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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 

OF THE

COMMITTEE ON NATURAL RESOURCES 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

FIRST SESSION 

Tuesday, July 25, 2017 

Serial No. 115–21 

Printed for the use of the Committee on Natural Resources 

( 

Available via the World Wide Web: http://www.fdsys.gov 

or 

Committee address: http://naturalresources.house.gov 

(II) 

COMMITTEE ON NATURAL RESOURCES 

ROB BISHOP, UT, Chairman 

RAU ́ L M. GRIJALVA, AZ, Ranking Democratic Member 

Don Young, AK 

Chairman Emeritus 

Louie Gohmert, TX 

Vice Chairman 

Doug Lamborn, CO 

Robert J. Wittman, VA 

Tom McClintock, CA 

Stevan Pearce, NM 

Glenn Thompson, PA 

Paul A. Gosar, AZ 

Rau ́l R. Labrador, ID 

Scott R. Tipton, CO 

Doug LaMalfa, CA 

Jeff Denham, CA 

Paul Cook, CA 

Bruce Westerman, AR 

Garret Graves, LA 

Jody B. Hice, GA 

Aumua Amata Coleman Radewagen, AS 

Darin LaHood, IL 

Daniel Webster, FL 

Jack Bergman, MI 

Liz Cheney, WY 

Mike Johnson, LA 

Jenniffer Gonza ́lez-Colo ́n, PR 

Greg Gianforte, MT 

Grace F. Napolitano, CA 

Madeleine Z. Bordallo, GU 

Jim Costa, CA 

Gregorio Kilili Camacho Sablan, CNMI 

Niki Tsongas, MA 

Jared Huffman, CA 

Vice Ranking Member 

Alan S. Lowenthal, CA 

Donald S. Beyer, Jr., VA 

Norma J. Torres, CA 

Ruben Gallego, AZ 

Colleen Hanabusa, HI 

Nanette Diaz Barraga ́n, CA 

Darren Soto, FL 

A. Donald McEachin, VA 

Anthony G. Brown, MD 

Wm. Lacy Clay, MO 

Jimmy Gomez, CA 

Todd Ungerecht, Acting Chief of Staff 

Lisa Pittman, Chief Counsel 

David Watkins, Democratic Staff Director 

SUBCOMMITTEE ON INDIAN, INSULAR AND ALASKA NATIVE AFFAIRS 

DOUG LAMALFA, CA, Chairman 

NORMA J. TORRES, CA, Ranking Democratic Member 

Don Young, AK 

Jeff Denham, CA 

Paul Cook, CA 

Aumua Amata Coleman Radewagen, AS 

Darin LaHood, IL 

Jack Bergman, MI 

Jenniffer Gonza ́lez-Colo ́n, PR 

Vice Chairman 

Rob Bishop, UT, ex officio 

Madeleine Z. Bordallo, GU 

Gregorio Kilili Camacho Sablan, CNMI 

Ruben Gallego, AZ 

Darren Soto, FL 

Colleen Hanabusa, HI 

Rau ́l M. Grijalva, AZ, ex officio 

(III) 

CONTENTS 

Page 

Hearing held on Tuesday, July 25, 2017 ............................................................... 1 

Statement of Members: 

LaMalfa, Hon. Doug, a Representative in Congress from the State of 

California ....................................................................................................... 1 

Prepared statement of ............................................................................... 2 

Radewagen, Hon. Aumua Amata Coleman, a Delegate in Congress from 

the Territory of American Samoa ................................................................ 3 

Prepared statement of ............................................................................... 4 

Sablan, Gregorio Kilili Camacho, a Delegate in Congress from the 

Territory of the Northern Mariana Islands ................................................ 5 

Prepared statement of ............................................................................... 6 

Statement of Witnesses: 

Bussanich, Thomas, Director of Budget, Office of Insular Affairs, 

Department of the Interior, Washington, DC ............................................. 8 

Prepared statement of ............................................................................... 9 

Questions submitted for the record ......................................................... 10 

Faumuina, Taufete’e John, CEO-Director, Lyndon B. Johnson Tropical 

Medical Center, Faga’alu, American Samoa ............................................... 11 

Prepared statement of ............................................................................... 13 

Questions submitted for the record ......................................................... 14 

Young, Sandra King, Medicaid Director, American Samoa Medicaid 

Agency, Office of the Governor, Pago Pago, American Samoa .................. 17 

Prepared statement of ............................................................................... 19 

Additional Materials Submitted for the Record: 

List of documents submitted for the record retained in the Committee’s 

official files .................................................................................................... 36 

(1) 

OVERSIGHT HEARING ON ASSESSING CURRENT CONDITIONS AND CHALLENGES AT 

THE LYNDON B. JOHNSON TROPICAL 

MEDICAL CENTER IN AMERICAN SAMOA 

Tuesday, July 25, 2017 

U.S. House of Representatives 

Subcommittee on Indian, Insular and Alaska Native Affairs 

Committee on Natural Resources 

Washington, DC 

The Subcommittee met, pursuant to notice, at 10:04 a.m., in 

room 1324, Longworth House Office Building, Hon. Doug LaMalfa 

[Chairman of the Subcommittee] presiding. 

Present: Representatives LaMalfa, Gonza ́lez-Colo ́n, Radewagen, 

Bishop; and Sablan. 

Also present: Representative Westerman. 

Mr. LAMALFA. The Subcommittee on Indian, Insular and Alaska 

Native Affairs will come to order. The Subcommittee is meeting 

today to hear testimony on the topic of, ‘‘Assessing Current 

Conditions and Challenges at the Lyndon B. Johnson Tropical 

Medical Center in American Samoa.’’ 

I ask unanimous consent that the gentleman from Arkansas, Mr. 

Westerman, be allowed to sit in with the Committee and participate in the hearing. 

So ordered, without objection. 

Under Committee Rule 4(f), any oral opening statements at 

hearings are limited to the Chairman, the Ranking Minority 

Member, and the Vice Chair. This allows us to hear from our witnesses sooner, and helps Members to keep to their schedules. 

Therefore, I ask unanimous consent that all other Members’ opening statements be made part of the hearing record if they are submitted to the Subcommittee Clerk by 5:00 p.m. today. 

Without objection. 

STATEMENT OF THE HON. DOUG LAMALFA, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

Mr. LAMALFA. Good morning. The Subcommittee is meeting to 

discuss the previously mentioned topic. 

The islands of American Samoa joined the United States through 

Deeds of Cession back in the early 1900s, and thus their fate and 

well-being has been tied to that of our mainland for the last 117 

years. During that time, American Samoa has had its struggles 

with maintaining and providing healthcare services for their growing population. 

In 1966, President Lyndon Johnson gave remarks at the Tafuna 

International Airport in Pago Pago and his remarks acknowledged 

construction of the American Samoa Tropical Medical Center, the 

2 

territory’s first and only hospital, ‘‘which will provide the finest 

hospital care in this part of the world.’’ 

Unfortunately, the President’s hopes for the Tropical Medical 

Center did not come to fruition, as the hospital is in a state of disrepair, far below expectations. With this deteriorating infrastructure and the strain of rising healthcare costs that plague many of 

America’s rural areas, the hospital administration is being forced 

to tackle an expanding list of challenges: shortage of qualified medical staff and the remoteness of the South Pacific. 

It is, indeed, a struggle to provide this everyday treatment that 

is needed. Many have to journey 5 hours via airplane to Hawaii, 

instead, to receive proper care. The cost of travel is a burden for 

them, and places an incredible challenge in meeting these costs. 

Congress has a responsibility to the territories, and to review the 

Federal policies and programs that affect the daily lives of the 

Americans living and working in these far-off places. 

The testimony received today will be a crucial step forward for 

Congress to review and better understand how our policies are affecting these Americans at the local level in the Nation’s most 

remote territories. 

[The prepared statement of Mr. LaMalfa follows:] 

PREPARED STATEMENT OF THE HON. DOUG LAMALFA, CHAIRMAN, SUBCOMMITTEE ON

INDIAN, INSULAR AND ALASKA NATIVE AFFAIRS

Good Morning. The Subcommittee is meeting today to discuss a topic not many 

Americans are familiar with, in a place not many Americans are familiar with, the 

Lyndon B. Johnson Tropical Medical Center in American Samoa. 

The islands of American Samoa joined the United States through Deeds of 

Cession back in the early 1900s and thus their fate and well-being has been tied 

to that of our mainland for the last 117 years. During that time, American Samoa 

has had its struggles with maintaining and providing healthcare services for their 

growing population. 

On a visit in 1966, then-President Lyndon Baines Johnson gave remarks at 

Tafuna International Airport in Pago Pago. In his remarks, the President acknowledged the construction of the American Samoa Tropical Medical Center, the 

territory’s first and only hospital, ‘‘. . . which will provide the finest hospital care 

in this part of the world.’’ 

Unfortunately, the President’s hopes for the Tropical Medical Center did not come 

to fruition as the hospital is in a state of disrepair, far below expectations. With 

deteriorating infrastructure and the strain of rising healthcare costs that plague 

many of America’s most rural areas, the hospital administration is being forced to 

tackle an expanding list of challenges. 

A shortage of qualified medical staff and the remoteness of the territory’s location 

in the South Pacific make recruitment of vital medical care providers a daunting 

task. The struggle to provide adequate medical treatment is an everyday fight for 

the hospital’s limited staff and all too often a futile one, as many patients in need 

of advanced treatment are forced to journey 5 hours via airplane to Hawaii in order 

to receive proper care. The cost of this travel for healthcare only continues to overburden both the territory and the Federal programs that are in place to cover a 

portion of these enormous costs. 

These challenges are ones that the hospital administration and local government 

cannot possibly tackle on their own and in today’s hearing we will look at the role 

the Federal Government has played in this partnership and if there are ways for 

improvements to be made, both in infrastructure and under current Federal 

healthcare programs. Congress has a responsibility to the territories and to review 

the Federal policies and programs that affect the daily lives of the Americans living 

and working in these far-off places. 

All too often, it is easy to leave the territories on the fringes of our Nation’s collective dialogue, and what might seem like minor policy changes to folks here living 

in the mainland United States can have very major consequences to those living in 

our most remote districts. 

3 

I thank all the witnesses that made the roughly 7,000 mile journey from the 

South Pacific to be with us here today to share their valuable expertise and insight 

as to the conditions at the LBJ hospital. The testimony we receive here today will 

be a crucial step forward for Congress to review and better understand how our 

Federal policies are affecting the Americans at the local level in the Nation’s most 

remote territory. 

Mr. LAMALFA. With that, I would like to yield time to our 

colleague from American Samoa, Mrs. Radewagen. 

STATEMENT OF THE HON. AUMUA AMATA COLEMAN 

RADEWAGEN, A DELEGATE IN CONGRESS FROM THE 

TERRITORY OF AMERICAN SAMOA 

Mrs. RADEWAGEN. Thank you, Mr. Chairman. I first want to 

thank you and the members of the Committee for holding today’s 

hearing. It has been a long time coming, and I am glad to see us 

finally sitting down to tackle this issue that is so important to my 

home district of American Samoa. 

I also want to welcome our witnesses, who have traveled halfway 

around the world to be here, including Taufete’e John Faumuina, 

CEO and Director of the LBJ Tropical Medical Center; Dr. Reese 

Tuato’o—do I see Dr. Reese Tuato’o?; and Sandra King Young, 

Medicaid Director for the territory. Thank you all for being here 

today. Your dedication to your work is much appreciated. 

Welcome also to Mr. Tom Bussanich, from the Department of the 

Interior. 

This hearing is the result of the CODEL that traveled to 

American Samoa in February, and I want to thank Chairman 

Bishop and the Members who were able to join us. During the visit, 

the Members were given a tour of LBJ Hospital, the only medical 

treatment facility on the island. 

I want it in the record that our doctors and nurses who work 

there do an excellent job with the limited resources they have 

available, and they should be commended for their efforts to maintain the good health of our people. 

LBJ is approximately a 150-bed facility which opened in 1968 

and has since had only minor facelifts, such as new doors and fresh 

paint. The capabilities of the facility have largely remained the 

same. 

