back for a minute and think about just the basic information, we can clearly understand why so many residents rely on medicaid for healthcare or uninsured. More than 16,206 individuals in the Medicaid Program constitute 46 of the u. S. Citizens. The government, the Medicaid Program and its beneficiaries from the Health System are in a dire situation following the additional funding provided underneath the aca and the devastating impacts that happened in 2018. Im here to play the u. S. Congress to provide medicaid Disaster Assistance and to address inequities in the Medicaid Program for the territories. I have worked in this Medicaid Program since 1986, over 32 years ago, and all these years i have never been more emotionally affected. We are currently in the process of severely curtailing services, limiting choice of providers in the program and making decisions knowing full well the short and longterm consequences our decisions will have i am frightened and saddened, and each step in our undertaking because i understand this on our people and our Healthcare System. We are doing our very best to determine what might be intellectually characterized that the socalled best interest given the limited resources of. Decisions regarding what services should be continued, what should be curtailed or dropped, and what providers can be paid are and will continue to be made. It is hard to explain to those who come to our Office Asking whether the Health Services that they are receiving will be cut. It is hard to listen to their stories. What should we do with a patient that has been in an off Island Hospital in another state that maybe dying . Should we not inform the patient, and parents that we are sorry that we will no longer pay for any other medical bills. It is impossible for me to see not the see the faces of the people behind the numbers. In summary, we are desperate and the u. S. Citizens on this island deserve equity in healthcare. As such we are humbly pleading for the u. S. Congress to plead help please help treat this equitably and if i may have he asked quickly. Thank you once more for taking the time to hear this issue. Another Perfect Timing witness and, so, thank you very much ms. Sablan. This time i would like to recognize ms. Teresa arcangel for her five minutes, please. Thank you mr. Chairman and Committee Members. For the record my name is teresa arcangel. I oversee the Medicaid Administration and guam. Im here with the director of the department, on behalf of the governor and the people of guam we thank you for inviting us to testify about our guam and medicaid financial issues. The cost of providing healthcare and guam is quite high due to its geographic location. The lack of efficient centers and other healthcare professionals. Some medical providers refuse to accept medicaid patients due to delayed payment, if we further increase the medical cost because recipients are forced to seek treatment at the hospital emergency room. Additionally, the cost of drugs is more expensive in guam compared to the u. S. Mainland because theyre only five that ship drugs to guam compared to the hundreds of Companies Available here. These vendors may tend to impose high price due to the lack of competition. The shipping cost, and the risk of drugs that have limited shelf life also contribute to this high cost. Guam has been burdened for years by the u. S. Treaty obligations which allows immigration. U. S. Immigrants have constant to the changes in guams demographics. In an effort april 2017, guam estimated nearly 147 million was spent in the education, public safety, healthcare, and social services for these migrants. Among that 35. 8 million was for healthcare and Welfare Services a. Once an economy based in the tourism industry. The influx created an additional hardship on guams economy. The government has been unable to guarantee the ability of local matching funds. Guam administers medicaid under the federal regulations that are different from the 50 states and the district of columbia. Guam medicaid federal medical assistance at 30 55 . In addition, the federal medicaid funding to guam is subject to a funding cap which is 17. 97 million for the fiscal year, unlike the state and the dc that are open ended. Furthermore, beginning in 2014, the federal government funded the state that implemented aca Medicaid Expansion at 100 of the coverage cost for the first three years. This is not applicable and guam. Instead, section 205 of aca provided guam 268 million which is a shortfall not only of our Medicaid Program but once locally funded medical assistant programs for most of the citizens qualify. A funding allowed guam to shift to the Emergency Services to medicaid, but before the percent percent provides hardship and fully expanding the program, to cover more uninsured population. , unfortunately guam would not be able to expand on the aca funding which will expire this fiscal year. If aca is not extended or replaced, the guam medicaid can be forced to increase the byline and terminate some of its programs. This will further increase the uninsured population and guam. The u. S. Territories receive fewer federal dollars for low income Healthcare Programs than the u. S. States along spending regulations. There should be no disparity on the medicaid funding distribution. U. S. Citizens and guam are no different from the u. S. Citizens in the mainland, and so there healthcare, benefits, and need should not be viewed or viewed differently. Hence guam proposes to remove the Expiration Date underneath 2005 and 1323 of aca until it is fully expanded. Remove the medicaid cap, and increase the fmap of guam and other u. S. Territories. We applaud the committee for this opportunity to take the necessary steps to even with the needs of guam and the other territories. Thank you for the opportunity to speak regarding this important issue. Thank you. Ms. Arcangel Perfect Timing again. I appreciate your coming in testifying, i would like to now recognize ms. Michal rhymerbrowne, did i get that right ms. Michal rhymer browne . You are recognized for five minutes. Chairman sablan, Ranking Member bishop and members of the committee, thank you for the opportunity to provide testimony on the Significant Impact to our Healthcare System and the people of the United States Virgin Islands. In light of the impending medicated fiscal funding cliff, which will impact us beginning october 2019 i am michal rhymerbrowne, assistant commissioner of the Virgin Islands department of Human Services. And i have direct oversight of the medicaid division. Accompanying me today is mr. Gary smith, our Virgin Islands medicaid director. I must also thank the commission or designee of the Vi Department of Human Services. She has extended to us her complete support as we prepare to come to this Important Committee meeting today. On behalf of the honorable governor albert brian junior and the more than 100,000 american citizens living in the u. S. Virgin islands, we bring you greetings and as we say in the Virgin Islands a pleasant good morning. As a people, we want to convey our heartfelt gratitude, appreciation, and thanks for the concern and support that you and your colleagues in congress have provided. As we continue to recover from the unprecedented damages caused by hurricanes irma and maria, two category five hurricanes which ravaged the Virgin Islands in september 2017. We are a resilient people, but my testimony today is truly intended to actualize the empathy. I appear before you today to request your continued urgent support to address the critical federal and local funding crisis. Which we are facing in our Healthcare System. On september 30th, 2019 by that date we are currently projecting we will have a fully expanded the additional 142. 5 million and federal medical funding provided under the dba. Members with no exaggeration, the congress, together with the Administration Must act by september 30th, 2019 to avert catastrophic damage to our Healthcare System. At that point, the federal medicaid matching rate will revert back to the statutorily mandated 55 matching rate for most of our Medicaid Programs and the federal medicaid funding cap of approximately 18. 8 million. This is not sustainable given the current state of our Medicaid Program. If the Virgin Islands only received the statutory cap amounts of 18. 