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captioning performed by vitac >> -- this hearing on the medicaid cliff currently facing the u.s. territories. the medicaid funding is provided -- provided by the aca is set to expire this calendar year and the lack of a funding solution will be particularly harmful for american samoa as i know it will be for the other territories. i'd 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. aca's first allotment of funds

became available in july of 2011, long before i and many of us here were elected to congress. those funds were only accessible after the normal annual allotment was exhausted. medicaid and chip payment and access commission, otherwise moan as mack pack published a fact sheet for american samoa which has a list for cal table of total medicaid spending from fy '11 to fy '17 taken from reported expenditures from the centers for medicare and medicaid expenditures. the annual expenditure is $30 million for that period. mr. chairman, i ask for unanimous consent to enter into the record a march 2019 mack pack report on medicaid and chip in american samoa, a may 2019 mack pack issue brief on

territory exhaustion of federal medicaid funds, the april 2016 gao report on medicaid in the u.s. territories and a government -- and a 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 would be able to sufficiently operate 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 don't have a real issue with the local match or the fmap with the -- with our local hospital. it really has to do with the new services and any future planned 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, we could give that would make it sustainable, but based on historical utilization of what we have used, it would be about 80%, minimum 80% for our fmap, but we can definitely do more financial 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 for the territories. fmap aside, what is the needed amount of federal funding to fully support american samoa's medicaid system? >> currently we have submitted information that what we would like to request is a $30 million annual allotment for medicaid. this is based on the historical spending out of the 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 federal share, and then we would need an additional $10 million for all new services for federal

share. that would make it a $30 million federal share block grant increase for american samoa. >> thank you, director. i have more questions that i will be submitting for the record. mr. chairman, i yield back. >> thank you, the gentlelady yields back. i'd like to recognize myself, but before doing that 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 asian pacific health organizations, a letter from -- oh, my goodness -- from national and community organizations signed by -- supported by many organizations, actually, a list of over 20, and also a letter from the guam

regional medical city that i've been asked to submit for the record. >> mr. chairman -- >> yes. >> mr. chairman, sorry to interrupt. can i do the same thing. >> when i recognize you, yeah. >> okay. perfect. >> thank you. and so now i recognize myself for questioning. ms. sablan, welcome. i want to compliment you on all your colleagues including ms. muna, how you managed the obamacare money. so american samoa, guam and the u.s. virgin islands they have hundreds of millions of dollars of obamacare funding unspent, but you have been able to use up all your money, is that correct? >> yes. >> and you used certified public expenditures to make the local match and release the federal funds, is that also right? >> yes, we work with the hospital to use the cpe for our

local match. >> and that is good because the commonwealth government would have had to match the $109 million that we put into obamacare with about $50 million of local funds. the commonwealth did not make that match, did it? >> no, we did not have the money. >> interesting, actually, because all last year the chairman of the [ inaudible ] ways and means committee kept bragging about how he was responsible for the biggest budget ever in the commonwealth history, yet he could not find matching funds for obamacare medicaid money. so, again, i understand that you've had to stop making medical payments to private providers at this time. yes? >> that's right. >> and you also have had to stop paying for medicaid patients to use the fed real qualified cat

man community 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 its share for medicaid, it's not your responsibility, you have to do the best you could with what you were given -- or actually not given, i guess i would have to say, right? >> yes. >> and working with the federal centers for medicare and medicaid services, the congressional office, was able to help you get another $8.2 million, but that has to be adjusted and we could be now down as $4 million, but we also have another $36 million in the disaster supplemental appropriation where it is my hope that you could see yourself through the end of the year. would that help you, help your program? >> yes, thank you, congressman, that would be very much

appreciated. >> okay. again, i want to thank you. i have a little bit more time. ms. muna, thank you also, esther, for coming here and thank you for helping managing this program. what i want to know, ms. muna, how important obamacare funding has been to the hospital. you said local funding was cut in 2010 about $40 million -- from 40 to 5 for your hospital, but then obamacare began in 2011. without obamacare would the hospital have stayed open? >> i don't think so. >> at the same time you were losing local funding, also in danger of losing cmf certification. without obamacare would you have lost certification? >> absolutely. >> wow. and of course if you had lost certification that would mean medicare patients as well as medicaid patients, probably as well as private insurance patients, could not use the hospital, is that correct?

>> that's correct. >> so you testified that obamacare money made it possible to see more patients and to expand services. you tripled your medicaid staff -- your medical staff added specialty services including oncology, implemented quality assurance unit. is that right? >> that's correct. >> and medicaid money helped? >> yes, absolutely. >> and these improvements patient outcomes have improved? >> yes, and they will be able to take -- have it at home. >> and readmission rates have improved? >> correct. >> you said that hospital revenues also quadrupled during this time. it looks like the improvement of services that medicaid made possible helped to make the hospital more financially viable. is that true? >> yes, it is true. >> so to summarize, the obamacare that congress provided you $109 million meant the hospital stayed open, you keep your certification, expand

services, improve patient outcomes and [ inaudible ] your bottom line. >> yes. >> ladies, please, the six questions you have i would really like for you to respond in writing to the committee in ten days. it's going to be part of the hearing record. it is critical that we answer that as completely and as correct as possible. thank you. my time is up. at this time i'd like to yield to my colleague, the ranking member, ms. gonzales. >> thank you, mr. chairman. before my time ends i want to ask unanimous consent to put for the record memorandum of medicaid financing in puerto rico and the u.s. virgin islands made by the kaiser foundation. we were in a panel yesterday of healthcare we did here with puerto rico administration and many others in the private sector. this will be one and the second