Additionally, further adding to the applause we should be heaping upon our doctors and nurses is the fact that the facility is drastically under-staffed, as getting qualified medical personnel to the 

island has proven to be difficult, an issue that I hope we can find 

a solution to through this hearing and the work that will follow. 

The American Samoa Government Operations account, which is 

included in the annual Interior appropriations bill, provides approximately $7 million annually for hospital operations. That 

account not only funds a portion of the local hospital, but also the 

local judiciary, the Department of Education and local community 

college—originated in 1974 at an amount of approximately $17 

million, annually. 

Since then, it has been increased only once, in 1986, to $22.75 

million a year, where it sits today. And if one were to use the 

standard CPI formula, that amount would now be over $50 million 

4 

annually. Again, the hospital’s take from this appropriation is 

approximately $7.5 million. 

Compare that to any other facility of the same size here in the 

states, and the gap in equity becomes very clear. For example, this 

year’s total budget for LBJ was about $51 million, while a hospital 

of the same size in Washington State has a 2017 budget of roughly 

$200 million. 

The people of American Samoa need better access to care without 

having to take a flight. The fact is it is beyond time for a significant increase to the account. The reasoning provided in DOI’s 

budget report for the lack of any increase to the ASG operations 

account over the years is to promote self-sufficiency on the island, 

which is all fine and well, but near impossible when, at the same 

time, the Federal Government has closed off large swaths of fishing 

grounds in the Pacific that our people have used for a millennium, 

and long before any relationship with the United States, and at the 

same time imposed federally mandated minimum-wage laws, irresponsibly putting the territory, which is both economically and geographically isolated, on the same playing field as the states. 

Mr. LAMALFA. The gentlelady will have to come back to the rest 

of your statement a little bit later. Our time has expired. 

Mrs. RADEWAGEN. Thank you, Mr. Chairman. I yield back. 

[The prepared statement of Mrs. Radewagen follows:] 

PREPARED STATEMENT OF THE HON. AUMUA AMATA RADEWAGEN, A DELEGATE IN

CONGRESS FROM THE TERRITORY OF AMERICAN SAMOA

Thank you Mr. Chairman. I thank my colleague for yielding her time. 

I first want to thank you and the members of the Committee for holding today’s 

hearing. It has been a long time coming, and I am glad to see us finally sitting down 

to tackle this issue that is so important to my home district of American Samoa. 

I also want to welcome our witnesses who have traveled halfway around the world 

to be here including: Taufete’e John Faumuina, CEO and Director of LBJ Tropical 

Medical Center; Dr. Reese Tuato’o, Chief of Internal Medicine at LBJ; and 

Tofoitaufa Sandra Young, Medicaid Director for the territory. Thank you all for 

being here today. Your dedication to your work is appreciated. 

This hearing is the result of the CODEL that traveled to American Samoa in 

February, and I want to thank Chairman Bishop and those Members who were able 

to join us. During the visit, the Members were given a tour of LBJ Hospital, the 

only medical treatment facility on the island. I want it in the record that our doctors 

and nurses who work there do an excellent job with the limited resources they have 

available, and they should be commended for their efforts to maintain the good 

health of our people. 

LBJ is a 150-bed facility which opened in 1968, and has since had only minor 

facelifts, such as new doors and fresh paint. The capabilities of the facility have 

largely remained the same. Additionally, further adding to the applause we should 

be heaping upon our doctors and nurses is the fact that the facility is drastically 

under-staffed, as getting qualified medical personnel to the island has proven to be 

difficult, an issue that I hope we can find a solution to through this hearing and 

the work that will follow. 

The American Samoa Government Operations account, which is included in the 

annual Interior appropriations bill, provides approximately $7 million annually for 

hospital operations. That account not only funds a portion of the local hospital, but 

also the local judiciary, the Department of Education, and local community college— 

originated in 1974 at the amount of approximately $17 million annually. Since then, 

it has been increased only once in 1986 to $22.75 million a year where it sits today. 

If one were to use the standard CPI formula, that amount would now be over $50 

million annually. Again, the hospital’s take from this appropriation is approximately 

$7.5 million. 

Compare that to another facility of the same size here in the states, and the gap 

in equity becomes very clear. For example, this year’s total budget for LBJ was $51 

million, while a hospital of the same size in Washington State has a 2017 budget 

5 

of roughly $200 million. The people of American Samoa need better access to care 

without having to take a flight. The fact is, it is beyond time for a significant 

increase to the account. 

The reasoning provided in DOI’s budget report for the lack of any increase to the 

ASG operations account over the years is to ‘‘promote self-sufficiency’’ on the island, 

which is all fine and well, but near impossible when at the same time, the Federal 

Government has closed off large swaths of fishing grounds in the Pacific that our 

people have used for a millennium, and long before any relationship with the United 

States, and at the same time imposed federally mandated minimum wage laws, irresponsibly putting the territory, which is both economically and geographically 

isolated, on the same playing field as the states—a policy that has already forced 

one tuna cannery to leave the island for Thailand where they pay their workers a 

mere fraction of what ours are required to pay. I recently introduced legislation to 

resolve this issue, H.R. 3021, the American Samoa Job Protection and Expansion 

Act, and I look forward to seeing congressional action on it. 

Regarding LBJ and any improvements to be made following congressional action, 

I will be introducing a bill shortly that calls for a GAO study in partnership with 

DOI, the VA and HHS to assess the feasibility of either a new or updated facility, 

and I encourage my colleagues to support the measure. It is high-time that we here 

in Congress recognize the issues happening in the insular areas, and I am encouraged by today’s hearing and the action it will bring. 

Again, I want to thank our witnesses for traveling so far to be here today. I know 

that the work they do on the islands is indispensable and I know that their testimony will provide even more insight into the issues we are facing on the island in 

regards to providing accessible and quality health care for our people. I look forward 

to their testimony and moving forward with some real solutions to improve the 

health care for the people of American Samoa. 

Thank you Mr. Chairman, I yield back. 

Mr. LAMALFA. Thank you. I would now like to recognize our 

Ranking Member, Mr. Sablan. 

STATEMENT OF THE HON. GREGORIO KILILI CAMACHO 

SABLAN, A DELEGATE IN CONGRESS FROM THE TERRITORY 

OF THE NORTHERN MARIANA ISLANDS 

Mr. SABLAN. Thank you very much, Mr. Chairman, for agreeing 

to hold this important hearing. I welcome our witnesses, particularly those who traveled from American Samoa. 

I had the opportunity to visit the LBJ Tropical Medical Center 

in American Samoa last year, led by Chairman Bishop and hosted 

by my friend, Congresswoman Radewagen. We got a firsthand look 

at the hospital, the deterioration of the physical plant, the lack of 

equipment and supplies, the difficulty of hiring and retaining staff. 

I look forward to hearing what ideas our witnesses offer, particularly the Office of Insular Affairs, on how we can make sure the 

people of American Samoa get the health care that all Americans 

have the right to and that all of us here in Congress enjoy. 

But American Samoa is not the only insular area struggling with 

health care. As recently as last December, officials at the Centers 

for Medicare and Medicaid Services threatened to decertify the 

Juan F. Luis Hospital and Medical Center in the U.S. Virgin 

Islands, because the hospital failed to meet basic Federal 

standards. 

6 

In my own district, the Northern Marianas, our only hospital 

also faced CMS decertification in 2012. A team from the U.S. 

Public Health Service and funding from other Federal agencies 

came to the rescue and kept the hospital opened. But to this day, 

the hospital has not met all of the standards required to lift the 

threat of decertification. 

And though the problems at the Marianas hospital were of long 

standing, the real catalyst was the decision by the Commonwealth 

government in 2008 to cut off funding and create a quasiindependent Commonwealth Healthcare Corporation. The corporation has struggled with the costs of delivering healthcare services 

to the people of the Marianas. Half are below the Federal poverty 

line and one-third have no health insurance, so patients are often 

unable to pay for care. 

The only reason the hospital has been able to remain open, the 

corporation’s Chief Executive Officer has said, is because of the 

extra Medicaid money that was provided by Obamacare: $109 

million. As we all know, that extra money runs out at the end of 

Fiscal Year 2019 or earlier, depending on whether the Majority 

repeals Obamacare, as it has promised to do. 

Mr. Chairman, 9 years ago the Inspector General of the Department of the Interior issued a report entitled, ‘‘Insular Healthcare 

at the Crossroads to Total Breakdown.’’ Insular governments were 

unable to provide comprehensive healthcare services to their citizens, the report stated, because of shortages of supplies, medicines, 

specialty physicians, and because of inadequate, antiquated, or 

damaged infrastructure. 

Sadly, little has changed. This is why any replacement of 

Obamacare, which the Majority has promised, must include the 

U.S. insular areas. At a minimum, Medicaid must be available to 

our areas in exactly the same way it is available to every part of 

the country. Beyond that, the federally funded tax credits that are 

being proposed in the Majority’s Better Care Act, that will provide 

help to individuals and families to buy private insurance, must be 

available to Americans in American Samoa, Guam, the Marianas, 

and the U.S. Virgin Islands. 

The President has promised ‘‘insurance for all.’’ We are all 

waiting. 

I look forward to working with you, Mr. Chairman, and all our 

colleagues, to fulfill the President’s promise, and include the people 

of the insular areas fully and equally in our national healthcare 

programs. 

Thank you, and I yield back. 

[The prepared statement of Mr. Sablan follows:] 

PREPARED STATEMENT OF THE HON. GREGORIO KILILI CAMACHO SABLAN, A

DELEGATE IN CONGRESS FROM THE TERRITORY OF THE NORTHERN MARIANA ISLANDS

Thank you, Mr. Chairman, for agreeing to hold this important hearing. I welcome 

our witnesses, particularly those who traveled from American Samoa. 

I had the opportunity to visit the LBJ Tropical Medical Center in American 

Samoa last year, led by Chairman Bishop and hosted by Representative Radewagen. 

We got a firsthand look at the hospital—the deterioration of the physical plant, the 

lack of equipment and supplies, the difficulty of hiring and retaining staff. 

I look forward to hearing what ideas our witnesses offer—particularly the Office 

of Insular Affairs—on how we can make sure the people of American Samoa get the 

health care that all Americans have a right to and all of us here in Congress enjoy. 

7 

But American Samoa is not the only insular area struggling with health care. As 

recently as last December, officials at the Centers for Medicare and Medicaid 

Services threatened to decertify the Juan Luis Hospital in the Virgin Islands, because the hospital failed to meet basic Federal standards. 

In my own district, the Marianas, our only hospital also faced decertification in 

2012. A team from the Public Health Service and funding from other Federal agencies came to the rescue and kept the hospital open. But, to this day, the hospital 

has not met all of the standards required to lift the threat of decertification. 

Though the problems at the Marianas hospital were of long-standing, the real catalyst was the decision by the Commonwealth government in 2008 to cut off funding 

and create a quasi-independent Commonwealth Healthcare Corporation. The 

Corporation has struggled to meet the costs of delivering healthcare services to the 

people of the Marianas. Half are below the Federal poverty line and one-third have 

no health insurance. So, patients are often unable to pay for care. 

The only reason the hospital has been able to remain open, the Corporation’s 

Chief Executive Officer has said, is because of the extra Medicaid money that was 

provided by Obamacare—$109 million. As we all know, that extra money runs out 

at the end of Fiscal Year 2019—or earlier depending on whether the Majority 

repeals Obamacare, as it has promised to do. 

Mr. Chairman, 10 years ago the Inspector General of the Department of the 

Interior issued a report entitled: Insular Health Care ‘‘at the crossroads to total 

breakdown.’’ Insular governments were unable to provide comprehensive healthcare 

services to their citizens, the report stated, because of shortages of supplies, medicines and specialty physicians, and because of inadequate, antiquated or damaged 

infrastructure. Sadly, little has changed. 

This is why any replacement of Obamacare, which the Majority has promised, 

must include the U.S. insular areas. At a minimum, Medicaid must be available to 

our areas in exactly the same way it is available to every other part of our country. 