7 million at the 55 rate, that funding is projected to only cover 26 of the federal funding needed during the fiscal year. We believe that there needs to be a permanent statutory fix that addresses the unfair and disparate treatment all territories face in their Medicaid Programs, along the lines of hr 1354, the Territories Health equity act introduced on february 25th, 2019 by our elegant stacey plaskett. Delegate stacey plaskett. We are requesting the congress, and the administration, work with us to support the following five year medicaid funding request. We are requesting 100 federal medicaid matching rates, to be extended to the u. S. Virgin islands for two additional federal fiscal years, and we are currently projecting that at least 251. 5 million in additional federal medicaid funding be provided during this period as was done in the be vba 2018. Secondly, we are requesting an additional 377 million in federal medicaid funding based upon our current production in lieu of our annual medicaid cap be provided to the u. S. Virgin islands. Unless the congress, and the administration, act with support for the two requests i have outlined above before september 30th, 2019 we will be faced with potentially catastrophic damage to our Medicaid Program in our Healthcare System. To include having to remove upwards of 15,000 individuals from our Medicaid Program who still need Healthcare Services, and having to deny men, women, and children and infants who need to be transferred to the u. S. Mainland for care not available. We want to thank you for the opportunity for being here today, and we strongly urge that we are considered for additional funding going forth in the next fiscal year. Thank you very much. Thank you, such wonderful witnesses, i love you all. [ laughter ] thank you again ms. Michal rhymerbrowne. I would like to, at this time, recognize ms. Sandra king young , who this is not her first appearance she has been here before. Ms. Young you have five minutes, please. Good morning chairman Gregorio Sablan, Ranking Member fmap and audible memories members of the committee honorable members of the committee. Thank you for this important hearing provide information on the impact of the september expiration of the medicaid funding for American Samoa and our sister territories. My name is Sandra King Young director for American Samoa. My written testimony submitted outlines the devastating impact of the laws of the aca funds that the American Samoa has not been able to spend, and the reasons why, so i will not reiterate those points here. At the outset, i want to point out again that for American Samoa, medicaid is our only Health Insurance plan available to the public at large. Insurance carriers have historically designed the client to provide Health Insurance to our people because we are high risk and a very sick population with one of the highest rates of obesity and noncommunicable diseases in the world. We are a very poor community. Without medicaid, our people will have no Health Insurance coverage in our Healthcare System will face an absolute collapse in insolvency. Medicaid is our people and our territorys lifeline for medical Care Services. As we have repeatedly shared, the two Biggest Challenges with our Medicaid Program are our governments inability to fund the local match requirement for the Medicaid Program. Second, the statutory caps annual funding for block grants placed on the territories prohibits us from fully executing the benefit requirement under our state plan and the Social Security act. Because we have exhausted our local match for the fiscal year, as of today, our Medicaid Agency has extended or x all offer for island patients to new zealand. We have expended any new patient payments, meaning needing wheelchairs or other Durable Medical Equipment including prosthetics. And we are cutting back on assistance to our medical care medicare eligible population. Our hospital however continues to receive medicaid funding underneath the aca because it does not need a local match dollars under its certified Public Expenditure Payment Method. Often times we tried to explain why we need the relief from local match and why we cannot spend all of our aca medicaid dollars at the people not their heads nod their heads, but they dont really know what that means to a patients life, to their family or to our community. The real life stories of life changing impact on patients because of the availability of the aca funding justifies an increase in the territorys block grant the devastating life and death outcomes that we face with the potential loss of the aca funding, without a resolution, justifies an increase in the territories medicaid funding block grant. Last year, i had to make a difficult decision on whether we were going to refer a child, an infant of six months, to new zealand severely disabled cerebral palsy. We got the quote back from new zealand that the child ethically they must accept, but prognosis, they do not think the child will survive beyond 12 months. And in that 12 month they would have to care for the child because we cannot care for the child on island. But the child will likely die anyway. And it will cost us 1 million, if not more. Our government only provided us 2 million in local match to do the off island referral, we made a difficult decision to deny the referral of this child because we do not have the local match. A few weeks later, the infant died. Currently, we have two patients in new zealand, one is a middle aged father who was sent for neurological surgery on his back. This week we got word that the man is severely ill and requires triple bypass heart surgery. At a cost of nearly 100,000. And i had to deny that because we do not have the local match. And just yesterday i had to reverse my decision because the family is devastated and we have to deal with that now on how we are going to make that payment when the invoice arrives in our office. We have one patient in new zealand, a young man with his whole life ahead of him, an on thejob injury a pile of plywood fell on his back back and broke his neck. And he had to be air ambulance to to new zealand. Last week in new zealand requested if he could stay two more months to do a sleep study to see how well he could survive if he returns home. Again, we had to deny the referral but again this week we reversed our decision because we have to deal with that. New zealand will not discharge the patient, ethically they wont. Why are we sending our patients to new zealand . Because we have a block grant and we cannot for the local match. We cannot afford the medicare cost in the u. S. For congress to fail to increase the territorys annual medicaid block grant and provide a more fair fmap for the territories in light of the knowledge of the consequences and the loss of lives and potentially crippling physical and cognitive outcomes for our people because of insufficient medical fundings is morally unconscionable. We need your help, only congress can solve these medicaid challenges for the territories. Thank you mr. Chairman and the committee for this opportunity. Thank you very much for that ms. Young. Ms. Avila from puerto rico. You have five minutes. Thank you. Good morning mr. Chairman, member gonzales and members of this committee. Thank you for the opportunity to testify today on puerto ricos impending medicaid cliff. I am honored to be here on behalf of the government of puerto rico and to be at the witness table with friends and colleagues from the other territories. Puerto ricos Medicaid Program serves as more of our nations most vulnerable citizens. We serve approximately 425,000 children and a 305,000 elderly and disabled. We provide care to 1. 5 million individuals out of the population of 3. 