one will be another letter from the puerto rico hospital association to be introduced in the record. >> without objection, so ordered. >> thank you, mr. chairman. now i will begin with my line of questioning. in the case of puerto rico we got -- actually, i got some slides regarding some of the data that it's important to note the difference. this is a medicaid funding that has been approved for all the territories. when you see the difference of the spending in terms of how much is federal funding approved and how much is state funded or territories put in their money, you can see that most of our territories are actually doing the spending by using local funds to comply with the requirements of the programs. congress is not acting a lot of people are going to lose their insurance. a lot of people are going to lose their services and that's the reason behind this hearing.

the other information i want to show is how difference -- how different it is the spending for territories and for the states. in the case of puerto rico, as an example, you can have mississippi and many other states receiving more than $700,000 and less than 2,000 to our territory. i know this is kind of the same thing with the rest of territories as well. that's the reason the fmap, the formal -- for the mapping funds it needs to be changed. there are several options to this. we can have 100% federal cost share like we did during the bipartisan bill last year and puerto rico got $4.8 billion for two years, they're going to be expiring in december, or we can lift the cap of 55% that that will allow in the case of puerto rico with the per capita up to 83% of federal funding. and i think this is the best way to do it, taking away -- just allowing the territories to have

the same formula of the states and that's a bill that we actually filed. there we're talking about how much money will be receiving each state if we don't do something with that. in that case i would like to ask -- this is the difference between some states and medicaid funding annually. so the difference is we are not talking about a difference of just 20%. it's up to 80% and 70% of difference, the funding that the states are receiving. so in the case of puerto rico, we are losing providers, we are losing doctors, our profession in the healthcare system are receiving less than half of whatever other professional is receiving in the mainland and that's the reason we're losing a doctor per day during the last years. during the last ten years we've been losing a lot of our professionals, even lacking of specialized physicians. so, ms. avila, i would like to

begin with you and i would love to have an answer directly, yes or no, or the numbers. how many people in puerto rico will lose their healthcare coverage if we do not address the impeding medicaid cliff and how many people will see their benefits or coverage service be reduced if congress is not acting on september of this year? >> we are expecting -- we have right now according to the -- >> a number. i just need a number. >> approximately 600,000 and that will be if we can keep the program viable for puerto rico. >> 600,000 people may lose their insurance if we do not act in september? >> that's right. >> during the last congress i just said that we received $4.8 billion, were approved and the president signed after hurricane

season. out of this more than $1.2 pll were made available. if puerto rico certified that they have data to transform medical statistics system and establish a medicaid fraud control unit. the question has been has puerto rico been able to access the entire allocation of $4.8 billion, including the additional 1.2? >> yes. >> hhs certified that puerto rico was reliable reporting data and establishing medicaid fraud control unit? >> yes, that's correct. >> how duds the inn equal treatment under medicaid program and the fact that we are losing a lot of our people every year, how has the government of puerto rico had the ability to budget to reform our healthcare system if we don't receive the money? >> we are not allowed to forecast any funding that we don't have any assurance.

it has to be certified. this is because the fiscal board requires that. >> so the oversight board required to the island to include all future plans regarding healthcare and that means if we don't receive the money the state, in this case puerto rico, needs to put up front the money from the state to do the job that the federal government is supposed to do in the state? >> yes, that's correct. >> thank you. i will wait for a second round of questions. thank you, mr. chairman. >> i'd like the ranking member's suggestion, but thank you. this time i'd like to recognize the jeptel lady from the united states virgin islands, ms. plaskett, for five minutes. >> thank you, mr. chairman, and thank you to all of the witnesses who are here. did i not see mr. smith with you sitting behind you, i guess he is there to provide support and any additional information. thank you as well for being with us. i wanted to just get state to the questions because i know in your written testimony you give

a lot more statistics and a lot more specific examples of how this has affected us. we've seen on the chart that was demonstrated by my good friend and my colleague about how the difference between what we have provided locally as well as what the federal government was provided, but one of the things that i need to highlight and i think would be important for you to highlight, specific to the virgin islands which may be different from other places, i'm not sure, that you stated that there were approximately how many people that would need to come off of the books or the support that we're receiving now if this funding is -- ends, meaning how many people presently that we've been able to include that no longer will be able to receive those services? >> we would have to reduce upward of 15,000 individuals of the 27,000 approximately members of the medicaid program. >> great. but i think another number that was not brought out that i would

love for you, if you have that number, is how many individuals would we like to bring on the rolls that we believe qualify for medicaid, but we have not given those services to? >> an additional 15,000 to 20,000 individuals who would be eligible for the medicaid program. >> so there are individuals that are presently in the virgin islands, maybe in other territories as well, who are just not receiving any health insurance. we have a large population that have no health insurance that would qualify except for the fact that there is this arbitrary cap that has been put on the amount of money that congress gives to us, and the virgin islands rather than going out and borrowing money, finding other ways, we have done the fiscally prudent and responsible thing and said we just can't service those individuals, is that correct? >> exactly. that is correct. >> and how are some of the other ways that this is impacting us? if you can talk about the