Beyond that, the federally-funded tax credits that are being proposed in the 

Majority’s Better Care Act—that will provide help to individuals and families to buy 

private insurance—must be available to Americans in American Samoa, Guam, the 

Marianas, and the Virgin Islands. 

The President has promised ‘‘insurance for all.’’ We are all waiting. 

I look forward to working with you, Mr. Chairman and our other colleagues, to 

fulfill the President’s promise and include the people of the insular areas fully and 

equally in our national healthcare programs. Thank you. 

Mr. LAMALFA. Thank you, Mr. Sablan. Again, I want to thank 

the witnesses who have made the 7,000-mile journey that you did 

to be here today and provide their expertise. So, let me introduce 

them. 

We have Mr. Thomas Bussanich, Director of Budget at the Office 

of Insular Affairs, Department of the Interior; Mr. Taufete’e 

Faumuina, CEO of the Lyndon B. Johnson Tropical Medical 

Center; and Sandra King Young, a Medicaid Director, American 

Samoa Medicaid Agency, from the Office of the Governor. 

Let me remind our witnesses that under our Committee Rules, 

they must have their oral statements limited to 5 minutes, but 

their entire written statement will appear in the hearing record. 

Microphones are not automatic, you have to press the button to 

begin. The light will then turn green. When it turns yellow, you 

have 1 minute to go. When it is red, you know what that means, 

I ask you to complete your statement at that point. 

I will also allow the entire panel to testify before questioning by 

our panel up here. 

The Chair will now recognize Mr. Bussanich to testify. 

You have 5 minutes. 

8 

STATEMENT OF THOMAS BUSSANICH, DIRECTOR OF BUDGET, 

OFFICE OF INSULAR AFFAIRS, DEPARTMENT OF THE 

INTERIOR, WASHINGTON, DC 

Mr. BUSSANICH. Mr. Chairman and members of the 

Subcommittee, thank you for the opportunity to speak regarding 

the LBJ Tropical Medical Center, the primary healthcare facility in 

American Samoa. 

The Office of Insular Affairs has been a partner with the 

American Samoa government for many years, providing supplemental funding for the operations and renovation of the hospital 

that was beyond the capacity of the local community. 

The American Samoa government is a recipient of the significant 

share of the annual $27.7 million in capital infrastructure funding 

available from the Office of Insular Affairs. Historically, American 

Samoa has received at least one-third of the money in infrastructure funds set aside for the four flag territories. 

For the American Samoa government, the allocation of its capital 

funds is conditioned on submission of 5-year capital improvement 

plans that outline local priorities for capital spending. For many 

years, American Samoa’s top priority was health. And, therefore, 

the LBJ Tropical Medical Center received large shares of capital 

spending. 

In the 5-year CIP plan for 2016 through 2020, priorities changed 

due to the fragility of the territory’s main industry, tuna canning. 

The new 5-year plan elevates economic development to priority 

number one, and education to number two. Health is bumped to 

number three. The allocation decisions are made by the American 

Samoa government and are not set by the Office of Insular Affairs. 

The LBJ Tropical Medical Center was constructed in the 1960s. 

During the past 15 years, CIP funding has been used to renovate 

much of the hospital to bring it into compliance with modern 

hospital standards. Currently, the labor, delivery, and surgical 

wings are under major renovation and expansion. Construction is 

ongoing, and when the renovation project is completed in 2020, 

approximately 60 percent of the hospital’s physical plant will count 

as having been rebuilt. 

The Office of Insular Affairs also provides operational funding for 

the LBJ Hospital from the annual American Samoa operations 

grant. In the current fiscal year, the grant totals $22.7 million. The 

actual use of the grant is proposed by the American Samoa government, which is using $7.9 million to support LBJ in this fiscal year. 

The remainder of the grant is used to support general education— 

$11.4 million; the community college at $1.4 million; and the high 

court, at $900,000. 

Over the past 15 years, the Office of Insular Affairs has provided 

$132 million in operations funding and $30 million in CIP funding 

for the LBJ Tropical Medical Center. The Department of the 

Interior is proud to have been a partner with the American Samoa 

government in improving LBJ Tropical Medical Center. There is a 

great deal that still needs to be done, and we look forward to continuing to work to improve conditions and serve the people of 

American Samoa. Thank you. 

[The prepared statement of Mr. Bussanich follows:] 

9 

PREPARED STATEMENT OF THOMAS BUSSANICH, DIRECTOR OF BUDGET, OFFICE OF

INSULAR AFFAIRS, DEPARTMENT OF THE INTERIOR

ASSESSING CURRENT CONDITIONS AND CHALLENGES AT THE LBJ TROPICAL MEDICAL

CENTER IN AMERICAN SAMOA

Chairman LaMalfa, Ranking Member Torres and members of the Subcommittee 

on Indian, Insular and Alaska Native Affairs, thank you for the opportunity to 

speak regarding the LBJ Tropical Medical Center in American Samoa. 

The LBJ Tropical Medical Center is the primary healthcare facility in American 

Samoa. The Office of Insular Affairs (OIA) has been a partner with the American 

Samoa government for many years, providing supplemental funding for the 

operations and renovation of the hospital that was beyond the capacity of the local 

community. Although health care is not a primary function of OIA, our broad 

authorities make it possible to provide assistance in American Samoa. 

In recent years, the primary goals of OIA has been to ‘‘Create Economic 

Opportunity,’’ ‘‘Improve the Quality of Life,’’ and ‘‘Promote Efficient and Effective 

Governance’’ in the U.S. insular areas. Our assistance for the LBJ hospital is in 

accord with these goals, as we provide both operational funding and capital improvement funding to help improve health care for the American Samoa community. 

CAPITAL IMPROVEMENTS

American Samoa Government (ASG) is a recipient of a significant share of the 

annual mandatory $27.72 million in capital infrastructure funding available from 

the Office of Insular Affairs. Historically, American Samoa has received at least onethird of the $27.72 million in infrastructure funds set aside for the four smaller 

territories. 

2012 $10,089,000 

2013 $9,964,000 

2014 $10,047,000 

2015 $9,297,000 

2016 $9,505,000 

2017 $9,613,000 

2018 (request) $10,321,000 

For the ASG, its allocation of capital improvement funds is conditioned on submission of 5-year capital improvement project (CIP) plans that outline local priorities 

for capital spending. For many years, American Samoa’s top priority was health and 

therefore the LBJ Tropical Medical Center received larger shares of capital 

spending. Normally, between 15 and 24 percent of American Samoa’s Federal capital improvement allotment have been devoted to phased construction at the LBJ 

hospital. In the 5-year CIP plan for 2016 through 2020, ASG priorities changed due 

to the fragility of the territory’s main industry, tuna canning. The new 5-year plan 

elevates economic development to priority Number one and education to Number 

two. Health was bumped to Number three. The allocation decisions are made by the 

American Samoa government and are not set by the Office of Insular Affairs. 

The LBJ Tropical Medical Center was constructed in the 1960s. During the past 

15 years CIP funding has been used to renovate much of the hospital to bring it 

into compliance with modern hospital standards. Currently, the labor, delivery and 

surgical wings are under major renovation and expansion. Construction is ongoing, 

and when the renovation project is completed in 2020, approximately 60 percent of 

the hospital’s physical plant will count as having been rebuilt. 

The Office of Insular Affairs also provides operational funding for the LBJ 

hospital from the annual American Samoa Operations Grant. In the current fiscal 

year, the grant totals $22.75 million. The actual use of the grant is proposed by the 

ASG, which is using $7.9 million to support LBJ in Fiscal Year 2017. The remainder of the grant is used to support general education ($11.4 M), the community 

college ($1.4 M), and the High Court ($.9 M). 

For a quick look at both operations and CIP spending over the past 15 years, 

please see below. It shows that the Office Insular Affairs has provided $132 million 

in operations funding and $30 million in CIP funding for the LBJ Tropical Medical 

Center in American Samoa. 

10 

Fiscal Year Operations Funding to LBJ Fiscal Year CIP Funding to LBJ 

2003 $7,721,000 2003 $1,710,000 

2004 $7,675,938 2004 $2,000,000 

2005 $7,664,000 2005 $1,545,000 

2006 $13,264,000 2006 $1,800,000 

2007 $13,264,000 2007 $1,736,842 

2008 $13,039,906 2008 $1,902,684 

2009 $7,652,000 2009 $1,473,684 

2010 $7,657,000 2010 $2,000,000 

2011 $7,642,000 2011 $7,094,737 

2012 $7,645,000 2012 $1,368,421 

2013 $7,657,000 2013 $2,631,579 

2014 $7,900,000 2014 $2,632,000 

2015 $7,900,000 2015 $168,421 

2016 $7,900,000 2016 $1,789,474 

2017 $7,900,000 2017 TBD

TOTAL $132,481,844 TOTAL $29,852,842 

The Department of the Interior is proud to have been a partner with the 

American Samoa government in improving the LBJ Tropical Medical Center. There 

is a great deal that still needs to be done and we look forward to continuing the 

work to improve conditions and serve the people of American Samoa. 

QUESTIONS SUBMITTED FOR THE RECORD BY REP. SABLAN TO THOMAS BUSSANICH, 

DIRECTOR OF BUDGET, OFFICE OF INSULAR AFFAIRS, DEPARTMENT OF THE INTERIOR

Question 1. Director Bussanich, as you know, Section 2005 of the Affordable Care 

Act provided a total of $6.3 billion in additional Federal funds to the territories. 

These funds were primarily used to augment the islands already meager Medicaid 

programs. Unfortunately, because the funding for the ACA was for budgetary 

reasons, only for a 10-year window, the additional Medicaid funding will expire in 

2019. 

Has OIA (Office of Insular Affairs) or the IGIA (Interagency Group on Insular 

Areas)—to your knowledge—been working with the Insular Areas and their 

representatives on a strategy for getting these funds extended? We know that there 

is a great deal of focus on the impact that the loss of these funds would have on 

Puerto Rico because of the affect it will have on their ability to successfully address 

their debt crisis—but it is no less of a big deal for the other islands as well. 

Answer. Office ofInsular Affairs (OIA) officials have regularly discussed the 

healthcare challenges facing U.S. territories with the leadership of the insular 

areas, as well as within the Interagency Group on Insular Areas. OIA is aware of 

the shortage of resources for health care in the territories and would like to find 

a workable solution to address the growing healthcare needs of the territories. OIA 

continues to reach out and work with our colleagues at the Department of Health 

and Human Services (HHS), as the lead agency responsible for administering the 

Medicaid program, and will continue to work with HHS in a cooperative manner 

to reflect the priorities and needs of the territories. 

11 

Question 2. According to your statement, the LBJ Medical Center has received 

almost $30 million in CIP funding from OIA since 2003. Broadly speaking, can you 

tell us what these have primarily been used for? 

Answer. Please see the following listing of Capital Improvement Project grants 

relating to the LBJ Hospital. 

***** 

Mr. LAMALFA. Thank you. 

The Chair will now recognize Mr. Faumuina to testify. 

STATEMENT OF TAUFETE’E JOHN FAUMUINA, CEO-DIRECTOR, 

LYNDON B. JOHNSON TROPICAL MEDICAL CENTER, 

FAGA’ALU, AMERICAN SAMOA 

Mr. FAUMUINA. Thank you for the opportunity to provide testimony on assessing current conditions and challenges at the Lyndon 

B. Johnson Tropical Medical Center in American Samoa. I am 

Taufete’e John Faumuina, the Chief Executive Officer of the LBJ 

Tropical Medical Center. I would like to also thank the congressional delegation, CODEL, who visited American Samoa earlier 

this year, and had the chance to tour our hospital facility. 

In 1968, LBJ opened its doors to provide patient-focused, comprehensive, high-quality, and cost-effective health care and related 

services that addressed the health needs of the people. LBJ is the 

12 

sole hospital providing tertiary services to all of American Samoa, 

with a population over 60,000. In order for LBJ to keep its doors 

open, we need to retain Medicare certification through CMS. We 

must comply to the conditions of participation. 