2 million u. S. Citizens. Yet, a federal healthcare funding for puerto rico has been insufficient for generations. Puerto ricos medicaid system has been chronically underfunded due to historical low federal medical assistance. Percentage known as fmap because the high local matching requirement and the cap on federal funding. Commonly, we are operating on the increase medicaid funding and the temporary 100 fmap which we received in the aftermath of hurricane maria. The worst Natural Disaster in our nations history. However, the supplemental funding will expire on september 30th, 2019. If no action is taken for fiscal year 2020, the fmap will revert back to the statutorily mandated 55 fmap up to the federal medicaid funding cap of approximately 380 million. This level of federal funding is not sustainable as it will only cover 19 of the federal funding needed during fiscal year 2020 and will last approximately three months. Once this funding is exhausted, puerto rico will have not fully funded the deficit as it has in the past and pay for its medical services with 100 local funding. Giving the islands current financial situation, local funding is unavailable. Unless congress acts, we will be faced with potentially catastrophic damage to our Medicaid Program and our Healthcare System. We will be forced to potentially remove any services that are not required under the medicaid rules such as pharmacy coverage, dental coverage. We have to end coverage for the common population who receive healthcare with local funds. We will face further delays in muchneeded improvements to our hospitals, clinics, and other Healthcare Providers. We will continue to lose more of our medical providers because we will not be able to ensure reimbursement. We will face a Mental Health crisis as individuals and families continue to struggle to have the most basic needs met. Earlier this month, the governor submitted puerto ricos official medicaid to congress. 15. 1 million in funding at an 83 fmap for five years. This funding will provide puerto rico with certainty in the short term while we Work Together on sustainable long term funding mechanisms. As far as the governors request, we have identified critical sustained ability measures needed to further stabilize and improve the Healthcare System in puerto rico. As a whole. Which includes keeping physicians within the system to avoid critical storage, provide lifesaving hepatitis c drugs, provide part to be premium medicaid coverage and adjust the puerto rico property level. The medicaid cliff that puerto rico is facing is an emergency that must be dealt with swiftly and smartly. I love my island. It is my home. And i am committed to working with congress to create a Medicaid Program that all of us can be proud of and that provides the necessary care to the 1. 5 million u. S. Citizens who rely on it. Thank you for your attention in these urgent matters. I welcome any questions you may have. Thank you. Thank you very much ms. Avila. We are going to go to questioning the members who have five minutes. But, before i do that i would like to ask unanimous consent. I have a set of six questions. I can hear all of us here speaking to the fact that we all want to be part of the full Medicare Program. Stateside so i have the six questions that i would ask you to take home and if you could provide us your written response within 10 days it will become a part of the record. It is not just a matter of money, there are many requirements that all of us, our governments have to set up before we can become eligible for the full program like any state or the district of columbia. If i may, i have for each of one of you, all of the state directors, we can Work Together on responses. Thank you all of you for your valuable testimony. In the chair when i recognize members for questions and under Committee Role 3d each member will be recognized for five minutes. I would like to recognize myself. Actually, i am going to recognize the gentle lady from American Samoa first. She needs to catch a flight. You have five minutes. Thank you vice chairman Gregorio Sablan and Ranking Member Jenniffer Gonzalez colon. For putting together this hearing on the medicaid currently facing the u. S. Territories. The medicaid funding is provided by the aca and expected to expire this calendar year. A lack of a funding solution will be particularly harmful for American Samoa as i know it will be for the other territories. I would like to thank our witnesses for making the long trip to washington to testify before the committee today. Welcome. Each of your firsthand experiences will provide congress with an accurate assessment of the situation. Acas first allotment of funds became available in july of 2011. Long before i come and many of us here were elected to congress. Those funds were only accessible after the normal annual allotment was exhausted. The medicaid and chip payments and access commission, otherwise known as macpac published a fax sheet for American Samoa which has the historical table of total medicaid spending from fy 11 to fy 17 taken from reported expenditures to the centers for medicare and medicaid services. The average total medicaid expenditure in American Samoa, according to the report, is 30 million for the period. Mr. Chairman, i ask for unanimous consent to enter into the record a march 2019 report on medicaid and chip in American Samoa. A may 2019 issued a brief on territory exhaustion of federal medicaid funds. The april 2016 gao report on medicaid in the u. S. Territories. In the letter to the governor dated march 15th, 2019. I do have a couple of questions here for the director. The maximum fmap is statutorily set at 83 . Now, if congress is unable to align the territory fmap formula to that of the states , is there a level that American Samoa, given an appropriate federal cap will be able to sufficiently upgrade the Medicaid Program . The answer to that question would be yes. Our major medicaid provider is the hospital. And the hospital has the best Payment Method under the state plan which is a certified Public Expenditure. So we dont have a real issue with the local match or the fmap with our local hospitals. It really has a do with the new services and any future Plan Services that we want to do outside of the hospital which is very much needed and this includes the department of health. I cannot comment exactly on what the appropriate fmap would be that would make it sustainable, but based on historical utilization of what we have used, it would be about 80 . Minimum 80 for the fmap. We can definitely do more financial analyst analyst analysis study our history of spending and give you a more accurate fmap. Thank you. Thank you for your response. We know the fmap and the federal caps need to be changed because they are not equitable in the territories. Fmap aside, what is the needed amount of federal funding to fully support American Samoas medicaid system . Currently, we have submitted information that we would like to request is a 30 million annual allotment for medicaid. This is based on the historical spending out of medicaid spending that we have. I provided a chart of expenditures, historical expenditures, based on the availability of the aca that shows that we need, for the hospital alone, an additional 8 million for the 20 million a federal share. And we would need an additional 10 million for all new services with federal share. That would make it a 30 million federal share block grant increase for American Samoa. Thank you director. I have more questions i will be submitting for the record. Mr. Chairman, i yield back. Thank you gentle lady. I would like to recognize myself, before doing so, i ask unanimous consent to enter into the record a letter from the financial oversight and Management Board for puerto rico. A letter from the association of the Pacific Health Community Health organizations. A letter from, oh my goodness, the national and Community Organizations all signed by Many Organizations actually. And a letter from the guam Regional Medical city that i have been asked to submit for the record. Mr. Chairman, sorry to interrupt. And i do the same thing . When i recognize you, yeah. Thank you. Thank you. So now, i recognize myself for questioning. Ms. Sablan , welcome. I want to compliment you on how you and your colleagues, including ms. Muna , managed the obama care money. So American Samoa, guam, and the u. S. Virgin islands have hundreds of millions of dollars of obama care funding unspent. But you have been able to use up all your money, is that correct . Yes. You use certified Public Expenditures to make the local match and release the federal funds, is that also right. Yes we work at the hospital. That is good. We have to match the 109 million that we put into obama care with 50 million of local funds. But the commonwealth did not make that much, did it . No, we do not have the money. That is interesting actually, because all last year the chairman of the legislature Means Committee kept bragging about how he was responsible for the biggest budget ever in the commonwealth history. Yet he cannot find matching funds for obama care medicaid money so i understand that you had to stop making medical payments to private providers at this time . Is that right . That is right. You also have had to stop paying for medicaid patients to use the federally qualified health center, is that correct . Yes. So, could the Community Health center also use cp system to make the local match . No. Okay. Well, i know that our legislature is not paying the share for medicaid, it is not your responsibility and you had to do the best you could with what you were given or actually not given i guess i would have to say. Right . Yes. Working with the federal centers for medicare and medicaid services, the Congressional Office should be able to help you get another 8. 