hospitals in the virgin islands. presently we do not receive dish as other places do, for the disproportionate share for hospitals that is an additional bump up that's given in rural areas, although the virgin islands qualifies for it, meets the qualifications, congress and cms have said we would not receive that. what are some of the other ways that our hospital healthcare services are impacted because in the trickle down effect of not receiving this funding? >> well, our hospitals on an every day basis is struggling even though. since 2017 they have been experiencing extreme infrastructure issues. the hospital is unable because of the limited moneys that we're able to give them to be able to bring all of the specialties and all of the specialized equipment. that is one of the reasons that the hospital has frequently called us over the last two years to airlift many of the individuals who go there who have real catastrophic illnesses

and needing specialized procedures. so the hospital in effect has to turn away several individuals who have these extreme circumstances and illnesses and we have to airlift them to the united states for treatment. >> thank you. you also -- i know that our governor has declared an emergency with mental health issues and others. can you talk about that very briefly. >> yes. our behavioral health situation is really -- is really burdened right now. again, the need for more psychiatrists, the need for more of our individuals who have long-term care, behavioral health services. this has been hampered because of just the inequities of our hospitals and of our medicaid program as a whole. it is very, very important for us to also have a skilled nursing facility in both districts of the u.s. virgin

islands. we do not have skilled nursing program within the territory. our hospitals are really, really burdened to provide behavioral health services as well as our community clinics. >> thank you. and finally could you state the things that the virgin islands has done, things that we put in place to provide the compliance and the accountability that congress has asked for for medicaid. i know that there are quite a number of systems that we put in place. >> certainly. we implemented the first ever territory medicaid management information system for claims, the cms. also certified maji compliant our on line medicaid eligibility system. we, too, implemented a medicaid fraud control unit in 2018. we also implemented the temsis the transform medicaid system, we also will be completing all

of our cost report audit reconciliations of our two hospitals, we also completed the am he had kad program integrity review and we have a host of other programs we have been going through for the last few years and especially with the aca dollars we've been able to do all of these things that i just mentioned prior. >> thank you so much for all the work that you're doing and thank you, mr. chairman, for allowing us the opportunity to highlight those for our colleagues here in congress. >> thank you. we're going to have a second round of questioning and i'm going to start with myself, please. ms. rhymer-browne, you just -- including in your recent testimony, but you just listed a series of items that you implemented in your program,

establishing the relationship between the extra medicaid money the virgin islands received in last year's disaster appropriations and the improvements you made in administering the program fraud unit, again, reporting data to cms, to the medicaid management information system, but you were able to do that because of the incentive funding included in the disaster bill, is that correct? >> that is totally correct. without that we would have been unable -- >> that was my next question. i think you're reading my script here, right? but without that incentive funding you would have been able to -- would you have been able to add state like features -- >> could you repeat that, please? >> without that incentive funding would you have been able to do what you did? >> no way. we could not have. >> so it seems to me there is some model there for how we can add other state-like features to the territorial medicaid

programs that if we provide incentive funding, if we give you the resources you need to build capacity then you're willing to do it. is that right? >> we certainly are. >> so i want to congratulate the virgin islands on the work you're doing and i do think what is happening on your islands to be a model for how we make medicaid for state-like in the other insular areas. thank you for showing us what can be done. let me ask the other directors very quickly, if you had up front money to make your programs more like state-like in terms of the services you offer and in terms of how you manage your system, would you make those changes become more like the state, ms. sablan? >> i think so. >> okay. ms. arcangel? >> definitely. >> ms. young, director young, could your program be run like a state if you had state-like funding? >> i believe so. >> thank you.

and how long do you think that would make? could you do it over a period of ten years? would that be reasonable, ms. is a sablan? >> probably. >> ms. arcangel. >> i think so, yes. >> ten years? i didn't hear your answer. >> yes. >> okay. wow. and ms. rhymer-browne. >> yes. >> and, of course -- >> yes, i think that's reasonable. >> ms. avila, i'm not ignoring you, it's just that puerto rico's program is so huge, but would you also be able to do these things and some of which you are already starting to do? >> yes. the answer is yes. thank you. >> okay. look, the fact is that the federal government isn't saving money by not treating the territories equally in medicaid. it has been a big factor in many

territorial citizens moving to a state. so, for example, many puerto ricans have abandoned territory for a state that is more than three-fifths of all people of puerto rican states live in the states. further, medicaid programs in the states spend multiples of what territories spend. in the case of puerto rico three times as much. they are not treating us the same, they are not treating anybody differently, it's just an issue that -- yeah. so they're not saving any money, right, ms. avila? by not giving you the money, the federal government is not saving money because your citizens move to florida and -- >> i will say that is more costly for the states to have our residents here. >> and also costly to us because we're having our people leave

home. and, again, i cannot overemphasize the importance of your written response as concise and as complete to the six items i gave you. those are going to, again, go into the record. it will be shared with the committee of jurisdiction, energy and commerce, and it is a plan that would allow its territory to work through a program, get financial incentives to do those things that require us that will get us hopefully to a full state-like medicare program, not just in terms of money, but in terms of services to our citizens. my time is up. at this time i yield to my -- the ranking member, ms. gonzales-colon. >> thank you, mr. chairman, i will take the same question you were making -- yes, it is on. you were saying about american taxpayers' money will be more