My testimony will focus this morning on four main areas of the 

challenges and needs of our hospital. 

First, compliance with CMS standards. LBJ needs to adopt a 

suitable budget to address all non-compliance issues pertaining to 

medical staffing, nursing staffing, ancillary services, and supporting services across the board to meet the standard of care. The 

need to comply comes with substantial financial commitment, offer 

better compensations to recruit qualified doctors, nurses, certified 

technicians, and supporting staff, assign appropriate budget to 

properly provide maintenance for the aging facility, and schedule 

preventative maintenance and repairs for all equipment. 

Second, staffing inequities and workforce development. With 

LBJ’s 150 beds, we require 95 physicians; we only have 57. We are 

required to have 110 RNs; we only have 73. We are required to 

have 11 pharmacists; we only have 3. With the radiology department, we must contract off island services to read our diagnostics. 

We do not have a permanent radiologist. We also contract a 

nephrologist who visits American Samoa quarterly to treat the 167 

patients with 36 staff to handle a workload of 1,900 treatments per 

month. 

Third, our healthcare facilities. We have struggled to upkeep the 

aging facility, acquire new equipment, and to provide continuous 

preventative maintenance and repairs. We are grateful for the CIP 

funding from DOI that has allowed LBJ to conduct minor and 

major renovations to address CMS infrastructure citations. 

Presently, 41 percent of the facility has been renovated to meet 

CMS standards. Upon completion of the current labor/delivery 

nursery expansion and renovation project, our facility will be 65 

percent renovated. We continue to face the challenge of increased 

outpatient visits and high inpatient census. One of the solutions 

that we are presently exploring is a new 200-bed hospital to accommodate increase in population, as well as inpatient and outpatient 

visits. Space in the present location is severely limited, and we are 

unable to expand the existing building which, in turn, limits 

services. 

And fourth, our financial conditions—our annual budget appropriations are quite inadequate. We need to increase Federal appropriations, explore other revenue sources, lifting the cap on 

Medicaid, restructure FMAP percentage favorable to American 

Samoa, and extend the expiration of the ACA funds beyond 2019. 

We want to thank you for this rare opportunity given to us. We 

are humbled and extremely grateful to be able to share our challenges and needs with this honorable Subcommittee. And we hope 

for your favorable considerations to agree to fund a new hospital 

that will meet all quality of care. [Speaking native language.] 

[The prepared statement of Mr. Faumuina follows:] 

13 

PREPARED STATEMENT OF TAUFETE’E JOHN P. FAUMUINA, CHIEF EXECUTIVE

OFFICER, LYNDON B. JOHNSON TROPICAL MEDICAL CENTER

Mr. Chairman and members of the Subcommittee on Indian, Insular and Alaska 

Native Affairs, 

Talofa lava ma fa’afetai lava. Thank you for the opportunity to provide testimony 

on, ‘‘Assessing Current Conditions and Challenges at the Lyndon B. Johnson 

Tropical Medical Center in American Samoa.’’ 

I am Taufete’e John Faumuina. I am the Chief Executive Officer (CEO) of the 

American Samoa Medical Center Authority doing business as Lyndon B. Johnson 

Tropical Medical Center (LBJTMC) in the U.S. Territory of American Samoa. 

I would like to thank the Congress Delegates (CODEL) who visited American 

Samoa earlier this year and had the chance to tour our hospital facility. They 

dialogued with our staff about the limitations, woes and tribulations we face in providing quality and safe patient care to the people of our islands. 

In 1968, LBJ opened its doors to provide patient focused, comprehensive, high 

quality, and cost effective health care and related services that address the health 

needs of the people. LBJ is the sole hospital providing tertiary services to all of 

American Samoa with a population over 60,000. In order for LBJ to keep its doors 

open we need to retain Medicare certification through the Centers for Medicare & 

Medicaid Services (CMS), we must comply with the Conditions of Participations. 

My testimony will focus on four main areas of the challenges and needs of our 

hospital. 

CHALLENGES

Compliance with CMS Standards 

• LBJ needs to adopt a suitable budget to address all noncompliance issues pertaining to medical staffing, nursing staffing, ancillary services and supporting 

services across the board to meet the standard of care. The need to comply 

comes with substantial financial commitment, offer better compensations to 

recruit qualified Doctors, Nurses, Certified Technicians and supporting staff. 

Assign appropriate budget to properly provide maintenance for the aging 

facility and scheduled preventative maintenance and repairs for all equipment. For the record, LBJ is currently operating under a $50 million budget 

to sustain and provide the best health care for the people of American Samoa. 

Staffing Inequities and Workforce Development 

• With LBJ’s 147 beds, we require 95 physicians, we only have 57. We are required to have 110 RNs, we only have 73. We are required to have 11 

pharmacists, but we only have 3. 

• With the radiology department, we must contract off-island services to read 

our diagnostics. We do not have a permanent radiologist. 

• We also contract a nephrologist who visits American Samoa quarterly to treat 

the 167 patients with 36 staff to handle a workload of 1,900 treatments per 

month. 

Healthcare Facilities 

• Struggle to upkeep aging facility and acquire new equipment and to provide 

continuous preventative maintenance and repairs. 

• We are grateful for the CIP funding from DOI that has allowed LBJ to 

conduct minor and major renovations, to address CMS infrastructure citations. The laboratory was expanded and renovated to provide proper space for 

new diagnostic lab equipment to accommodate the increase types of testing 

for patient care. The Diagnostic Imaging-Radiology Department was expanded 

and renovated to house more modern equipment such as the radiographic xray machines, CT scans, C-arm X-rays, portable x-rays, etc. 

• Presently, 41 percent of the facility has been renovated to meet CMS standards. Upon completion of the current Labor/Delivery Nursery expansion and 

renovation project, our facility will be 65 percent renovated. 

• With the completed expansion and extensions of existing infrastructure, we 

are still struggling to cut down on patient waiting time in ER and Clinical 

Services because of the overwhelming number of patient visits, with ER 

seeing an average of over 2,500 visits per month. Patient admission process 

is also delayed due to overflow and non-availability of beds in the wards because of constant high census. 

14 

• One of the solutions that we are presently exploring is a new 200-bed hospital 

to accommodate increase in population, as well as inpatient and outpatient 

visits. Space in the present location is severely limited, and we are unable 

to expand the existing building which in turn limits services. 

Financials 

• Annual Budget—Inadequate appropriation 

— Increased Federal appropriation 

— Explore other revenue sources 

• Lifting the cap on Medicaid 

• Restructure FMAP percentage favorable to American Samoa 

• Extend the expiration of ACA funds 

CONCLUSION

We want to thank you for this rare opportunity given to us. We are humbled and 

extremely grateful to be able to share our challenges and needs with this honorable 

Subcommittee, and we hope for your favorable consideration to our plea to fund a 

new hospital that will meet all quality of care. 

Faafetai ma le faaaloalo lava. SOIFUA! 

QUESTIONS SUBMITTED FOR THE RECORD BY REP. SABLAN TO TAUFETE’E JOHN

FAUMUINA, CEO-DIRECTOR, LYNDON B. JOHNSON TROPICAL MEDICAL CENTER

Question 1. LBJ hospital is subject to certain standards and regulations mandated 

by CMS, the Centers for Medicare and Medicaid Services. You mentioned that ‘‘these 

Federal mandates place constraints and difficulties’’ on your operations, even though 

you welcome CMS’ participation. Can you elaborate on those constraints? What are 

your biggest obstacle to addressing them—is it adequate funding? 

Answer. The Lyndon B. Johnson Tropical Medical Center (LBJTMC) in American 

Samoa presently and continuously embraces CMS’ Conditions of Participation (CoP) 

for our hospital to retain its eligibility for Medicare certification. To receive 

Medicare/Medicaid payment, hospitals are required to be in compliance with the 

Federal requirements set forth in the Medicare CoP. As the sole hospital in 

American Samoa, without this Medicare certification to operate, LBJTMC will not 

be able to fulfill its critical role in providing access to essential acute care services 

to the residents of American Samoa. Although we continue to face obstacles, difficulties and constraints meeting the CoPs set forth by CMS, but these requirements are 

what improve our standards of practice and allow us to offer quality and safe 

patient care to our people. We recognize the value as recipients of CMS. 

I will elaborate more on some of the constraints and difficulties on the operation 

of our hospital. Please note the following four main areas of my written testimony 

from the July 25, 2017 hearing: 

1. Compliance with CMS Standards 

2. Staffing Inequities and Workforce Development 

3. Healthcare Facilities 

4. Financials 

1. COMPLIANCE WITH CMS STANDARDS 

Over the years, LBJ has faced continuous difficulties to be compliant with the 

requirements as a provider of services with the Medicare Program established under 

Title XVIII of the Social Security Act. However, we will continue to strive toward 

improvement as required by CMS CoPs. In the last year, the recent challenges we 

have faced with compliance are: 

• In June 2014, we were documented non-compliance with nine (9) CoPs. 

• A Medicare revisit survey on December 2015, documented nine (9) noncompliance CoPs. 

15 

• During our last revisit survey on January 27, 2017, with financial reserve and 

resources committed into operations, CMS identified six (6) areas of substantial non-compliance for LBJ. These deficiencies have an impact on the 

integral function of the four main areas identified in our written testimony. 

2. STAFFING INEQUITIES AND WORKFORCE DEVELOPMENT 

For staffing, human resources and workforce development, adequate staffing is required as part of CMS CoPs, yet we continue to experience staff shortages hospitalwide due to various reasons. Some causes for this inadequacy of staffing are: our 

inability to offer competitive salaries; our isolated and geographical location; our 

ability to recruit and retain; or lack of local pool of qualified, certified or 

credentialed prospects in American Samoa. The following critical areas continue to 

be a challenge to employ such as, but not limited to: 

• Medical Staff 

— On-site Radiologist 

— Nephrologists 

— Physicians 

• Nursing Department/Patient Care 

— Advanced Practice Nurses 

— Anesthetist Nurses 

• Ancillary 

— Respiratory Therapist 

— Occupational/Physical Therapist 

— Registered Dietitian 

— Medical Laboratory Technologist 

• Other professionals such as: 

— Infection Preventionist 

— Health Information Technologist 

— Bio-med Technicians 

3. HEALTHCARE FACILITIES 

As you may recall, this hospital was built in 1968 without the specification or mandates to meet CMS standards and life safety codes. While most hospitals in the 

United States currently have an ‘‘average age of plant,’’ of just less than eleven (11) 

years, LBJTMC is well over 50 years old. The routine and preventive maintenance; 

safety and testing activities are all part of CoPs for CMS. Maintaining the hospital 

throughout the years has been extremely costly. 

Although considered modern and state-of-the art at the time it was built, LBJ was 

not envisioned and constructed with CMS standards. As a result, it has become extremely costly to be in compliance with CMS Conditions of Participation. Therefore, 

understandably, to continue to provide quality healthcare services and be in compliance with CMS, a new hospital would be the most cost effective solution. CoP also 

requires that the LBJ hospital be constructed, arranged and maintained to ensure 

the safety of the patient and quality of care. 

4. FINANCIALS 

As depicted in our testimony, one of our continuous challenges and biggest obstacle 

in addressing our difficulties and constraints is funding. Many of the CMS CoPs require constant upgrades of facilities, increase of medical services, costs of resources 

to recruit and retain qualified professionals and overall hospital operations which 

all require financial support. 

Question 2. You mentioned that 35 percent of your pharmaceutical budget is for 

dialysis medications. What is the percentage of your overall budget is for 

medications? And, since American Samoa is outside the customs area of the United 

States are you able to purchase drugs internationally, which should provide savings 

over U.S. sourced drugs? 

Answer. The hospital’s budget for FY2016 was $46 million. The LBJ pharmacy’s 

pharmaceutical budget for FY2016 was $5.9 million which is approximately 12 

percent of the overall hospital budget. In our report, 35 percent or approximately 

16 

$2.06 million of pharmaceutical budget was spent for our dialysis population in 

FY2016. 