2 million, but i will have to be adjusted and it could be down to 4 million. We also have another 36 million in the disaster supplemental appropriation. My hope is that you can see yourself through the end of the year. Would that help your program . Yes, thank you congressman. That would be very much appreciated. Again, i want to thank you. I have a little more time now. Ms. Muna, thank you also for coming here and thank you for helping managing this program and of course our only hospital. What i want to know, how important has obama care funding been to the hospital . You said local funding was cut in 2010. About 40 million to 5 million. But then obama care began in 2011. Without obama care, with the hospital have stayed open . I dont the same time you were losing funding, you were losing certificatio following that would you have lost certification . Absolutely. You testified that obama care money made it possible to see more patients and expand services, you tripled your medical staff, and added Specialty Services. Is that right . That is correct. And that money helped . Absolutely. And Patient Outcome has also improved . Yes, there able to have it at home. And readmission rates have improved . But that is correct. Hospital revenue quadrupled . It looks like the improvement in services, that medicaid made it more financially viable. Is that true . Yes, that is true. So the obama care meant that hospital stay open, you kept your certification, you expanded services, and improved Patient Outcomes and your bottom line . Yes. My last at 10 seconds, the six questions you have, i would really like you to respond in writing to the community to be part of the hearing record and its critical that we answer it as correct as possible. Thank you my time is up. At this time i would like to yield to my colleague, the Ranking Member ms. Gonzalez. We had a panel that we did yesterday and this will be a letter from the Hospital Association to be introduced into the record. So order. Thank you mr. Chairman. Now to begin my line of questioning. In the case of puerto rico, i have some slides regarding some of the data that is important to know the difference. This is medicaid funding that has been approved for all territories. When you see the difference of spending in terms of how much is federal funding approved and how much is a statefunded, you can see that most of the territories are doing the spending by using local funding. Complying with the requirements a lot of people are going to lose their severance. The other information is how different the spending is for territories in the case of puerto rico you can have a mississippi and other states receiving 7000. I know its the same thing with the rest of territories as well. The formal for the matching funds. It needs to be changed. There are several options. We can have 100 federal cost chair like we had in that bipartisan bill and. Got 4. 8 billion. That will expire on december we can leave the cap of 55 . That would allow 83 of federal funding. I think that this is the best way to do it, allowing the territories to have the same. Thats a bill that we actually file. We are talking about how much money that we will receive if we do not do something with that. In that case i would like to ask the difference were not talking about a difference of 20 , the funding that states are receiving. We are losing providers and the doctors. We are receiving less than half of other professionals thats why we are losing a production during the day lacking the specialized physicians. Having people in puerto rico will Lose Health Care coverage if we do not address the impeding medicaid claim, and how many will see their benefits reduced if congress doesnt react on september of this year. Speck according to the statements i just need a number. Proximately 6000, and that is if we can keep the pro rent. 600,000 people may lose their insurance if we do not act in september . That is right. We received a 4. 8 billion, after the hurricane season. 1. 2 billion was made available , if. Certifies that they have reliable data, and they establish a medicaid fraud unit. Should be able to access the entire funding. Yes today certified that. Was a reliable for the data . Yes, that is great. How does the treatment, and the fact that we are losing a lot of people every year. How is the government in order to budget if we dont receive the money. We are not allowed to forecast any funding that we dont have any assurance. It has to be certified the physical law requires that. So they require it to include all future plans and that means if we dont receive that money, and rico needs to put the money to do the job . That is correct. I will wait for the second round of questions. Thank you. At this time i like to recognize the gentle lady from the Virgin Islands for five minutes. I did not see messersmith sitting behind you. I guess he is there to provide support and any additional information, thank you for being with us. I wanted to get straight to the questions. I know in the written testimony you give a lot more statistics and specific examples of how this has affected us. We have seen on the chart that was demonstrated by my good friend and colleague how the difference in what we provided locally as well as what the federal government provided. One of the things that i need to highlight i think is important is the specific to the Virgin Islands, it may be different from other places. You stated that there were approximately how many people that we need to come off the books, for support were receiving if this funding ends . How many people have we been able to include that will no longer be able to receive those services . We would have to reduce the 15,000 individuals of the 27,000 members of the Medicaid Program. I think another number that was not brought out that i would love to talk about is how many people that it we have not Given Services to, additional 50 to 20,000 who would be eligible for the Medicaid Program. There are individuals that are presently in the Virgin Islands or other territories that are not receiving any Health Insurance we have a Large Population that has no Health Insurance that would qualify except for the fact that there is an arbitrary that is been put on the amount of money that Congress Gives us. And the Virgin Islands rather than going out and borrowing money, we have done this physically fiscally prudent thing and not to service those individuals is that correct . Exactly, that is correct. What are the other ways that it is impacting us . Can you talk about the hospitals in the Virgin Islands. Presently we do not receive the dish for the disproportionate share for hospitals which is an additional bump up given in rural areas. Although the Virgin Islands qualifies, congress has said that we would not receive that. What are some of the other ways that hospitals and Healthcare Services are impacted because of the trickledown effect of not receiving this funding. Hospitals on everyday bases are struggling. Since 2017 may have been experiencing infrastructure, because of the limited money that we have been unable to give them. That is one of the reasons why the hospitals has a frequently called us over the last two years, to airlift many of the individuals that go there that have catastrophic illnesses and need specialized procedures. The hospital has to turn away several individuals that have extreme circumstances