effective if we address this issue now because in the case of puerto rico at least one more -- more than a million puerto ricans just moved to florida. in our case we just take a ticket and we move to a state and we receive the full benefits. so it will take longer -- more money to the united states to address this issue in the long term. if we fix it now we may save a lot of federal funds. so in that sense i would like so ask ms. avila, puerto rico this time just offered ten programs of the 17 medicaid programs, is that correct? >> could you repeat the question, i'm sorry? >> the federal rules for medicaid in puerto rico, for all the state benefits are generally applied to island, but because we -- i mean, we don't have enough funds to match the federal share, we are required to limit a lot of those

benefits. we are just offering 10 of 17 programs in the island, is that correct, yes or no? >> i will say i don't recall 10 or 17. i can mention -- >> just tell me the programs that do not apply on the island. >> right now we don't cover hep c patients within the program and even we have a cure right now for that condition. >> what other program? >> nonemergency transportation, we haven't been able -- >> what other program? >> long-term care. we lost a lot of people. >> what other program? >> those are the main ones that i can highlight right now. >> okay. in terms of -- you mention in your written statement that due to puerto rico's inn equal treatment and the historic low funding we've been forced to limit medicaid eligibility to income levels well below the federal poverty level used by the states. puerto rico has 47% of poverty

level. >> that's correct. >> so what benefits are the one you're limiting? >> well, the main ones would be pharmacy benefits and dental coverage benefits. drugs are [ inaudible ] for a healthcare system and we will not have funds to be able to sustain the drug program what's in the medicaid program in puerto rico. >> so in your experience and having identified areas of the programs, including drugs, how many medicaid eligible individuals in the mainland are not currently covered in puerto rico because of the disproportionate low level federal funding? >> it will be -- we are estimating like more than half a million u.s. citizens have not had their right right now to get into the program. >> more than half a million american citizens living in puerto rico they do not -- they are not covered by medicaid full programs as they were in the

states just because of the lack of funding of the treatment of the state of puerto rico. and i know the same case for the rest of the territories as well because if you don't have the funds, you need to be cutting some of the benefits in order to have more people or trying to at least address the most urgent needs of the island. in the year 2006 to 2016 the numbers of physicians, surgeons and providers of the island dropped from 14,000 to 9,000. >> that's -- >> is this trend exacerbated by the hurricane in 2017? >> that's correct. it has been. >> do we have any number of how many physicians and surgeons we do have on the island at this time? >> well, we are just validating the numbers. >> okay. >> but we have received preliminary information towards 3,000 or more physicians have left the island since the

hurricane. >> so we can say that between 6,000, 7,000 physicians and doctors are still on the island? >> that's right. >> and that trend will continue if they are paid less than the rest of the physicians providing the same service that is received in the states. my time is running but i do want to have some questions for the record and so you can answer later on and that will be specifically for all of the territories represented here. i know you do a lot with less resources and one of those will be how much do medicare program benefits actually cost in the states and in the case of puerto rico, there's no real medicaid financial cliff for puerto rico, this is the [ inaudible ] saying a few weeks ago, now in the letter you say that was submitted for the record they are endorsing receiving the

medicaid funds for puerto rico and i think that's finally common sense, but -- and this is for american samoa -- during the fiscal year there was a balance of $153 million in affordable care act funds in american samoa. can you explain the reasons for this plans in your testimony but my question will be -- and you can answer it later on -- do we need to do something for the territories so they can spend the money? is there any other requirement of the federal government, cms, hhs, that's given to the territories so you can access those funds? what's the reason behind it. with that i will yield back the balance. >> thank you, gentle lady's time has expired. but i also agree for american samoa it's an anomaly. there are not too many private providers. i found that out after our last time that you were on the witness stand, ms. young.

ms. plaskett has five minutes, please. >> thank you. i won't use the five minutes, i'm needed in another meeting, but i just wanted to follow up with a couple of short questions, particularly, of course, for my good woman from the virgin islands, ms. rhymer-browne. you talked about the disaster-related circumstances in which we've been given $100,000. that if we move back to the 55% match that had been previously that that would -- cap would bring us to about $18.7 million, correct? and what is -- >> correct. >> and what is the amount of money, if we were given the state-like treatment, that it would be at? do you know what that number would be? >> i am not sure, however, we are requesting, as i said, for the 100% we would be requesting $251 million for two years and then we would continue at the

83% federal level and those would be for the next three years, but i'm not sure exactly that number. >> what the percent of the 83 would be. >> yeah. >> but we know that for 55% it would be $18.7 million, right? >> yes. >> and that's woefully inadequate. what would be the delta that you would need from the $18.7 million to satisfy the needs of all the individuals that would, if given state-like treatment, be eligible for it? we're not sure at this time? >> we're not sure at this time. >> if you could get that number to me that would be certainly helpful for the record. >> yes, we certainly will. >> one of the other mention that i wanted to talk about, would you -- we talked a little bit

about the physicians and can you state specifically what specialty services we are not -- we are not providing for individuals right now? >> yes, there are several cancer-related situations that we need to airlift. our major cancer center was tremendously damaged on the island of st. thomas. we used to fly individuals from the island of st. croix over to st. thomas but now that center has been down for the last two years. the orthopedic specialists, the trauma specialists, when we have major accidents and situations, workplace accidents, we have to airlift our members off island to receive the treatment on the mainland. >> and how does this impact recruiting physicians to the virgin islands in terms of if there is a belief that we will be reduced in our medicaid treatment moving forward, how