Although, American Samoa is outside of the U.S. customs area, we cannot purchase pharmaceutical drugs internationally or from foreign manufacturers as 

LBJTMC is regulated by the Centers of Medicaid and Medicare (CMS). The LBJ 

pharmacy accesses the VA Federal Supply Schedule (FSS) and PRxO Generic 

(Pharmacy Prescription Generic Contract) contract pricing with our pharmaceutical 

vendor, AmerisourceBergen Wholesaler (ABC), a U.S. distributor. By using the FSS 

program, which is available to Federal and state government, we are able to procure 

our pharmaceutical products at a lower cost and affordability therefore providing 

savings and best value for our dollars. 

Also, we reached out to the pharmacy department at the Commonwealth 

Healthcare Corp (CHCC), Commonwealth of Northern Marianas Islands (CNMI) 

hospital to explore opportunities we could share as U.S. territories. Yet, we learned 

that we face similar deficiencies in meeting CMS mandates and difficulties in procuring and maintaining an inventory level especially with drugs listed on the 

national shortage. Furthermore, as regulated by CMS, all of CNMI’s pharmaceuticals have to meet FDA rules and they also procure their drugs through 

Mckesson Wholesaler, a U.S. distributor. 

As mentioned above, LBJTMC is regulated by the Centers for Medicaid and 

Medicare (CMS) and only FDA-approved medications are eligible for reimbursements. For patient safety, FDA’s current position on the importation of prescription 

drugs from foreign entities or unknown sources cannot ensure the safety and effectiveness of products. These unknowns put patient’s health at risk if they cannot be 

sure of the products identity, purity and source, therefore, FDA recommends ONLY 

obtaining medicines from legal sources in the United States. Drugs sold in the 

United States also must have proper labeling that conforms to the FDA’s requirements, and must be made in accordance with good manufacturing practices. As part 

of the FDA’s high standards, drugs can be manufactured only at plants registered 

with the agency, whether those facilities are domestic or foreign. If a foreign firm 

is listed as a manufacturer or supplier of a drug’s ingredient on a new drug application, the FDA generally travels to that site to inspect it. 

Here are some of the additional reasons why we cannot purchase from 

international manufacturers: 

1. LBJ participates in the Medicaid Drug Rebate Program to help subsidize the 

cost of medication for the territory. This program includes CMS, State 

Medicaid Agencies and participating drug manufacturers that help to offset 

the Federal and state costs of most outpatient prescription drugs dispensed 

to Medicaid patients. 

• Approximately 600 drug manufacturers participate in this program (all 

U.S.-based drug companies). 

• Only FDA-approved medications are eligible for the Federal Medicaid 

drug rebate reimbursement program. 

2. Benefits of a Closed System 

• Under the Food Drug & Cosmetic (FD&C) Act, the interstate shipment 

of any prescription drug that lacks required FDA approval is illegal. 

Interstate shipment includes importation—bringing drugs from a foreign 

country into the United States. 

3. FDB (first databank) provides patient safety medication for FDA-approved 

medications ONLY 

• Hospital advantage with offered programs including drug-drug 

interactions, drug-allergy, drug-disease interactions and duplicate 

therapy flags. 

• Electronic Health Record and prescription labels are linked with FDB to 

incorporate all essential medication information for both patients and 

health professionals alike. 

4. Early 2017—Drug Importation Bill being proposed to allow U.S. pharmacies 

to purchase medications from Canada (see details below)—has not passed yet, 

and when it does, it will definitely provide another avenue to procure 

medication if it is cost-effective. 

• The Affordable and Safe Prescription Drug Importation Act would instruct the Secretary of Health and Human Services, within 180 days after 

enactment of this Act, to issue regulations allowing wholesalers, licensed 

17 

U.S. pharmacies, and individuals to import qualifying prescription drugs 

manufactured at FDA-inspected facilities from licensed Canadian sellers. 

After 2 years, the Secretary would have the authority to permit importation from countries in the Organization for Economic Co-operation and 

Development (OECD) that meet specified statutory or regulatory standards that are comparable to U.S. standards. 

Question 3. You indicate that the LBJ pharmacy is constantly faced with severe 

shortages of critical drugs and that because LBJ is the only hospital in American 

Samoa; you do not have the capability of reaching out to another facility to procure 

or acquire essential lifesaving drugs. What about the America Samoa VA clinic 

named after our former colleague Eni Faleomavaega? Do they have a pharmacy on 

site that you can utilize to obtain critical drugs? 

Answer. This option has been already been explored by LBJ Pharmacy. At 

present, the Faleomavaega Fa’aua’a Hunkin Clinic does not have a pharmacy on 

site. The essential lifesaving drugs mentioned in our July 25, 2017, written response 

are the critical medications used in our hospital and intensive care units for 

patients who are in their critical stages and on life sustaining measures. 

On the VA Pacific Island Health Care System website, the ‘‘Faleomavaega 

Fa’aua’a Hunkin Community Based Outpatient Clinic in American Samoa is to provide primary health care to eligible veterans. It is a non-emergent care for veterans 

with stable chronic health problems or minor acute illnesses. It is NOT equipped 

to provide emergency services, and veterans shall seek treatment to Lyndon B. 

Johnson Medical Center for emergency services.’’ 

The clinic ONLY stocks emergency medications in their crash carts to use in 

emergency resuscitations for life support. All of the military retirees and veterans’ 

pharmaceutical needs and their prescriptions are sent from the VA hospital in 

Honolulu, Hawaii. 

Question 4. What will it mean for LBJ if Congress does not to extend the 2019 

ACA funds? 

Answer. At the current LBJ expenditure rate for Medicaid services, we are only 

able to tap into ACA funds by the third quarter of the fiscal year. A new Medicaid 

methodology for the reimbursement model process may be an immediate option to 

assist LBJ and an extension of the ACA 2019 expiration date. Our current Medicaid 

state plan methodology severely limits our ability to exhaust ACA funds. 

If the U.S. Congress does not extend the 2019 Affordable Care Act (ACA) funds 

expiration date, American Samoa stands the chance to lose out on optimizing 

opportunities to assist with a healthcare safety net to: 

1. Insure the medically vulnerable people of American Samoa’s low-income 

adults and children; 

2. To fund long-term services and support for adults and children with serious 

disabilities or illnesses who are at risk of impoverishment as a result of their 

health. 

Mr. LAMALFA. Thank you, Mr. Faumuina. 

Let’s now recognize Ms. Young for 5 minutes. 

Thank you. 

STATEMENT OF SANDRA KING YOUNG, MEDICAID DIRECTOR, 

AMERICAN SAMOA MEDICAID AGENCY, OFFICE OF THE 

GOVERNOR, PAGO PAGO, AMERICAN SAMOA 

Ms. YOUNG. Thank you. 

[Speaking native language] 

Chairman LaMalfa, Ranking Member Sablan, and members of 

the Committee. Thank you for the opportunity to present testimony 

regarding the LBJ Hospital and the role the American Samoa 

Medicaid program plays in our healthcare system. 

Medicaid is a very complicated Federal-State program, as it is 

administered in American Samoa. The American Samoa Medicaid 

program has remained unchanged, in terms of provider eligibility 

18 

and coverage, over its 35-year history, until the Lolo administration. 

Unlike other states and territories, Medicaid is the only publicly 

available health insurance provider in our territory. And the LBJ 

Hospital has been the only Medicaid provider until this year. 

Because Medicaid is a state-specific health plan, once we leave 

our territory we are no longer covered with a health insurance 

plan, should any medical emergency befall us, like when we are 

here for this hearing in DC. 

As the Medicaid Director, my responsibility is to ensure that our 

Medicaid beneficiaries, the people of American Samoa, have access 

to medical services, as required under the Social Security Act. 

When it comes to challenges that our hospital faces, the Medicaid 

agency is most concerned about the hospital’s compliance with the 

Centers for Medicare and Medicaid Services, conditions of participation, and compliance under the American Samoa Medicaid State 

Plan. 

Non-compliance puts at risk Medicare and Medicaid funding for 

the LBJ Hospital. The biggest help that LBJ needs to ensure compliance is the construction of a new hospital. Thus, we respectfully 

recommend that the Committee should introduce authorizing legislation to provide funding for the construction of a new hospital for 

American Samoa. 

American Samoa has already secured a potential site for this 

construction. The LBJ Hospital is a 50-year-old facility, and it sustained major damage in a 2009 earthquake and tsunami. While the 

facility was repaired after the tsunami, the hospital continues to 

struggle with infrastructure standards to maintain CMS certification. It would be more cost-effective to replace the current facility 

so that it meets the modern standards for CMS conditions of participation under a new hospital facility. 

In terms of Medicaid funding, the priority of the Lolo administration and of the territory is to maintain the Medicaid revenue 

stream that helps support the LBJ and our entire healthcare system. Prior to the passage of the Affordable Care Act in 2011, the 

LBJ Hospital was insolvent and continually went into debt to keep 

the hospital in operation and maintain needed medical services. 

The Medicaid funds under ACA helped to fully fund the Federal 

share of the Medicaid program. But, unfortunately, the expiration 

of these funds in 2019 weighs heavily over the territory. The 

American Samoa Medicaid Agency spent the last 3 years working 

with CMS to amend our state Medicaid plan to expand our 

Medicaid provider network. This year we received approval to 

make the federally qualified health centers a provider, and to enable the off-island medical referral services to be re-instated 

directly with off-island providers through our agency. 

Access to the ACA Medicaid funds is critical to fully implement 

the Medicaid state plan. If the time to expand the Medicaid funds 

provided for in the ACA is not extended, this would cripple our 

LBJ Hospital and the rest of our healthcare system, potentially 

forcing the territory to cut or suspend medical services all together. 

Looking long-term, after ACA funds are expended, it is necessary 

to increase the annual Medicaid block grant for American Samoa 

19 

in order to adequately sustain the provision of medical services, as 

required under the Social Security Act. 

Thank you again for this auspicious opportunity to testify, and 

I am happy to take questions from the Committee. 

[The prepared statement of Ms. Young follows:] 

PREPARED STATEMENT OF SANDRA KING YOUNG, AMERICAN SAMOA

MEDICAID DIRECTOR

Chairman LaMalfa, Ranking Member Torres and members of the Subcommittee, 

on behalf of American Samoa, I am honored to present testimony regarding our 

unique Medicaid program. Thank you for this prodigious opportunity to share with 

you the unique features of the Medicaid program in American Samoa. 

American Samoa was granted a 1902(j) waiver in 1983 to administer a Presumptive Eligibility model for the Medicaid Program. Under this waiver, American 

Samoa is the only U.S. jurisdiction where there is no eligibility and enrollment of 

individual beneficiaries. Beneficiaries are presumed eligible for Medicaid if they fall 

within the 200 percent U.S. Federal poverty level. 

In terms of Medicaid funds and its relation to LBJ hospital, the priority of the 

Lolo administration and of the territory, is to maintain the Medicaid revenue stream 

that helps support the LBJ and our whole healthcare system. First, the deadline 

to expend the Medicaid funds under ACA must be extended to allow American 

Samoa to increase access to medical services for beneficiaries. Second, we must have 

an increase of $15 million a year in the regular Medicaid block grant funds under 

the Social Security Act regardless of what happens to the ACA Medicaid funds. This 

will allow the Medicaid agency to adequately fund the needs of the American Samoa 

Medicaid program and avert the reduction or suspension of medical care services. 

If ACA is repealed or replaced without this increase in the regular Medicaid grant, 

the consequences would be devastating to the local government and our local economy, but most of all, it will cripple the LBJ hospital and our healthcare system so 

as to deny access to medical care for our people. 

One of the most significant challenges that the hospital faces is the chronic deficiencies with CMS Survey and Certification putting at risk its Medicare and 

Medicaid funding. The LBJ hospital was built in 1968 and is located in a tsunami 

zone and sustained major damage during the 2009 tsunami. American Samoa needs 

a modern hospital outside of the tsunami zone. Continuing to do band aid solutions 

to renovate the 50-year old LBJ hospital is not cost effective. American Samoa needs 

from Congress an appropriation of $200 million for a state-of-the-art hospital that 

would be fully compliant with Medicare Conditions of Participation and CMS 

standards for infrastructure. 