and illnesses, and we have to airlift them to the United States for treatment. Thank you. I know that the governor has declared an emergency with Mental Health issues, can you talk about that briefly . The Behavioral Health situation is is really burdened right now. The need for more psychiatrists, more individuals to have longterm care. Behavioral Health Services. It has been hampered by the inequities of the hospitals and the Medicaid Program as a whole. It is very important for us to have a Skilled Nursing facility in both districts. We do not have Skilled Nursing Program Within the territory. The hospitals are burdened to provide behavioral Health Services. Thank you slick you state the things that the Virgin Islands has done, the accountability that congress has asked for theres quite enough systems have been put in place speck of medicaid Management Systems for claims and the cms certified compliant for online the medicaid systems, we implement it a medicaid fraud statistical information system. We also the audit reconciliations of the hospitals we completed the Medicaid Program and we have a host of other programs that we have been going through for the last few years. Especially with the dollars that we have mentioned prior. Thank you so much for all the work youre doing and thank you for the opportunity to highlight those for our colleagues here in congress. Thank you. We are going to have a second round of questioning. Im going to start with myself. Ms. Brown you listed a series of items establishing the relationship between the extra medicaid money that the Virgin Islands received and the improvements he made in administering the program, fraud unit, reporting data to the medicaid management system. You are able to do that because of the incentive funding included. Is that correct . But that is correct without that we wouldve been unable. I think you are reading my script. Without that incentive funding, would you been able to add those features to the Virgin Island programs . Without the incentive funding . Would you been able to do what you did . No way, we could not have. It seems like there is a model for how we can add other features to the Medicaid Program. That it would provide funding, and give you the resources that you need, and that you are willing to do it. Is that correct . We certainly are. Congratulate, i think it is a model for how we make medicaid more state like. Thank you for showing us what can be done. Let me ask the other directors, which make those changes i think so. Director young. At program be run like that if you had state like funding . I believe so. How long do you think that would take . Tenures . With abby reasonable . Probably. Ms arcangel . Ms. Brown . Yes. The Puerto Rico Program is so huge. Would you also be able to do this . The answer is yes. The federal government isnt saving money, it is been a big factor. So Many Puerto Ricans have abandoned for a state that is the story. Further Medicaid Programs in the case of particle three times as much. They are not treating anyone differently, its just an issue. They are not saving any money is that correct . Theyre not giving you the money. And theyre not saving any money because your citizens moved to florida. I would say that it is more costly for the state to have are residence here its also costly to us because we are having people leave home, and i cannot over emphasize the importance of your written response. Its concise and complete to the six items i gave you. Those are going go into the record and it will be shared with the jurisdiction, it is a plan that would allow the territory to work through a program and give financial incentives that would get us to a full state like a Medicare Program. In terms of services for our citizens. My time is up, and i yield to ms. Gonzalezcolon. I will take the same question, you were saying about taxpayers money being more effective if we address this issue. In the case of puerto rico. More than 1 million have moved to florida. And our case we take a ticket and move to a state and receive the full benefits. It would take more money to address this issue in the long term, if we fix that now we may save a lot of the federal funding. With that sense,. Is offering 10 out of 17 of the Medicaid Programs, it is that correct . We dont have enough funding to match the federal share. We are required to limit those a benefit. So we are just offering 10 out of 17 programs on the island . Yes or no . I do not recall 17, speck tell me what applies to the item . Right now we have a cure for the hepatitis c. Longterm care we lost a lot of people. What other programs. s but those of the main ones that i can highlight right now. Is . You mentioned due to the unequal treatment of particle. And the historical low funding that we are forced to limit medicate well below the poverty level. Puerto rico had substantially less. What are the benefits that are you limited . The main would be pharmacy benefits and coverage benefits. They are made for Healthcare System, speck in your appearance with having to identify the program how many individuals on the mainland are not currently covered in puerto rico because of the disproportionate lowlevel funding . We are estimating half 1 million citizens have not had the rights. Theyre not covered by Medicaid Programs because of the lack of funding and treatment for puerto rico. I know the same case for the other tories because if you dont have the funds you have to have the benefits in order for more people to address the most urgent need for the island. The number of providers dropped from 14,000 to 9000. Is this trend exacerbated . Yes that is correct. We have an idea of how many physicians and surgeons that we have on the island at this time. We are evaluating the numbers, but we have received preliminary information of 6000 or more positions that have left the island. Of there are still 6000 doctors on the island . And if they are paid last they will receive in the states. I know my time is running out. I do have questions for the record, you can answer later on thatll be specific for all of the territories represented here. I know you do a lot, and one of those would be how much would the Medicare Program a benefits cost in the state . And in the case of puerto rico there is no financial clear you said that it in the letter that it was submitted for their record and they are endorsing the medicaid funds and i think that that is common sense. This is for American Samoa, the fiscal year, and you explain the reason for the balance, my question would be, do we need to do something for the territories so they can spend the money . Are there any other requirements that are given to the territories . So that you can access those funds . What is the reasoning behind it . Thank you. The time has expired. I also agree, it is in anomaly. They are not too many providers and i found that out after the last time that you were on the witness stand. Thank you, i will not use the five minutes i am needed and another meeting. I wanted to follow up with a couple of short questions. Particularly of course for the good woman from the Virgin Islands, ms. Brown. You talk about disaster circumstances where we have been given hundred thousand, and if we move back to the 55 match, that that would bring us to 18. 7 million. What is the amount of money if all we were given that it would be at statewide . Do know that number . But i am not sure. However we are requesting for the 100 . We would be requesting 251 million for two years. And continue at the 83 for the federal level. And that would be for the next three years. Im not exactly sure of those numbers. We know for 55 it would be 18. 