will that impact the ability to not just have specialty doctors, but to have regular physicians, general practitioners, pediatricians, et cetera, to treat this population? >> it would greatly reduce it. before our aca treatment and getting the additional moneys, we were perhaps maybe at about 200 to 300 providers, we have over 700 now because individuals were attracted that we had the additional moneys to provide services for our members, but if we were to be reduced once again, the ability to attract those especialspecializations w greatly -- it would be very hard for the territory to do that. >> thank you. i saw you had a note. was there anything you would like to add? >> yes, he has -- >> mr. smith, she can't read your handwriting. you are not only the director of medicaid, you must be a doctor as well. >> okay.

at the 55% federal we would require 87.2, is that correct? and at the 83%, 52.6. >> okay. thank you very much. and i yield back the balance of my time. >> thank you. and i now recognize the gentleman from nevada, mr. horsford, for five minutes. >> thank you, mr. chairman, for organizing today's hearing on the funding of medicaid in the u.s. territories. i appreciate the opportunity to discuss the shortfalls of medicaid funding in our territories and shed light on this very important issue. to start i want to make it clear that it is my priority as a member of this committee as well as the ways and means committee to ensure all americans including those living in u.s. territories have access to affordable and quality healthcare. sadly, as is often the case with the federal government's treatment of american samoa, the

northern mariana islands, guam, puerto rico and the u.s. virgin islands, u.s. citizens and nationals living in ans lar areas do not receive the same services and benefits afforded to the rest of american people. that's a very sad fact that we need to address. american citizens living in our territories are too often overlooked, mistreated and forgotten and the government services many of them depend on are treated similarly. territories commonly experience higher rates of poverty than states and in many cases our territories depend on medicaid even more than our states. for example, in american samoa because private health insurers refuse to provide the island healthcare coverage, medicaid is their only option. sadly, due to significant shortfalls in federal medicaid funding territories face serious challenges finding the funding needed to support medicaid coverage for all those who depend on t these challenges

from increased in recent years as debt crises, decreased tourism and natural disasters including hurricanes and typhoons, have added to their burdens and heightened economic distress. as a result all territories are forced to cut medicaid programs, heighten eligibility requirements and limit coverage options. we cannot continue to stand by while people in need lose their healthcare coverage. our territories face a significant crisis and they need this congress to find a medicaid funding solution that can address the serious funding setbacks they face. more than 1.3 million people in u.s. territories rely on medicaid which provides health coverage to children, pregnant women, parents, seniors and individuals with disabilities. without a medicaid funding fix, thousands of individuals in need risk losing healthcare coverage and benefits under medicaid.

i want to thank each one of you for your testimony today, i hope your insight can help the members of this congress better understand the challenges our territories face and solutions that are needed. ms. sablan, i want to share my sympathy with you and express my regret that you and your colleagues have been forced to make such tough decisions regarding cuts to medicaid. can you talk through what sofrs the commonwealth would be forced to cut if we do not address the medicaid cliff? will women not be able to get a mammogram, will children not be able to have an annual physical, will seniors lose access to nursing facilities? what options are left for these individuals if they lose their medicaid coverage? >> we will have to cut those not optional services and some of the mandatory services because

my first quarter of the fiscal year we exhaust our 1108 funding. >> and explain what you mean by cut optional services. when i was in the nevada state senate and we had a republican governor who wanted to cut medicaid across the board, it meant cutting diapers from seniors in nursing homes and we rejected that. so what does it mean to you? >> optional services includes prescription drugs, dental services and other care services, that is critical for our patients. >> and what will happen to those individuals without that support? >> well, if they are not -- if they don't get their medications then eventually they will end up at the hospital and that will cost us more money in our inpatient services, as well as dental services. if they are not treated, then they are going to end up in

emergency room services and that costs us more money. >> and, again, is it the case that there are no other options available to them? >> there is no other options because they don't afford to get health insurance. the income that they get is pretty much to put food on their table. >> thank you very much. this is a very important issue, one that affects all the u.s. territories and i commend the chairman and the members of this committee. we have to address this issue and it cannot continue to persist. thank you. i yield back. >> thank you. thank you to the gentleman. i recognize mr. cox from california. no questions. all right. there is another californian at the table here, mr. lowenthal. >> you can yield. >> thank you. thank you, mr. chairman, and i

thank you for recognizing the great state of california also. you know, congress -- i have two questions, one is about the future and one is a little bit about how we got here. first question is if congress does take the steps we've discussed today to treat the territories equitably, such as providing uncapped medicaid funding, calculating fund matching in the same way it does for the states, really begins to treat the territories as part of the united states in an equitable and fair way, are there any mandatory medicaid benefit requirements the territories still wouldn't be able to meet due to territory-specific limitations? are there still other things that need to be addressed, maybe anybody from the committee, are there any unique characteristics of any of the territories that will prevent you from being able