The Lyndon B. Johnson Tropical Medical Center has been the only Medicaid 

provider on island, until February 2017 when the American Samoa Department of 

Health’s Federally Qualified Health Center (FQHC) became the second Medicaid 

provider in the 35-year history of the program. The 1902(j) waiver under the Social 

Security Act gives the American Samoa Medicaid agency flexibility to waive Federal 

regulations that are inappropriate and not relevant for its small Medicaid program. 

It however, cannot waive three things: (1) the Medicaid cap funding, (2) the Federal 

Medicaid Assistance Percentages (FMAP) for local and Federal match requirements, 

and (3) the mandatory health services required under the Social Security Act. All 

three of these provisions create inconsistent Federal objectives because (1) and (2) 

limit funding for American Samoa thus making number (3) unachievable. In 

essence, number (3) becomes an unfunded mandate that the American Samoa 

Medicaid program cannot comply with because of inadequate funding. Unlike the 

states unlimited access to Medicaid funds, American Samoa and the territories 

Medicaid programs operate as a capped block grant. Further, the FMAP percentage 

match rate was imposed arbitrarily on all five U.S. territories—45 percent local/55 

percent Federal—and equivalent to the matching rates of wealthy states like 

California and Connecticut. By the third quarter of the fiscal year, American Samoa 

generally exhausts the territory’s regular Medicaid funds under the Social Security 

Act. 

The passage of the Affordable Care Act in 2011 provided an additional $181 

million in Medicaid funding for American Samoa plus an additional $16 million intended for an insurance marketplace. American Samoa was not able to establish an 

insurance marketplace because it does not have health insurance providers on the 

island—except for Medicaid. The $16 million was added to the ACA Medicaid funds 

for a total of $197 million for American Samoa. The territory benefited from the additional Medicaid funds and the shortfall of the regular annual Medicaid block grant 

20 

was now covered by the ACA Medicaid funds. Unfortunately, the 2019 deadline to 

expend the ACA Medicaid funds was not rationale. The ACA was passed with no 

input from American Samoa, for us to explain that simply setting aside so much 

Medicaid funds with a deadline for expenditure by 2019 was not logical, as 

American Samoa only had one Medicaid provider. The LBJ provides limited medical 

services to a small population. Like any health insurance plan, Medicaid can only 

reimburse for allowable medical expenses that are actually incurred by patients 

seeking treatment at a hospital. Since ACA, the LBJ hospital remains the only provider on island that can expend Medicaid dollars, until our local government can 

appropriate local funds for our new providers. 

The Medicaid agency does not expend Medicaid dollars but ensures that medical 

care costs are allowable and that funds for reimbursement of that care are disbursed to the healthcare providers—in this case LBJ—in a timely manner. Since 

ACA, LBJ has only been able to draw on average an additional $5 million dollars 

from the ACA account. In 2016, the LBJ hospital was able to draw $6 million. If 

we trend the LBJ’s annual expenditures of ACA Medicaid funds, with a beginning 

balance of $197 million and an average draw of $5 million a year, it will take LBJ 

39 years to draw all of the ACA Medicaid funds. To date our territory has only been 

able to draw about 20 percent of the ACA Medicaid funds because of our limited 

medical services. It is not possible for the LBJ to draw all the ACA Medicaid funds 

by 2019 without additional services or an expanded provider network. There are options that the Medicaid agency has successfully pursued to increase access to 

medical care that would be covered by the ACA Medicaid funds. 

The Medicaid agency after nearly years of development and negotiations, 

submitted two major amendments to CMS to change our Medicaid state plan. The 

priority was to enable the Department of Health’s FQHC to become a provider. This 

was approved February 2017. The second was the Off-Island Medical Referral program that the LBJ hospital could not implement due to cash-flow problems. This 

was approved recently in June. The Medicaid agency is waiting for the local budget 

process to be completed and should the agency receive local match funds, it will be 

able to draw down ACA Medicaid funds to reimburse the FQHC and providers of 

the Off-Island Medical Referral program. 

The Children’s Health Insurance Program (CHIP) is up for reauthorization and 

is an instrumental part of the funding that supports the health of the most vulnerable of our population—our children. We strongly support the reauthorization of this 

bill and further request that the cap on CHIP funding for the territories also be 

lifted. 

I wish to thank you Chairman LaMalfa and the Subcommittee for this opportunity. Thank you also to our Representative Radewagen and the Representatives 

from all the U.S. territories for their support to strengthen Medicaid for the 

territories. It is not lost on me the importance of this opportunity to appear before 

this Committee and the attention being afforded to our small island territories. I 

am most grateful. 

Thank you very much. Fa’afetai tele lava. 

Mr. LAMALFA. Thank you, Ms. Young. And I want to thank, 

again, the panel for your testimony. I will remind the Members 

that Committee Rule 3(d) imposes a 5-minute limit on questions by 

the Members. 

The Chairman will now recognize Members for questions. I will 

first recognize myself for 5 minutes. 

Let me direct this to Mr. Bussanich. You spoke of promoting the 

efficient and effective governments in all island areas, and then, as 

it applies to American Samoa and the hospital. 

It is designated as a high-risk grantee. So, requirements of these 

grantees to comply with special conditions for future or existing 

grants. How, so far, has this designation improved the accountability for Federal funds so that we know that further investment 

will be a positive? 

Mr. BUSSANICH. Well, the high-risk designation, it sends signals 

in both directions. It sends a signal to the local government that 

it needs to focus on improvements in financial management and 

21 

practices, and it does serve, to a certain extent, I would suppose, 

as a warning. But, certainly, it is a warning to Federal agencies 

and others to make sure that the funds that they are granting are 

reported on and used appropriately. 

I do think, though, in our case, we have done a lot of focus on 

working on audits, improving the outcomes of audits, and we are 

also aware that a recent Subcommittee report is also focusing on 

this issue. 

We certainly believe that American Samoa has the ability to 

make the improvements to get itself off the high-risk designation 

list. 

Mr. LAMALFA. Do you see this designation being revisited any 

time soon? 

Mr. BUSSANICH. Yes. It is revisited, certainly, every year. 

Mr. LAMALFA. Every year? 

Mr. BUSSANICH. Yes. 

Mr. LAMALFA. So, a new, comprehensive look at how 

performance is going, and—— 

Mr. BUSSANICH. Yes. And a lot of that depends on the contents 

of the annual single audits, which—— 

Mr. LAMALFA. Is there a criteria that is nearly being met for the 

designation to be removed? 

Mr. BUSSANICH. Beg your pardon, sir? 

Mr. LAMALFA. Is it nearing the point of meeting the criteria for 

the designation to be removed or revised? 

Mr. BUSSANICH. I believe so, yes. We are certainly interested in 

taking whatever final steps are needed to do that. 

Mr. LAMALFA. OK. I would like to yield the balance of my time 

to Mrs. Radewagen for questions. 

Mrs. RADEWAGEN. Thank you, Mr. Chairman. I wondered if I 

might complete my opening statement, since we had a difference of 

opinion as to the time limit. 

As I was saying, for example, this year’s total budget for LBJ was $51 million, while the hospital of the same size in Washington 

State has a 2017 budget of roughly $200 million. 

The people of American Samoa need better access to care without 

having to take an airplane off-island. The fact is, it is beyond time 

for a significant increase to the account. 

The reasoning provided in DOI’s budget report for the lack of any 

increase to the ASG operations account over the years is to promote self-sufficiency on the island, which is all fine and well, but 

near impossible when, at the same time, the Federal Government 

has closed off large swaths of fishing grounds in the Pacific that 

our people have used for a millennium, and long before any relationship with the United States, and at the same time imposed 

federally mandated minimum wage laws, irresponsibly putting the 

territory, which is both economically and geographically isolated, 

on the same playing field as the states—policy that has already 

forced one tuna cannery to leave the island for Thailand, where 

they pay their workers a mere fraction of what ours are required 

to pay. 

I recently introduced legislation to resolve this issue: H.R. 3021, 

the American Samoa Job Protection and Expansion Act, and I look 

forward to seeing congressional action on it. 

22 

Regarding LBJ and any improvements to be made following congressional action, I will be introducing a bill shortly that calls for 

GAO study, in partnership with DOI, the VA, and HHS to assess 

the feasibility of either a new or updated facility, and I encourage 

my colleagues to support the measure. 

It is high time that we here in Congress recognize the issues 

happening in the insular areas, and I am encouraged by today’s 

hearing and the action it will bring. Again, I want to thank our 

witnesses for traveling so far to be here today. I know that the 

work they do in the islands is indispensable, and I know that their 

testimony will provide even more insight into the issues we are facing in the islands in regards to providing accessible and quality 

health care for our people. 

Thank you, Mr. Chairman. I yield back my time. 

Mr. LAMALFA. OK, thank you. We will now recognize the 

Ranking Member, Mr. Sablan. 

Mr. SABLAN. Well, thank you very much, Mr. Chairman. Let me 

start with Mr. Bussanich. 

According to your statement, the LBJ Medical Center has received almost $30 million in CIP funding from OIA since 2003. So, 

broadly speaking, can you tell us what these have primarily been 

used for? Has it been to renovate the facility? 

Mr. BUSSANICH. Yes, sir, I can. And I can show you a list of all 

the different projects that we have done since 2003. 

But the most significant ones have been a $5 million project to 

upgrade the electrical system. We are in the process of a $5.7 

million project to improve the labor, delivery, and operation room 

suite. There was $4.7 million spent on a forensic psychiatry facility, 

and $3.2 million on a dialysis unit expansion, among other projects. 

These have been, I think, very significant and very useful projects. 

Mr. SABLAN. Right, thank you. And could we get that information 

to the Committee, please? 

Mr. BUSSANICH. Yes, sir. 

Mr. SABLAN. I appreciate that, because in a previous hearing I 

made a statement that OIA should re-examine its criteria for the 

capital improvement project funds, and base it not on the financial 

criteria, but basically on the public health needs. 

Like, say, for the Northern Marianas, it is the only municipality 

in the Nation that does not have 24/7 water, and there is a public 

health crisis that is growing from that. Thank you. 

Ms. Young, if I may, you state also that, to date, our territory 

has only been able to draw 20 percent of the ACA Medicaid fund 

because of our limited medical services. The inability to draw down 

the additional ACA Medicaid funds is not unique to American 

Samoa. The other insular areas, except for Puerto Rico, face a similar challenge because of the 55–45 FMAP. 

In the Marianas, however, the Commonwealth Healthcare 

Corporation, which operates our only hospital, and our Medicaid 

managers have been able to meet the FMAP challenge by using a 

statutorily-recognized Medicaid financial approach known as certified public expenditures, or CPEs. And current projections show 

that they are on track to use all or almost all of the Marianas’ ACA 

Medicaid funds before the 2019 expiration date. I am not an expert 

23 

on the particulars of CPA accounting, but it looks like they are successfully using the ACA money. 

I also understand, according to Medicaid and CHIP, an access 

commission, and a MACPAC, which is a non-partisan legislative 

branch agency that advises Congress, that American Samoa uses 

CPEs for your local match. 

However, I am not sure why you have not been similarly successful in certifying the use of public funds to support the cost of providing Medicaid-covered services to allow you to access more of 

your ACA Medicaid dollars. Are you familiar with the approach the 

Marianas uses with CPEs to access our ACA Medicaid dollars? 

Ms. YOUNG. Thank you, Congressman. Yes, I am. Our challenges 

with drawing down the additional ACA Medicaid funds is due to 

several factors. But the CPE methodology is probably not one of 

them. 

CPE methodology is a very good methodology for our LBJ 

Hospital. The certified public expenditure methodology was approved by CMS some years ago, after the hospital had significant 

problems with over-billing. The CPE methodology allows the hospital to do a number of things. It stabilizes their annual funding, 

and it also allows them to forecast for their budgets. 

The challenges of drawing down the Medicaid money that is provided for under ACA is, first, Medicaid dollars can only be used to 

reimburse for allowable medical care expenses. 