75 million. And that is woefully inadequate. What would the delta be that you would need to satisfy the needs of all the individuals that would be eligible . We are not sure at this time. If you can get that number to me, that would be very helpful for the record. One of the other things i wanted to talk about. We talked a little bit about physicians, can you state specifically what Specialty Services we are not providing for individuals currently . Yes, there several cancer related situations that individuals need to be airlifted. The Cancer Center was tremendously damaged on the island of st. Thomas. We used to fly them from st. Croix to st. Thomas. Now that center has been down for the last two years. The orthopedic specialist and the trauma specialist when we have major accidents and situations, workplace accidents we have to airlift the members off island to receive the treatment on the mainland. How does this impact recruiting physicians to the Virgin Islands . If there is a belief that we will be reduced and our medicated treatment moving forward, how will that impact the ability to not just have specialty doctors, but to have a regular physicians, general practitioners, pediatricians and etc. To treat this population . It would greatly reduce it. Before the additional money we were at 200 to 300 providers. We now have more than 700 providers. They were attracted by the additional money to provide services to members. If we were to be reduced once again, the ability to attract those specializations would be very hard for the territory. Thank you very much. I saw you had a note, was there anything you wanted to add . Yes. You are the director of medicaid and a doctor, she cannot read your handwriting. The 55 federal, would require 87. 2 million and that 83 it would be 52. 6 million. Thank you and i yobak the balance of my time. Thank you. I now recognize the gentleman from nevada for five minutes. Thank you mr. Chairman for organize the hearing on funding for medicaid. I appreciate the opportunity to discuss the shortfalls of medicaid of funding in our territories and shed light on this very important issue. I want to make it clear that it is my priority as a member of this committee to ensure that all americans have access to affordable and quality healthcare. Sadly as is the case with the treatment of American Samoa, and the Mariana Islands, guam, puerto rico, and the u. S. Virgin islands u. S. Citizens and nationals living in these areas do not receive the same services and benefits afforded to the rest of the american people. That is a very sad fact that we need to address. American citizens are overlooked, mistreated, and forgotten and the Government Services are treated similarly. Territories have higher rates of poverty than the state. And they depend on medicaid even more than our state. For example, and American Samoa, because private Health Insurance refuses to provide island healthcare coverage, medicaid is their only option, sadly due to significant shortfalls in that medicaid funding, territories face serious challenges finding the funding needed to support medicaid coverage. This is increased in recent years, its decreased tourism, National Disasters including hurricanes and typhoons. As a result, all territories are forced to cut Medicaid Programs, heightened eligibility , we cannot continue to stand by while people in need lose their healthcare coverage, the territories face a significant crisis. And we need congress to find a solution that can address the funding setbacks they face. 1. 3 Million People rely on medicaid which provides Health Coverage to children, pregnant women, seniors and individuals with disabilities. Without medicaid funding, thousands of individuals will lose healthcare coverage under medicaid. I want to thank each one of you for your testimony and i hope your insight can help the members of this Congress Better understand the challenges that our territories face and the solutions that are needed. I want to share my sympathy with you, and my regret that youve had to make such tough decisions regarding cuts to medicaid. Will women not be able to get a mammogram, will children not be able to have an annual physical . Will seniors a lose access to nursing facilities . What options are left for these individuals if they lose their medicaid coverage . We have exhausted our funding at the beginning of the fiscal year. What you mean by cut optional services. We had a republican governor who wanted to cut medicaid, and that meant cutting diapers from seniors in Nursing Homes and we rejected that. Optional services are prescription drugs, dental services, and other Care Services that are critical for our patients. What will happen to those individuals . If they dont get their medication, they will end up at the hospital, and thats going to cost more money for inpatient services, as well as dental services. If they are not treated, they will be in an emergency room and that costs more money. Is it a case that there are no other options available to them . There are no other options, because they cannot afford Health Insurance the income that they get is to put food on the table. Thank you very much. This is a very important issue one that affects all of the u. S. Territories. I commend the chairman and the members of this committee. We have to address this issue. Cannot continue to process. Thank you. Thank you rep. Horsford. I recognize mr. Cox from california. You can yield. Thank you mr. Chairman. Thank you for recognizing the great state of california. I have two questions. What is about the future and a little bit about how we got here. If congress does take the steps that have been discussed today to treat the territory equitably , providing uncapped medicaid funding, calculating Fund Matching like it does for the states, and begins to treat the territories as part of the United States are there any mandatory medicaid benefits . The territory would not be able to meet . Are there still other things that need to be addressed . Maybe anybody from the committee . Are there any unique characteristics of the territories that will prevent you from being able to provide mandatory medicaid benefits . We have to get rid of the cap, we hear that, you have to have the match and an likable way. Is there anything else that we should be looking at . To make sure that the uniqueness of the territory dozen preclude them from receiving certain benefits . We are trying to figure out where we go from here . Besides what is in the Medicaid Program, being able to keep the excess, and Healthcare Providers its a great challenge for the island and the other territories as well we need to find a way to distribute funds, to start stabilizing the program and to see what other needs need to be confronted. Its so urgent to keep the doctors in the island. And its urgent to avoid the hospitals. I will say that we will need to have more support in terms of longterm care to develop the structure to support that population and area, according to the guidelines that we would need to identify what else we can do better to have a more Sustainable Program but i want to echo for the longterm care. This will be a very important area for the u. S. Virgin islands. We havent aging population, and we would definitely need additional Technical Assistance to obtain certification and to maintain the Skilled Nursing facility certification, that Technical Assistance is greatly needed. The other question, how did we get here . I dont know if anyone can answer. Im just wondering in the negotiation in the passage there were benefits, the Medicaid Expansion and in some sense it did provide for Certain Services for the territories. Looking back it was a terrible hindrance. It put limits on the territory that he didnt put on the rest of the country. Spoke with a gentleman yield . When we passed the Affordable Care act, under the budget reconciliation project we have to address the senate bill, and all truthfulness, we could go into conference, because there was not enough for us to pass. We used up all the reconciliation, addressing the states and territories. We work with the white house, and we got increased money in addition to the regular grants, with additional, if her to get into the full programming, there needs to be improvements to not just procedures but also the standard of care for patients the improvements that would be implemented to satisfy would not just benefit medicaid patients, it would benefit the entire population, it would provide services that are not presently available, but are available in the state. We could do this over a period of 10 years. There would be money to help incentivize them to meet those standards and allow one territory, the other may take six years. Allowing them to work with the secretary and when they submit those plans, and that territory would get into a full Medicaid Program like they have in the states the rest would take additional time. It would take time and incentivizing them. They would