to provide mandatory -- well, the mandatory medicaid benefits? we have to get rid of the cap, we're hearing that is correct you have to have the match in an equitable way that doesn't penalize, but what else should we be -- is there anything else we should be looking at also to make sure that the uniqueness of the territories does not preclude them from receiving certain benefits? anybody? because we're really trying to figure out where do we go from her here. >> this is angie avila from puerto rico. well, besides what is [ inaudible ] for the healthcare system within the medicaid program just to be able to have -- keep the doctors and healthcare providers, it is a great challenge for the island and for the other territories as

well. so we need to find a way to -- with these funds and with this structure that we already have developed, just to start stabilizing the program and see what other needs we will need to confront right now. but it's so urgent just to keep the doctors in the island -- >> keep the doctors. >> it's urgent to avoid the hospitals to collapse that i will say probably we will need to have more support in terms of long-term care to develop the structure to support that population in that area, but according to the guidelines of the cms or hhs federal healthcare program that we will need to identify what else we can do better just to have a more continuing and sustainable program in the island. >> thank you. anybody else want to add something that might be --

>> yes, i just want to echo for the long-term care that this will be a very, very important area for the u.s. virgin islands. we have an aging population and from cms we definitely would need additional technical assistance to not only obtain skilled nursing facility certification, but to maintain these skilled nursing facility certifications, so that technical assistance would be greatly, greatly needed. >> the other question i have is a little bit -- that's looking forward, what you need. how did we get here? you know, and i don't know if anybody can answer t i'm just sitting here wondering in the negotiations does anybody -- maybe gregorio knows better -- in the passage of the aca there were benefits -- there was the medicaid expansion and in some sense it did provide for certain kinds of services for the

territories, yet looking back it was a terrible hindrance, also. it put limits on the territories that it did not put on the rest of the country. how did that happen? >> would the gentleman yield? >> yes, i will yield. >> when we had passed the affordable care act -- >> yes. >> -- and ppa also, under the budget reconciliation process we had to address the senate bill. at that time in all truthfulness we couldn't go into conference because when we come out there will not be enough votes to pass the bill. >> okay. >> so we used that reconciliation process and, of course, we had to go the senate version which the senate addressed the states, not territories, and so we had the -- we worked with the white house and we got increased

money. >> right. >> in addition to the regular programs. but those moneys were used as block grants itself. now, with additional -- if we're going to get into the full full program, there has to be also made improvements to not just the procedures in the process of the program, but also the standard of care for patients. the improvements that they would implement to satisfy medicaid would not just make it for our benefit, it would also benefit the entire patient population in the territories. it would provide services that are not at the present time available in the territories that are available in the states. we could do this over a period of 10 years, there would be money to incentivize them to

meet those standards and at the same time allow also maybe one territory could get this done in five years and the other one may take six years or allow them to work with the secretary of hhs. when they submit plans and the secretary approves the plan, then that territory would get into a full medicare, medicaid program like they do in the states, the rest would take the additional time they would need. it will take time and incentivizing them and they would need financial assistance. but it can be done. it is possible. and that is also for me personally, that is my hope that we would get into the

i use my time very wisely. no questions, you always do mr. lowenthal. mr. tonko from new york. he is recognized for five minutes. thank you mr. chairman. thank you to our witnesses as well for being here today. certainly i believe in the richest country on earth, healthcare should be a guarantor right. not just for residents of the 50 states but for all who call themselves americans. unfortunately, healthcare in america has been segregated between haves and have-nots and the status of medicaid in the insular areas is no exception. like many aspects of federal law, the way the medicaid program views the insular area is a second-class citizen providing fewer resources and less predictability to care for the territories are generally poorer than the 50 states but are subjected to medicaid funding caps and restrictions that have made it significantly challenging for them to provide services to individuals living

below the federal poverty level. despite temporary increases in funds to puerto rico and u.s. virgin islands healthcare systems, they are fragile especially in the wake of hurricanes irma and maria. following these two disasters, residents struggle with substantial health needs. it is imperative i believe that congress properly addressed the medicaid financing issues. expiration of funding could result in even more significant shortfalls and could further restrict program eligibility and cut benefits and system programs. this could be devastating for territories budgets, coverage and healthcare systems more broadly. so, my question to ms. sablan and ms. young, both american samoa and commonwealth of the northern mariana islands relied on a single hospital to provide most of the care to medicaid what are some challenges that arrive with this model and with having uncapped medicaid funding and a higher federal match help

the territories draw an additional providers outside the hospital system? ms. sablan? >> can you repeat your question? > with your reliance on a single hospital for most of the care for medicaid eligible, what are some challenges that arise with this model and would having uncapped medicaid federal funding and a higher federal match help the territories draw an additional providers outside of those in the hospital system? we have to send our patients off island, either to guam, hawaii, the u.s. it really is costing us a lot of money to send our patients with a cap. the limited cap we get and then requiring the local match.