Second, our hospital is the only Medicaid provider, and has been 

the only Medicaid provider for 35 years, until this February, when 

the FQHC became a Medicaid provider. 

And third, we don’t have enough medical services on island. We 

have not had off-island referral services for the last 10 years, and 

that normally has taken wind. It was being implemented, normally 

took up a lot of medical funds from the hospital, and it was not 

sustainable. 

Mr. SABLAN. Thank you. 

Mr. Chairman, my time is up. 

Mr. LAMALFA. Thank you. We will now recognize Miss Gonza ́lez, 

our Vice Chair, for 5 minutes. 

Miss GONZA ́LEZ-COLO ́ N. Thank you, Mr. Chairman, and thank 

you, the whole panel, for being here today. 

I do understand what you are talking about, because I was part 

of the CODEL that traveled to American Samoa in February of this 

year, and I thank Mrs. Radewagen for making that one of the main 

purposes of the trip. But I have many questions. I will try to direct 

myself. 

Ms. Young, you said in your testimony that a state-of-the-art 

replacement hospital in American Samoa will require Federal appropriation of $200 million. How do you arrive at this figure? 

Ms. YOUNG. That is a number that we have thrown around 

amongst ourselves locally, talking about what it would take to 

build a new hospital on our wish list. But there is no official 

documentation. 

I think that Congresswoman Radewagen has suggested a really 

great idea to do a report with GAO, DOI, and our local government 

to come up with a realistic estimate on how much it would take us 

to build a new hospital. 

24 

Miss GONZA ́LEZ-COLO ́ N. So, we don’t have any support that establishes that $200 million as the correct amount, correct? 

Ms. YOUNG. Yes, that is an unofficial estimate that we came up 

with on our own. 

Miss GONZA ́LEZ-COLO ́ N. Thank you. As part of the territories, we 

face the same situation as Mr. Sablan stated with the Medicaid, so 

we understand what is going on in American Samoa. But in our 

case, we use the money that was allocated in 2012 with the 

Obamacare. 

Ms. Young, American Samoa has so much money that remains 

unspent for so long, why? Can you tell us about it? 

Ms. YOUNG. Sure. Since 2011, the hospital has been drawing 

down on the ACA Medicaid money, but just not as much as we 

would like to. Part of that is, like I mentioned earlier, Medicaid 

money can only be used to reimburse allowable medical care 

services. 

And the history of the draw-down—LBJ Hospital is averaging about $5 million a year in draw-down. And the Medicaid agency 

can ask for as much money as we need for the LBJ Hospital. But 

through the certified public expenditure payment method, the way 

we pay the hospital is based on the Medicare cost report. The 

Medicare cost report is the financial statement that the hospital 

has to file every year, and it has to be settled and finalized by a 

certified CPA firm, and eventually with CMS. 

Based on that Medicare cost report, we annualize the payments 

for the hospital. Right now, that annual payment averages about 

$1.6 million a month for the hospital. We run it through a calculation formula that is approved by CMS within our state plan. 

Usually, the hospital exhausts its regular Medicaid funding under 

the Social Security Act by the third quarter. That is a legal requirement. We have to exhaust our regular Medicaid funding first, 

before we can tap into the ACA funds. 

Miss GONZA ́LEZ-COLO ́ N. Question, Ms. Young. How much is 

remaining in that fund? 

Ms. YOUNG. It is approximately about $150 million. 

Miss GONZA ́LEZ-COLO ́ N. One hundred and fifty? And it was allocated at $186 million? 

Ms. YOUNG. I believe it was $181 million, with an additional $16 

million from the health insurance marketplace. 

Miss GONZA ́LEZ-COLO ́ N. So, you still have more than $150 million 

in that account. In our case, in Puerto Rico, when we have those 

kind of problems, we fix it by making the changes, complying with 

the CMS, to try to get use of that money. I encourage American 

Samoa to do the same in the case you can do it. 

Mr. Faumuina, you also touched in your testimony, that in your 

opinion, it will make more sense to replace LBJ entirely, rather 

than attempt to renovate when that facility is still in use. Why? 

Mr. FAUMUINA. The renovation project is carried out in order for 

us to meet CMS standards. Every time they visit, they point out 

deficiencies for us to do certifications of participation. So, we are 

forced to do that. 

Miss GONZA ́LEZ-COLO ́ N. Thank you, Mr. Chairman. I yield back. 

Mr. LAMALFA. Thank you. We will go ahead and recognize Mrs. 

Radewagen for 5 minutes. 

25 

Mrs. RADEWAGEN. Thank you, Mr. Chairman. You mentioned 

this earlier. My question is for Mr. Bussanich. 

The Chairman mentioned OIA has designated American Samoa 

as a high-risk grantee. And I think you have more or less elaborated on how the failure to comply can have this impact on securing Federal funding. But providing that the Interior appropriations 

bill that just passed out of Committee gets signed into law, we will 

then see the first increase to the ASG operations account since 

1986. It is my understanding that the bill report recommends that 

the increase be used to bring ASG into Federal compliance. 

Can you assure me, Mr. Bussanich, that OIA will commit to 

working with ASG to use these funds to meet Federal standards? 

Mr. BUSSANICH. Oh, absolutely. We saw that language and we 

were encouraged by it, as well, to be able to use the funds to work 

with the government to address specific problems to get that highrisk designation completely taken off the books. 

Mrs. RADEWAGEN. How does this DOI subsidy work? You folks 

send it, or it is drawn down by ASG, and then you send it down 

to ASG? You don’t send it to the hospital directly? Why not? 

Mr. BUSSANICH. Well, generally, I am just checking to make sure. 

I am not exactly sure where the draw-down goes. But the grants 

are typically made to the government of American Samoa, and the 

Treasury there handles the actual draw-downs. 

The payments are made on a regular basis, according to a schedule. As far as I know, there is nothing that has really gotten in the 

way of us actually passing money to the American Samoa government. 

Mrs. RADEWAGEN. So, to your knowledge, nothing has been lost, 

nothing has been subtracted from that DOI subsidy that is 

intended for the hospital? 

Mr. BUSSANICH. I certainly don’t think—— 

Mrs. RADEWAGEN. So, the full amount or installment reaches the 

hospital directly. Is that what you are saying? 

Mr. BUSSANICH. It has never been brought to my attention that 

it has gone elsewhere. We would certainly look into it and insist 

that it goes to the LBJ Hospital if it were brought to our attention 

that it was going somewhere else. 

Mrs. RADEWAGEN. Thank you, Mr. Chairman. I yield back my 

time. 

Mr. LAMALFA. Thank you. We will now recognize Mr. Westerman 

for 5 minutes. 

Mr. WESTERMAN. Thank you, Mr. Chairman, for allowing me to 

join the hearing today. I thank the witnesses for being here, especially the ones who traveled so far. And my colleague, Mrs. 

Radewagen, for all the hard work you are doing, representing 

American Samoa. 

Director Bussanich, in your testimony you list three primary 

goals of the Office of Insular Affairs: the first being to create economic opportunity and the second is to improve the quality of life. 

I, too, was on the CODEL that visited American Samoa, and I can 

testify it is a long ways from here to there. It is a very isolated part 

of the world. 

In testimony submitted for the record by Governor Lolo Moliga, 

major issues are still lingering from policies of the Obama 

26 

administration. And the Governor described those as Federal overregulation that has crippled the territory’s ability to develop a 

strong economy, and thus have stymied local funding that would 

otherwise be directed toward the LBJ Hospital. Those are the 

Governor’s words. 

Two of those issues fall directly under the jurisdiction of this 

Committee: the national ocean monuments and sanctuary expansions, and prohibition placed on fishing in the high seas. I know 

that when we were there, the issue of fishing on the high seas was 

discussed, and there were questions about whether that was even 

doing anything to help the tuna population, as other countries were 

coming in and over-fishing those areas. 

Do you agree with the Governor’s claim that if the Federal overregulations still lingering from the previous administration are left 

in place, that the territory will be unable to develop a sustainable 

economy, and thus will be forced to continue under-funding the 

LBJ Hospital? 

Mr. BUSSANICH. Actually, sir, I think that is a question kind of 

beyond the view of my office. I mean the example you gave about 

fisheries, while it was certainly a subject of the Obama administration, was not part of the Office of Insular Affairs. 

We certainly are an advocate for American Samoa within the 

current administration. And if tasked to look at this, we would certainly give our opinion. 

Mr. WESTERMAN. Can you share with the Subcommittee any efforts that OIA has begun during this new Trump administration to 

review policies regarding marine monument expansion in American 

Samoa? 

Mr. BUSSANICH. I would have to deflect that to the appropriate 

bureau or office, because the Office of Insular Affairs itself does not 

participate in those regulatory schemes. 

Mr. WESTERMAN. OK. Shifting gears a little bit, we obviously 

visited a hospital while we were there, and also visited the VA 

facility. As an observer from far away, and I represent a very rural 

district in Arkansas, but I can probably count up at least a halfdozen hospitals in my district that have had a lot more capital put 

into them and are much more advanced than the hospital on 

American Samoa, as far as the infrastructure and facilities there. 

But, obviously, there were some very dedicated healthcare professionals there doing the best they could with the facilities they have. 

In my district, there are a lot more hospitals, and there are much 

larger, nicer hospitals just a few hours away from some of these 

small, remote hospitals. 

Also, at the VA facility, we saw that people were having to be 

air-evacuated to Hawaii for major health concerns. And it dawned 

on me, shouldn’t the VA and the local hospital be working together, 

and maybe some of that money the VA is spending to airlift people 

could go toward having a better hospital there on the island that 

everyone could take advantage of. 

Ms. Young, has there been any work between the VA and the 

hospital on the island, trying to coordinate and provide, or pool the 

efforts so you could provide better services? 

Ms. YOUNG. I know that our agency does not get involved in 

those discussions. That is a high-level discussion usually done 

27 

between—I know that we have had cases in the past where our 

governor has been in touch with our Congresswoman to assist in 

triggering those types of services and assistance to the territory. 

This is a followup to Congresswoman Colo ́n’s question—the 

Medicaid state plan has not been changed until now, and it took 

us almost 3 years in negotiations with CMS to make some of those 

changes. One of those changes, which is very key to the off-island 

referral program, is to allow our agency to reinstate the off-island 

medical referral program directly with our agency. That would 

allow my agency to contract directly with the air carriers, as well 

as hospitals in the United States, as well as in New Zealand. 

Under the Medicaid state plan, the Medicaid funding can be used 

for transportation services. Currently, the hospital does use some 

of that for nominal transportation airfares. But because the LBJ 

Hospital has not implemented the off-island referral program for 

nearly 10 years, they cannot draw down transportation Medicaid 

funds. 

We will be able to do that starting in the new fiscal year, once 

the local government provides local funding. When that is done, we 

hope that we can better resolve the issues of air transportation, including air ambulance services to the United States through the 

Medicaid program, which will also allow us to draw down our 

Medicaid additional ACA funding provided through the ACA law. 

Mr. LAMALFA. Thank you, Mr. Westerman. I recognize Chairman 

Bishop for 5 minutes, if you so wish. 

Mr. BISHOP. Thank you, I appreciate that. I appreciate you holding this hearing. I was with all of you—most of you, anyway—at 

this hospital. And it was an enlightening spot. 

Mr. Westerman, I would actually like to follow up on where you 

were going with that. Would you like a couple minutes to continue 

on with that? The issue of VA spending especially, as we have the 

CHOICE Act—if indeed the services can be there at the island, or 

if everyone still has to fly, does the Medicaid you are talking about, 

does that solve this particular issue? Can I yield to you a couple 

of minutes to continue on with that? 

Mr. WESTERMAN. Well, you are heading right down the line of 

questioning. And would you care to address that more? 

Ms. YOUNG. Sure. We have approached that. Three years ago, 

when Governor Lolo came into the administration, his mandate to 

our office, as well as to the CEO and to the Director of the Department of Health, was for us to pursue every avenue to see how we 

can better improve the delivery of healthcare services in American 

Samoa, which included reaching out to the VA. 

