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Medicaid in the Territories: Program Features, Challenges, and Changes

Executive Summary
  1. This brief accompanies the 18th annual budget survey of Medicaid officials in all 50 states and the District of Columbia, which examines trends in Medicaid programs across the country.

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Issue Brief
  1. This report does not include information on the Northern Mariana Islands Medicaid program, as that territory did not complete the survey. This brief accompanies the 18th annual budget survey of Medicaid officials in all 50 states and the District of Columbia, which examines trends in Medicaid programs in all states across the country. The territories received a separate survey tailored to them, but most territories were not able to complete all of the questions.

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  2. July 2018 estimates from The World Factbook (Washington, DC: Central Intelligence Agency, Accessed January 2019), https://www.cia.gov/library/publications/the-world-factbook/index.html.

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  3. 50 states and DC and Puerto Rico: Kaiser Family Foundation analysis of 2017 American Community Survey (ACS), 1-Year Estimates. For other U.S. territories: U.S. Census Bureau, 2010 Census of the Islands Areas, Tables DP-2 and DP-3, using American FactFinder, http://factfinder.census.gov.

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  4. Kaiser Family Foundation analysis of the 2016 (USVI) and 2017 (50 States and D.C., Guam, Puerto Rico) Behavioral Risk Factor Surveillance System (BRFSS). Significance testing for USVI BRFSS data from 2016 was completed using 2016 BRFSS data for the 50 states and D.C., while significance testing for Guam and Puerto Rico used 2017 BRFSS data. BRFSS data from 2016 and 2017 were not available for American Samoa and Northern Mariana Islands.

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  5. Ibid.

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  6. 114th Congress of the United States of America. Public Law 114-187. “Puerto Rico Oversight, Management, and Economic Stability Act [PROMESA]” (Washington, DC: U.S. Congress, June 30, 2016), https://www.congress.gov/114/plaws/publ187/PLAW-114publ187.pdf.

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  7. U.S. Virgin Islands Hurricane Recovery and Resilience Task Force. “USVI Hurricane Recovery and Resilience Task Force: Report 2018” (St. Thomas, U.S. Virgin Islands: Sept. 6, 2018), https://reliefweb.int/sites/reliefweb.int/files/resources/USVI%20Task%20Force%20Initial%20Report.pdf.

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  8. Allyson Ciu, Chris Mooney, & Juliet Eilperin, Washington Post. “Extreme Category 5 typhoon, the worst U.S. storm since 1935, leaves Northern Mariana Islands devastated” (Washington, DC: Oct. 25, 2018), https://www.washingtonpost.com/energy-environment/2018/10/24/extreme-category-typhoon-yutu-makes-devastating-landfall-northern-mariana-islands-us-commonwealth/?utm_term=.7a95693c2387; Haidee Eugenio, Pacific Daily News. “Homes, roads, power system damaged by Mangkhut. Guam poised to ask Trump for emergency declaration” (Hagatna, Guam: Sept. 11, 2018), https://www.guampdn.com/story/news/2018/09/11/homes-roads-power-system-damaged-mangkhut/1261431002/.

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  9. U.S. Census Bureau, Quick Facts; https://www.census.gov/quickfacts/fact/table/ms,pr/DIS010217#DIS010217.

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  10. Congressional Research Service. “Medicaid Funding for the Territories” (Oct. 29, 2018), https://fas.org/sgp/crs/misc/IF11012.pdf.

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  11. Under Sections 2005 and 1323 of the ACA. Does not reflect any utilization of these funds by the territories. Does not include the additional $295.9 million in funds added to the amount Puerto Rico received under the Consolidated Appropriations Act of 2017 or the funds provided to Puerto Rico and USVI by the Balanced Budget Act of 2018.

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  12. Government of Puerto Rico, as certified by the Financial Oversight and Management Board for Puerto Rico. “New Fiscal Plan for Puerto Rico: Restoring Growth and Prosperity” (Oct. 23, 2018), https://drive.google.com/file/d/17ca0ALe7vpYn0jEzTz3RfykpsFSM0ujK/view.

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  13. MACPAC, “Medicaid and CHIP in the Territories” (Feb. 2018), https://www.macpac.gov/wp-content/uploads/2016/09/Medicaid-and-CHIP-in-the-Territories.pdf; MACPAC, “Medicaid and CHIP in the Commonwealth of the Northern Mariana Islands” (Oct. 2017), https://www.macpac.gov/wp-content/uploads/2016/09/Medicaid-and-CHIP-in-the-Commonwealth-of-the-Northern-Mariana-Islands.pdf.

