WASHINGTON — Witnesses from a handful of U.S. territories urged Congress to avert a Medicaid “cliff” that has the potential to jeopardize medical care for U.S. citizens in already hurting island territories, during a subcommittee hearing of the House Committee on Natural Resources last week.
In the insular territories — American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands (USVI) — 1.6 million Americans rely on Medicaid.
Like in the states, Medicaid programs in the territories are governed by a Federal Medical Assistance Percentage (FMAP); funding to territories, however, is capped, while funding to states is open-ended, Committee Vice Chair for Insular Affairs Gregorio Kilili Camacho Sablan (D-Northern Mariana Islands) explained. In other words, when states on the mainland have a need for services, as long as states contribute their matching funding, the care is always paid for, but in the territories this isn’t the case.
Representatives of the territories also argue that the match allotted to them is far less generous than the match rate given to poorer states. In the states, match rates are adjusted each year to reflect individual states per capita income, explained Vice Ranking Member Jenniffer González Colón (R-Puerto Rico).
For years, the territories’ match rates stood at 50% — the lowest possible rate.
Under the Affordable Care Act (ACA), that rate increased from 50% to 55% and the federal government allotted $7.3 billion to the five territories combined, but the majority of this funding is slated to expire at the end of September 2019.
While Puerto Rico and the USVI saw a boost in federal funding after the devastation wrought by Hurricanes Irma and Maria — when their share of Medicaid expenditures was temporarily zeroed out and territories provided a 100% match — neither territory has fully recovered from the storms.
Michal Rhymer-Browne, assistant commissioner of the USVI Department of Human Services, who oversees the territory’s Medicaid division, said the $142.5 million allotted to the islands by the Bipartisan Budget Act of 2018 is projected to have been expended by Sept. 30, 2019. In addition, the USVI anticipate losing access to nearly $158.9 million in leftover ACA funding.
Rhymer-Browne predicts “catastrophic damage” to the islands’ healthcare system if it is forced to return to the previous funding cap of $18.8 million.
The first bill aims to raise the cap on Medicaid funding and remove the statutory FMAP limits for Puerto Rico, explained González Colón, and the second aims to correct the same problem for all five territories.
Rhymer-Browne called for extending the 100% federal match rate in the USVI for another 2 years. She supports the proposed legislation for the territories and argued that if nothing is done before Sept. 30, more than 15,000 individuals will have to be removed from the Medicaid program, she estimated.
Similarly, Angela Avila, executive director for the Puerto Rico State Health Insurance Administration, said in her testimony that if no action is taken to address the funding cliff, and Puerto Rico reverts to its earlier match rate and funding cap — 55% and $380 million, respectively — the remaining Medicaid funding will last only 3 months.
Once the capped funding is spent, Puerto Rico would have to pay for Medicaid services with only local funding, which given the current economic instability of the island, isn’t available, Avila explained.
The island might then strip itself of any non-required benefits and services such as dental and pharmacy coverage, Avila continued. Additionally, since the island’s program would not be able to reliably pay providers, Avila anticipates the funding cliff would further exacerbate the provider shortage, she said.
Sandra King Young, Medicaid director for the American Samoa government, struggled to speak as she described the “devastating life and death outcomes” the island would face without new funding.
Already, King Young has had to decide whether to refer a severely disabled infant with cerebral palsy to New Zealand for care. The child’s prognosis was less than 12 months and the cost was at least $1 million.
“We made a difficult decision to deny the referral of this child because we didn’t have the local match. A few weeks later the infant died,” King Young said, blinking back tears.
“For Congress to fail to increase the territories annual Medicaid block grant and to provide a more fair FMAP for the territories in light of the knowledge of the consequences and the loss of lives … because of insufficient medical funding is morally unconscionable. We need your help,” King Young pleaded.