>> if we undo the cap and provide for higher federal match , what is the impact you think? that would really help us. we would be able to provide more >> ms. young, do you have any response? >> to answer the first prong of your question, we provide basic services in our one hospital. basically in our state plan, medically necessary care that is not available in our hospital must be sent off island. currently we send our patients to new zealand because it is the closest country to us. it is closer than hawaii. so, everything from orthopedics

to cardiology to urology, acute, serious pediatrics go to new zealand. if the cap were lifted and we received a better f map, that would truly transform our healthcare system. what is amazing about this situation if you look at the territories, it doesn't take much in the overall scheme of the federal budget to give us a little more in our block grants so we can fully provide the services to our people and care for them. if that cap was lifted and we got a better f map, absolutely we would be able to provide to recruit or providers in our island. that is part of our problem. we don't have enough certified doctors for cms compliance issues and reimbursement

requirements. i think there are three doctors with empty degrees from the u.s. that allows us to claim for medicare. if we had more funding to recruit doctors from the u.s. with md degrees we would be able to do more of those types of cleaning. >> mr. chair, i yield back. >> i recognize miss gonzales. all the members are taking into account, it is important for congress to do something. i am willing to work across the aisle to reach a long term

solution for territories. i think we can do that in energy and commerce. that actually they went to the island in the last congress, both today chairman as ranking member, and i think there's a common sense, one that's sponsored by the territories. i commend members that co-sponsor those bills that will find a solution, permanent solution, even taking the cap of 55% off. or increasing the funding for many in puerto rico and the rest of the territories. i kmenld you for being regional co-sponsor of all those bills. this is something we can achieve during this congress, knowing

most territories suffered different disasters, including typhoons in the last two years. you were willing to answer the last question and time was up. are you finished? >> thank you, senator. >> when we become a state, i will become a senator. now i am in the house. >> thank you. i am used to speaking to guam senators. i'm sorry. to answer questions from congressman from new york, increasing the f map and removing the cap will help the territories. one for guam, our experience is because of lack of funding, local funding, we are unable too much. what happens then, because we have late payments to providers, they don't accept our patients. even off island providers.

what happens, our patients become more sick. their condition becomes more complicated. so the cost of health care increases. while we are waiting for them to draw down federal funding, our patients are staying in the hospital. though we don't have the center. really that's complete with specialties that can handle these people, even for nurses. the centers require all of the professionals in order for them to completely heal the patient. but these patients are waiting months in order to go off island because the providers of island does not want to because of late payments. one more thing with regards to the congressman -- >> do not use up my time. >> i'm sorry. >> i will -- >> i just want to emphasize the

territories does not receive any dish money, and that will help our hospitals. >> dish money for knowledge of members is disproportional share hospital segment. that means the low income patients are being attended at other hospitals without receiving their fair share to make it happen. same thing happened with low subsidy and hit, health insurance tax. our hospitals are paying a tax, we can benefit for the tax incentive that are provided for those hospitals. in puerto rico, we pay more than $200 million a year in the health insurance tax without getting the benefit. it will be the same for all hospitals because we don't have the exchange. there are several parts of health care problems, medicaid is one of them, medicare is

another problem as well. and i have -- i begin to question in my last term to lady from american samoa, we knew each other, how long have you been in the post? miss young? six years. what is the reason that american samoa haven't used or spent money that was allocated to the island? >> up until 2017 we only had one medicaid provider which is the hospital. and the hospital doesn't provide all of the mandatory services under the medicaid program. trying to inform medicaid state plan to add new providers to try to help us draw the federal money, the barrier for that was the local match. for the first time, our government was -- when our

administration came in, there was a lot of old debt that their priority was to focus on. we weren't able to get local match for new services until 2017. our hospital doesn't require local match. but all new services outside of the hospital requires local match. >> i would yield and i would love to have recommendations from the territories that have not spent the medicaid funds, given any problem you're facing, six years there, there should be some recommendations in order to draw that money. with that, i yield back. >> the time is expired. i recognize the gentleman from florida, thank you. that does sound nice.

>> you'll get your time. there's been a long running injustice in this country. i think we all understand that with our territories with regard to health care, taxes, benefits. even the right to vote. and we continue to be in this committee to right those wrongs, to fix those injustices. in puerto rico under the current medicaid system we have seen over 6,000 doctors leave the island, many of them for our great state of florida. hospitals in disrepair, debt added to prop up a medicaid program. all because puerto rico is not treated equally for purposes of medicaid. i know there's a similar story

in each of our territories. that's why we are here today. i have the honor of serving on the energy and commerce committee, name has been invoked about 100 times today. i will be working in both committees on this specifically. but it gets worse. hurricane maria or a typhoon, our territories have been designated by some of the storms, led with tragic things to provide health care after these emergencies, including in puerto rico and virgin islands. northern mariana islands and other areas. it is time to end the injustice. we appreciate you coming from so far away, from so many different corners of the united states to be here today, to make sure

americans have health care equality throughout the territories. i want to thank my fellow representatives because hr 2306 and 2304 are grade ideas of starting points where we need to be with energy and commerce with regard to these bills as well as here. we would like to remove the cap all together, would like territories to be treated as states, get the same type of treatment that they would get otherwise. i think that's where we want to go with these bills or with sort of a combination of them. another bill is to give access to the affordable care act exchanges which right now territories don't have access to. my family's native island of puerto rico, only 30% of people

are on employer based insurance. which is mind blowing compared to states. we need to boost that up. i noticed, this is where i get to my question for each of you. because you're not fully funded with medicaid, some of you aren't providing all services yet, although guam, they're doing all services. if we provided the full f map funding, whether you believe you can provide over the course of certain number of years all these services, and we will start with you.