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  14. Under the COFA, in exchange for exclusive U.S. defensive use and other operating rights in the islands, residents of the Marshall Islands, Micronesia, and Palau are able to move freely throughout the United States and its territories, including Guam, with a legal non-immigrant status. While COFA migrants in Guam are generally not eligible for Medicaid, the territory reported that COFA children will become eligible.

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  15. MACPAC, “Medicaid and CHIP in the Territories” (Feb. 2018), https://www.macpac.gov/wp-content/uploads/2016/09/Medicaid-and-CHIP-in-the-Territories.pdf.

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  16. Ibid.

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  17. American Samoa Medicaid Agency. State Plan Amendment #18-002 (approved Sept. 10, 2018), https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/AS/AS-18-002.pdf; American Samoa Medicaid Agency. “Frequently Asked Questions” (accessed Jan. 2019), https://medicaid.as.gov/faqs/.

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  18. U.S. Virgin Islands Hurricane Recovery and Resilience Task Force. “USVI Hurricane Recovery and Resilience Task Force: Report 2018” (St. Thomas, U.S. Virgin Islands: Sept. 6, 2018), https://reliefweb.int/sites/reliefweb.int/files/resources/USVI%20Task%20Force%20Initial%20Report.pdf.

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  19. Jerick Sablan, Pacific Daily News. “No. 5: Guam Regional Medical City opens” (Hagatna, Guam: Jan. 4, 2016), https://www.guampdn.com/story/entertainment/2015/12/31/no-5-guam-regional-medical-city-opens/77077524/.

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  20. Kevin Kerrigan, The Guam Daily Post. “Hospital to downsize” (Tamuning, Guam, Oct. 4, 2018), https://www.postguam.com/news/local/hospital-to-downsize/article_f339fa18-c795-11e8-a65a-b3e19c51230f.html.

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  21. Assessing Current Conditions and Challenges at the Lyndon B. Johnson Tropical Medical Center in American Samoa: Oversight Hearing before the Subcommittee on Indian, Insular, and Alaska Native Affairs; Committee on Natural Resources, U.S. House of Representatives; 115th Congress of the United States of America (Washington, DC: July 25, 2017), https://www.govinfo.gov/content/pkg/CHRG-115hhrg26408/html/CHRG-115hhrg26408.htm.

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  22. Pacific Daily News staff, Pacific Daily News. “Preliminary denial of GMH accreditation: Joint Commission letter” (Hagatna, Guam: Feb. 2, 2018), https://www.guampdn.com/story/news/2018/02/02/preliminary-denial-gmh-accreditation-joint-commission-letter/1089674001/.

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  23. John McCarthy, VI Free Press. “Juan Luis Hospital ‘Fully Certified’ by CMS for Medicare and Medicaid Funding” (Christiansted, St. Croix, USVI: Jan. 5, 2016), http://vifreepress.com/2016/01/juan-luis-hospital-fully-certified-by-cms-for-medicare-and-medicaid-funding/.

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  24. Krista Perreira, et al. Urban Institute. “Research Report: Environmental Scan of Puerto Rico’s Health Care Infrastructure” (Washington, DC: Jan. 2017), https://www.urban.org/sites/default/files/publication/87016/2001051-environmental-scan-of-puerto-ricos-health-care-infrastructure.pdf.

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  25. Ibid.

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  26. U.S. Virgin Islands Hurricane Recovery and Resilience Task Force. “USVI Hurricane Recovery and Resilience Task Force: Report 2018” (St. Thomas, U.S. Virgin Islands: Sept. 6, 2018), https://reliefweb.int/sites/reliefweb.int/files/resources/USVI%20Task%20Force%20Initial%20Report.pdf.

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  27. Assessing Current Conditions and Challenges at the Lyndon B. Johnson Tropical Medical Center in American Samoa: Oversight Hearing before the Subcommittee on Indian, Insular, and Alaska Native Affairs; Committee on Natural Resources, U.S. House of Representatives; 115th Congress of the United States of America (Washington, DC: July 25, 2017), https://www.govinfo.gov/content/pkg/CHRG-115hhrg26408/html/CHRG-115hhrg26408.htm.

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  28. Office of the Inspector General, U.S. Department of the Interior. “Guam Memorial Hospital Authority” (Washington, DC: Dec. 2014), https://www.oversight.gov/sites/default/files/oig-reports/HI-EV-OIA-0001-2014Public.pdf.

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  29. Governor Rosselló Nevares Announces Award of the New Model of My Health, July 6, 2018; accessed at https://www.fortaleza.pr.gov/content/gobernador-rossell-nevares-anuncia-adjudicaci-n-del-nuevo-modelo-de-mi-salud.

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