need financial assistance, but it can be done. And it is possible. That is also for me personally that is my hope that we would get into the full program. That i answer the question . Your time is up i use my time wisely. No question. You always do. Thank you to the chairman and the witnesses. Certainly i believe that the richest country on earth, that healthcare should be a right, not just for the residents but for all who call themselves americans. Unfortunately healthcare in america has been segregated between the have and have not. This is no exception. The way that the Medicaid Program views the other area is as secondclass citizens to care for some the most vulnerable. The territories are generally more poor than the 50 states, better subjective to the fundings. Despite temporary increases, it is a fragile, following these disasters residents have struggled with substantial health needs. It is imperative that it be addressed, funding could further restrict programs eligibility and suspend programs. This could be devastating for territory budgets, my question most American Samoa and that marianna items rely on a single hospital to provide care to medicaid beneficiaries. What are some of the challenges that arise with this model and would have an uncapped federal funding and match up the territories drawing additional providers outside of the system . You repeat your question . With your reliance on a single hospital for most of the care for medicaid eligible. What are some of the challenges that arise with this model, with having uncapped funding and would it help territories drawing additional providers outside of those in the Hospital System . We would have to send the patients off island to guam, hawaii, or the u. S. Mainland. It is costing us a lot of money to send our patients with ache, and then requiring a local match. If we undo that, and provide for higher federal match. What is the impact . That would really help us. We would be able to provide more services. Ms. Young . To have a response . Answer the first part of your question, we provide basic services at our one hospital. And medically necessary care that is not available must be sent off island, currently we send patients to new zealand because it is the closest country to us. It is closer than hawaii. Everything from orthopedics to cardiology to urology, acute serious pediatric. They go to new zealand. If you were lifted and we received a better map, that would truly transform the Health Care System what is amazing about the situation if you look at the territory it doesnt take much in the overall scheme to give us a little more in the block grants to fully provide those services to our people and care for them if that was lifted, absolutely we would be able to provide and recruit more. That is part of the problem we dont have enough certify that doctors for compliance issues and reimbursement requirements. We have three doctors with degrees that allow us to claim for medicare. That allow us to recruit doctors with md degrees. We could do more of those types of claims. Thank you. Mr. Chairman i yield back. Now i would like to recognize ms. Gonzalezcolon. For five minutes. Thank you mr. Chairman. I would like to recognize and take into account the situation the territories. Its important that congress does something. And i am willing to work across the aisle to reach a longTerm Solution for the territories. We can do that. They went to the island during the last congress, and as a Ranking Member, there is a common sense opportunity to reach an agreement. There are two bills that have been filed. One that is being sponsored by all the members of the territory. Hr 1354. And i commend the members that cosponsored those bills. That will find the permanent solution, taking the of a 55 off or increasing the funding for medicaid in puerto rico and the rest of the territories. And i want to commend you for being a cosponsor of those bills. This is something that we can achieve during this congress. Knowing that the territory suffer different disasters. Ms. Arcangel are you willing to finish . I am used to speaking to senators. To answer the question from the congressman from new york. Removing the cap would definitely help the territories. For guam the experience is because of lack of funding we are unable to match the federal. So what happens . We have late payments to the providers and they dont accept our patients. Our patients become more sick. There conditions becomes more complicated the cost of healthcare increases while we are waiting for a local match to drop down the federal funding. Are patients are staying in the hospital. We dont have a Specialty Center , that require all the professionals in order for them to completely heal the patient. These patients are waiting for months in order to go off island , because the provider is off island. Thank you. One more thing, in regards. Dont use my time. Okay, im sorry. You go ahead. I just want to emphasize that the territories do not receive any additional money, the dish money is the disproportionate share segment. That means that the low Income Patients are being attended by the hospitals without receiving their fair share in order to make that happen. The same thing happened with the low Income Subsidy and the Health Insurance tax. The hospitals are paying a tax thats included in the obama care. We cannot benefit for that tax incentives, in the case of puerto rico where paint 200 million annually in the Health Insurance tax without the benefit. I know that it would be the same for all the hospitals. We do not have the exchange. There are several parts of healthcare problems, medicaid is one of them, and medicare is another. I will begin the question during my last term to the lady from American Samoa. I know that we know each other. How long . Six years. What is the reason that American Samoa has not spent the money that was allocated to the island . Up until 2017 we only had one medicaid provider, the hospital, and they do not provide all of the mandatory services under the Medicaid Program. Trying to reform the medicaid state plan to add new providers to draw in that federal money the barrier was a local match for the first time the government, when the administration came in, there was a lot of old debt, and that was a priority. We were not able to get local match for services until 2017. Hospital does not require a local match. But all new Services Require a local match. I will yield and i would love to have recommendations from the territories that have not spent the medicaid funds given any problem that you are facing . There should be some recommendations in order to draw that money . Thank you i will recognize the gentleman from florida. Mr. Soto. That sounds nice. You will get your time also. Theres been a long running injustice in this country. And i think that we understand that regards to healthcare taxes benefits even the right to vote we continue to write those wrongs and fix those injustices. Weve seen over 6000 doctors leave the island many from our great state of florida. Hospitals in disrepair, debt added to prop up the Medicaid Program. All because theyre not treated equally for the purposes of medicaid. I know there is a similar story in each of our territories that is why we are here today. I had the honor of serving on the Energy Committee that name has been invoked 100 times today. Youre looking at somebody working in both committees but it gets worse with hurricane maria, our territories have been decimated by the storms it is led to tragic death due to the lack of money and the Healthcare System, including in puerto rico and the Virgin Islands. Along with other areas if you remember nothing else, its time to end this injustice. And we appreciate you coming from so far away, from so many corners of the United States to be here today and make sure that americans have health where carrie quality. I want to thank the representatives here today, because hr 204 are great ideas of where we need to be with regards to these bills, we would like to remove that all together and for territories to be treated as estates. And get the same treatment that they would be treated otherwise. And that is where we want to go with the combination of these bills. Another bill that we are working on, giving access to the Affordable Care act, right now they