would you be be able to provide the services and what kind of time period would you need? >> we are talking about we will start immediately. adjusting reimbursement rates to medicare providers. i will say that we will establish that program as it needs now. >> my time is limited. excuse me. miss king. >> yes, we would be able to do more if we were treated equitable funding and the f map. >> we would definitely be able to do more. one of the areas would be to

increase, develop skilled nursing facilities, not have a cap when we have skilled nursing facilities. >> we covered guam. >> there are some we are not covering. >> we are providing services, will be expanding. providing more services for the community at home. >> i appreciate you putting this meeting together. this hearing is impactful. to shine a brighter light on the

inequity everybody has spoken to, both in oral and written testimony. it is an equal treatment issue. very fundamental and simplistic. the way to deal with that is create resource equity on par with what communities in the united states on the main land receive. period. that's the goal. and i look forward to the various legislation 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 chairman pallone about expediting the piece of legislation to start to move

that. having said all that, i really want to ask one question to all of you. it was 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 at present, which would you prefer and why? i think that's the question some -- why don't we just add more money to what exists versus fundamentally making the formula equitable, the reimbursement formula equitable, but that's the one question for all of you,

and we can begin with ms. muna. then we can just go down the panel if you don't mind. thank you, mr. chairman. >> if we were going to choose, we would have to choose the more money 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 won't be able to -- even if you increase the f-map, it would basically be faster for you to expend the money rather than having actual cash available to pay for services that you're going to provide at home. >> thank you. >> i go with the removal of the cap instead of the f-map. and the reason why is we're spending more. we're spending over $72 million.

>> for guam, we spent $110.8 million last year. so if you're just going to increase the f-map, our current cap right now is $17.97 million. that's not enough to pay for those services. so we prefer to increase the funding. >> 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 can't make it. we can't go after it as seen in the aca dollars. >> i think for american samoa, this is an interesting question. i think in an ideal situation, both of these options need to be addressed simultaneously.

>> yes. >> complementary. but if we were given an option, then we would have to go for the more money, lifting of the cap. but what we would have to do as a territory, then, is 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 doesn't require the match. >> we would need to agree with virgin island that it's a combination of both. even if we have more money, if we don't 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 an increase of

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 the situation that puerto rico is facing right now because of trying to cope with the matching of 45% have taken our island to a financial situation that we are living today with the fiscal board and looking for funds to be able to pay what we get to be able to sustain the program and pay for the matching. >> thank you. mr. chairman, i hope that 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. it makes the effort much more powerful to be honest with you.

and so with that, thank you very much again for the hearing. i yield back, sir. >> thank you, mr. chairman. i'm going to take the liberty of asking ms. muna if she could respond, maybe take 30 seconds, one minute to respond to mr. tonko's question, please. >> about expanding services? i mean if you remove the cap -- yes. if you remove the cap, you know, there's a lot of opportunities for us to reform our health care system. and given the opportunity to have that predictable funding -- you have to have predictable funding and sustainable funding. and if you are able to have those, then you'll be able to basically manage the population,

bring health care reform, bring population health, and have a healthier population for your people. and that's an opportunity for us that we would love to have. thank you. >> thank you. thank you very much, everyone. i just want to let everyone know that we have not -- we didn't hold this hearing just on our own. we have been working with outside groups. we have been working with energy and commerce committee staff on trying to address this. so we don't want to blindside them. we also saw again, i will emphasize the really importance of getting as complete and as concise an answer to those six items i gave to you. i also would like again -- i'm really pleased with the virgin islands model that they have started, and i know that -- i understand that some of you have agreed to kick back on your own,

pay your own bill of course. maybe 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 these 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.

tonight on cspan3, a look at the d-day invasion. from the national memorial in bedford, virginia, alex kershaw talks about his book "the first wave." and mary lou ease roberts on her

book. on the invasion impact and aftermath on france. tonight, beginning at 8 eastern. the cspan cities tourist exploring the american story. we take book tv and american history tv on the road, in cooperation with spectrum cable partners, this weekend we take you to missoula, montana, a population of about 66,000, montana's second largest city sits in the western part of the state in the heart of the northern rocky mountains. >> we see bears here all the time, particularly in fall, they're out looking for wild and domestic fruit. the state for grislies and humans, we have to decide how much space to make for wild animals, particularly difficult wunlz like the grizzly.

>> join us on book tv for this and other offerings. sunday at 2:00 p.m., a look at missoula continues on cspan 3 american history tv. >> smoke jumping started in 1939. the goal with smoke jumper is to parachute into wildfires where it is inaccessible to other resources. we are jumping fires in the wilderness, keeping them from becoming massive wildfires. >> the cspan cities tour. exploring the american story, every first and third weekend each month. we take book tv and american history tv on the road. there has been discussion about an appearance before congress. any testimony from this office would not go beyond our report. it contains our findings and analysis and the reasons for the decisions we made. we chose those words carefully and the work speaks for itself.

and the report is my testimony. i would not provide information beyond that which is already public in any appearance before congress. >> former special counsel robert mueller set to appear before two committees of congress. the house judiciary committee and intelligence committee wednesday july 17th, 9:00 a.m. eastern. he will testify in open session about his report into russian interference in the 2016 election. watch live coverage on cspan 3, online at cspan.org on listen with the cspan free radio app. two household and security subcommittees held a joint hearing how fema contracts are awarded and managed. they want to know about a 30 million contract after hurricane maria was awarded to a new company and tarps were never delivered. they heard from fema, government accountability office and homeland security dar