dont have access to that. In my families at Native Island of puerto rico, only 30 are on employerbased insurance. That is mind blowing compared to the states. We need to boost that. This is where im going to get to my question, because youre not fully funded, some of you are not providing all the services. Is from guam . Guam is doing all of the services. You get the goldstar today. Very impressed, and you are not receiving the full funding to do that. For each of you, going down the list, it would be great to hear if we provided you with the full funding that you would get, whether you could provide all of these services, and will start with ms. Avila and we will go down the list. If you have the full funding would you be able to provide all the services under a mandatory benefit. And what kind of time. We do need . We would start immediately adjusting reimbursement rates to the medical providers. In a timeframe of no more than three years we would be able to establish the program as needed, the uncertainty that we have. I understand that my time is limited. Ms. Young . Yes, we would be able to do a lot more if we were treated equitably. Improvement in the map. Ms. Rhymerbrowne . Yes. We would definitely be able to do more, and one of the areas would be to increase, well, even develop our Skilled Nursing facilities and not have a cap when we do have the Skilled Nursing facilities. We already covered guam, so well, definitely all services thats mandated. Right now there are some that were not covering. Covering. Of course because theyre not fully funded. We are providing services and we will be expanding and providing more services for the community at home. Thank the gentleman. I now recognize the chairman of the committee, mr. Grijalva. Thank you very much. I appreciate you putting together this hearing. Its impactful and to shine a brighter light on this inequity that every one of you has spoken to both in oral and written testimony. And for equal treatment to me very fundamentally and very simplistically. The way to deal with that unequal treatment is to create resource equity on par with what communities here in the United States, on the mainland, receive, period. Thats the goal. And i look forward to the various legislation and under mr. Sablan and the representatives from all the territories and puerto rico, i think that from that would come a significant piece of legislation that we can look at, promote, and certainly i would be talking with the chairman about expediting the piece of legislation to start that move that. Having said all that, i really want to ask one question to all of you, and its a question that just one question, and thank you all for making the effort and coming from such a long way to be here. The one question is, if you had to choose between a larger federal match, around 85 , okay, for example, 85 or more money, or just more resources and more money, but the same 55 45 match that is present, which would you prefer and why . I think thats the question some why dont we just add more money to what exists versus fundamentally changing the making the formula equitiable. But the reimbursement formula equitable. But thats a question for all of you, and we can just go down the panel, if you dont mind. Thank you, mr. Chairman. If we are going to choose, we would have to choose the more money over the over the f map. And the reason is, even if you increase the f map for us personally, in the hospital we use the certified Public Expenditure. If the funds are not available, you wont be able to, even if you increase the f map, it will basically just be faster for you to drain or, i mean, expend the money than the cash available for services that you have at home. Thank you. I go with removal of the cap instead of the f map, and the reason why is were spending more, were spending over 72 million. For guam, we spent 110. 8 million last year, so if you just go in and increase the f map, our current cap right now is 17. 97 million. Thats not enough to pay for those services. So we prefer to increase the funding. Its very hard. We would need more money, so definitely we want the cap off, but the f map is needing to be off as well because more money and still have the 55 f map would make no sense. We cant make it. We cant go after it , as seen in the aca dollars. I think for america this is an interesting question. I think in an ideal situation, both of these have to be addressed simultaneously, complementary, but if we were to go for the more money, we would want the lifting of the cap. But we would have to do as a territory then, we would have to permanently omit and eliminate all outside providers outside of the hospital because our government is not able to raise the local match and we would have to, i think, and i think we can do that over years, continually improve our hospital and use our cpe method that doesnt require the match. I would agree that it is a combination of both, even though we have more money, if we dont have the local match to be able to comply with the matching funds, we are not doing anything good for the program. So it will be both relatively. We need to have more money and we need to have a higher f map to be able to do the matching of funds and not to be in desperation that puerto rico is facing right now, because the 45 has taken our island to a financial situation that we are leaving today with the fiscal and looking for the funds that we need to be able to sustain the program and pay for the matching. Thank you. Mr. Chairman, i hope Going Forward under your leadership that the consensus, the fact that all the stakeholders are before us, that as we move forward or move legislation, that we seek to continue to promote that consensus. That makes the effort much more much more powerful, to be honest with you. With that, thank you very much for the hearing. I yield back, sir. Thank you, mr. Chairman. Im going to take the liberty of asking ms. Muna if she could respond, maybe take 30 seconds, one minute, to respond to the question. About expanding services . I mean, if you remove the cap yes, if you remove the cap, you know, theres a lot of opportunities for us to reform our Healthcare System, and given the opportunity to have that predictable funding, you have to have predictable funding and sustainable funding. If youre able to have those, then you will be able to basically manage the population, bring healthcare reform, bring population health, and have a healthier population for your people. And thats an opportunity for us that we would love to have. Thank you. Thank you. Thank you very much, everyone. And i just want to let everyone know that we have not we didnt hold this hearing just on our own. We have been working with outside groups. We have been working with the Commerce Committee staff trying to address this also, we dont want to blindside them. So again i will emphasize the real importance of getting as complete and as concise an answer to those six items i gave to you. I also would like again im really pleased with the Virgin Islands model that they have started and i know that i understand that some of you have agreed to kickback on your own and pay your own bill, of course. Some may be able to sit back and talk a little bit more on how to address a model so we can put together something for legislation. But i want to thank the witnesses for their truly, truly valuable testimony and many of the members for their questions, their patience. The members of the committee may have some additional questions for our witnesses, and we would ask you to respond to this in writing. Under Committee Rule 30, members of the committee must submit witness questions within three Business Days following the hearing, and the hearing record will be held open for ten Business Days for these responses. There is no further business. Without objection, the committee stands adjourned. This is a special edition of American History tv, a sample of the compelling history programs that air every weekend on American History tv, like lectures in history, american artifacts, real america, the civil war, oral history, the presidency, and special event coverage about our history. Enjoy American History tv now and every weekend on cspan3. Here on American History tv, we take a look back at the 1969 stone wall riots and how they became a key turning point