And we have done that, and it is something that—the Medicaid 

agency is under the purview of CMS and the HHS. So, as a separate department, it requires partnership at a higher level with the 

VA. I don’t think we are precluded from continuing to pursue that, 

but it always comes down to funding, availability of resources, and 

the separate jurisdictions of our departments. 

We came in February of 2015, and one of the initiatives that the 

Governor wanted us to pursue was to also approach the Uniformed 

Services University for health services to see what they could do 

to help us with our workforce development for the medical care 

workforce. And we—— 

28 

Mr. WESTERMAN. Being mindful of the Chairman’s time, one 

other issue I remember was—and correct me if I am wrong—but 

the VA clinic indicated that the hospital did not meet standards for 

the VA care, so the hospital would have to be brought up to standards before the VA could use the hospital. Is that correct? 

Ms. YOUNG. That is my understanding. And I want to share the 

USU contact allowed the Governor and the President of the 

University to sign an MOU to allow graduate students of nurse 

practice to be located and assigned on TDY to the FQHC in American Samoa to help us with that. And the preceptors will come from 

both the LBJ Hospital and the FQHC. We hope that is a segue for 

us to develop an inroad to work more closely with the VA. 

But you are correct, sir, in saying that the VA cannot at this 

time utilize the LBJ Hospital. But they may be able to utilize the 

FQHC for VA services. 

Mr. WESTERMAN. I yield my time back. 

Mr. BISHOP. Mr. Faumuina, can I have you address that same 

particular issue? Is Medicaid funding going to be the solution to 

this, or do we have to do other things—you have a whole bunch of 

veterans in Samoa—to make it possible for them to come back and 

stay? 

Mr. FAUMUINA. I really don’t have a clear answer for that, your 

honor. 

Mr. BISHOP. Well, OK. I don’t either. 

Mr. FAUMUINA. I probably don’t understand the question. 

Mr. BISHOP. It was simply what we were talking about here, 

these two issues again, the ability of actually being able to provide 

services there at LBJ, and does an upgrade need to be there, and 

also does the upgrade need to take place? 

And the second one was does Medicaid funding, if you are looking at those funds in the future, does that solve the problem of 

transportation back to Hawaii, or to the mainland? 

Mr. FAUMUINA. At this point we are using our local funds to 

provide transportation only, and no medical care bills for outside 

providers. 

Mr. BISHOP. My gut feeling is that Medicare or Medicaid, by 

itself, will not solve that problem, will not be enough to meet the 

need that is actually there. Am I wrong with that gut feeling? 

Either way, anybody? Westerman, you can answer that. Whomever. 

[Laughter.] 

Ms. YOUNG. Chairman—— 

Mr. FAUMUINA. With respect to Medicaid funding, we are really 

at the mercy of the local Medicaid office to determine what LBJ is 

eligible for and what LBJ is not eligible for. We do submit our report to them, and they will process it through the system, and we 

get reimbursed for what is due to us. 

Mr. BISHOP. Thank you. My time is over. Once again, I do appreciate you being here, traveling this distance to come to talk about 

this issue. It is important. 

Mrs. Radewagen has been continuously telling us how important 

it is, and it is. So, I appreciate her bringing this to our attention 

all the time, too. 

Mr. LAMALFA. Thank you, Mr. Chairman. 

29 

All right, we will open it up for a second round of questions here. 

I would start off again, back to Mr. Faumuina. 

In previous testimony, you did mention that there has been discussion about a new facility, a 200-bed facility. But I wanted to roll 

back to the staffing difficulties there has been. You mentioned the 

number of pharmacists—I think the numbers were—11 would be 

required, and you have 3. On the nursing ratio it was about, I 

think, 120 or so and you have about 70. And doctors, I cannot quite 

remember those numbers. But you have had a real challenge with 

staffing. 

So, I guess relating—how would you get the staffing level up to 

what you have with the current facility, let alone a newer, larger 

facility? What is the magic, the silver bullet for getting that done? 

What do you see as the way to accomplish that? 

Mr. FAUMUINA. The staffing is always a challenge for us because 

of the difficulty of recruiting the right or qualified personnel to 

take over the positions for doctors, nursing, and other technical 

assistants. 

When the CMS comes to do their assessment of our patient care, 

they discover that there are times that we do not have enough physicians to attend to the needs of the patients. The same goes with 

our registered nursing staff. In those areas, when they go through 

the charts and the forms, they discover that we do not have enough 

staff. 

And the problem with management, we cannot recruit when we 

do not have the resources to recruit them. 

Mr. LAMALFA. Where is the recruiting, how far do you have to 

cast the net for recruiting? 

Mr. FAUMUINA. We recruit from everywhere. We go as far as the 

Philippines, Fiji, and the Pacific, but most importantly we try to recruit from the United States. But it is so difficult for them to—they 

are interested to come to the Pacific, but at the end of the day, the 

salary issue becomes prohibitive for them to make a decision. 

Mr. LAMALFA. Are there any other comments you would like to 

make, with the remaining time I have, on the issue in general? I 

again respect the amount of travel you had to be here. Are there 

any other issues you would like the time to cover a little bit? 

Mr. FAUMUINA. [No response.] 

Mr. LAMALFA. Sorry I caught you on the spot. Let me throw that 

to Ms. Young here, too. 

What areas would you like to emphasize in front of this 

Committee today that we may have fallen short on for time? 

Ms. YOUNG. Thank you, Mr. Chairman. I believe that in our testimonies we have laid out the priorities for our government and for 

the territory, which is the need to extend the timeline for us to expend the ACA money. 

But also, because DOI is here—and this is not a comment that 

would help answer the question of why it is that we cannot draw 

down enough of the money, besides the fact that we only have a 

small population, we have limited medical services, we have only 

one hospital provider—I think what needs to also happen is the 

Department of the Interior—and this is my recommendation—is to 

provide technical assistance to the hospital to allow the hospital to 

30 

better capture, and more effectively capture, the cost of doing 

business in the hospital. 

Capture the costs. Because only then can we help increase their 

draw-downs through their certified public expenditure payment 

method through the Medicare cost report. It would be very helpful 

for DOI to hear that, that LBJ Hospital would benefit greatly, but 

because the hospital has not had enough funding, and their cashflow is a problem, they have been unable to consult with a 

Medicare cost report expert to better capture the cost of doing business, as a hospital. Thank you very much. 

Mr. LAMALFA. Thank you. On my remaining time, Mr. 

Bussanich, is it realistic for OIA to expect the Samoan government 

to be able to promote efficient and effective governance while still 

Federal regulations are hindering, really, the growth of the 

territory? 

Mr. BUSSANICH. Well, from our point of view, given that we are 

working under whatever statutes and regulations are in place 

throughout the United States, I think, we take those as a given. 

We also recognize, as we were speaking of, the relative isolation, 

kind of the economic isolation of a territory still makes it very 

difficult. 

I think we are always in a dialogue with the governors, all of the 

territories, looking at similar problems, and trying to represent 

them in what Councils that we can to ensure that the environment 

that they work in for economic development is as suitable as 

possible. 

Mr. LAMALFA. OK. I better stop there. Let me recognize Mr. 

Sablan for 5 minutes, thank you. 

Mr. SABLAN. Thank you very much. Let me go back again. 

Ms. Young, on the issue of the certified public expenditure—I 

know you are an attorney, and I am not an expert on the particulars, but the Northern Marianas have one hospital. You have 57 

doctors, 93 RNs, and 3 pharmacists. I am envious, because you 

have more doctors than we do. 

Yet, the cost of medical referral that is incurred by LBJ—and 

they are going to say hospitals in Hawaii that meet CMS standards. They are paying for it already. Then that cost should be used 

as the CPEs, the certified public expenditures, so that draw-downs 

on Medicaid could be done. 

Are you doing it for LBJ? 

Ms. YOUNG. That is a really good—— 

Mr. SABLAN. I need to ask this, because here we are, trying to 

find a way to continue funding after 2019 for the territories. And 

Puerto Rico at 2019 will spend 128 percent of its money. The 

Northern Marianas would have spent 93 percent. 

And it hurts our effort when somebody points and says, ‘‘Wait,’’ 

because they see this as a pot of money. And they said, ‘‘Look, you 

have’’—the way we are going now means we would have spent 53 

percent of the total pot of money. And they are going to say, ‘‘You 

have money left over on the table,’’ because I need to protect the 

Northern Marianas, too. So, why aren’t you using that public expenditure, since they are qualified as CPEs? 

Ms. YOUNG. Very good question. American Samoa is very different from CNMI. American Samoa has no private providers. 

31 

CNMI, I talk with your Medicaid Director every year, and am 

always consulting with her to say how do you, how can we help 

ourselves expend our Medicaid funding more from ACA. 

And the problem is, we only have one Medicaid provider, the LBJ 

Hospital. That means we can only pay LBJ. 

Mr. SABLAN. Right. 

Ms. YOUNG. We have no private doctors that are Medicaid providers and we don’t do off-island referral. The off-island referral 

that we do right now over the last 10 years, is simply partial payment of airfare. 

We do not do individual claims. The CPE is a monthly, one day, 

one sheet of paper that comes to our Medicaid agency that basically 

shows us, in aggregate, in line item, all the different departments 

of the hospital and what they expend. And that is what we pay. 

We don’t pay individual claims, we don’t track. We cannot track individual referrals off-island, because we don’t do them. 

When people go for off-island referral, the hospital simply captures that off-island airfare in the Medicare cost report, and then 

the patient is left on their own to pay out of pocket, so we have 

no way in our system to track the expenses of off-island referral patients that take themselves for off-island care in Hawaii or 

California. 

And it is a problem. We recognize that. But it is going to take 

us a while to resolve those system issues. We have started doing 

that since the Lolo administration came in, but it has taken a number of years for us to negotiate those changes in our Medicaid state 

plan. It cannot happen and does not happen overnight, but we are 

getting there. We just got an FQHC approved, we have the offisland referral approved. And hopefully, in the next year, we will 

see a substantial draw-down in our ACA funds. 

Mr. SABLAN. Let me ask, Mr. Faumuina, what will it mean for 

LBJ if Congress does not extend the 2019 ACA funds? 

Mr. FAUMUINA. Well, the experience that we have now is that the 

present Medicaid appropriations, which LBJ is eligible for, is always exhausted on the third quarter of every fiscal year. So, on the 

fourth quarter of the fiscal year we kind of rely on this ACA fund. 

Without that, then, we have to be very creative in coming up with 

other revenue sources to make up for that loss. 

Mr. SABLAN. Yes. Some people will tell me that you guys just 

have too much money, if you are leaving 80 percent on the table 

unspent. 

Mr. Bussanich, I need to ask this. Either OIA or IGIA, to your 

knowledge, have they been working with insular areas and their 

representatives on a strategy for getting these funds extended? You 

said you are continually working with the territories. When is the 

last time you contacted a congressional office from the four insular 

areas on ACA? 

Mr. BUSSANICH. Well, I must say I don’t know the answer to 

that. 

Mr. SABLAN. Well, Steve may. He is right behind you. When is 

the last time, because you said you continually work with us. 

Mr. BUSSANICH. I don’t think we have spoken about that, sir. 

Mr. SABLAN. And you know it is a cliff, it is a funding cliff that 

will hurt critically needed—this is a public health issue. You are 

32 

our foremost advocate in the executive branch, and it is 2017. And 

you know that 2019 will be a funding cliff. And you have not raised 

a finger, as far as you are telling me, and yet you testify that you 

are continually working it. 

I don’t want to put you on the spot, but it is a matter of your 

testimony. Yet, you tell me that you don’t remember. 

My time is up, Mr. Chairman. 

Mr. LAMALFA. Thank you, Mr. Sablan. Let’s recognize Miss 

Gonza ́lez for 5 minutes. 

Miss GONZA ́LEZ-COLO ́ N. Thank you, Mr. Chairman. We have a 

big problem here, and the treatment the territories are receiving in 

Medicaid. That is the bottom line of the problem. 

And, of course, being American Samoa in the Pacific, that triggers a lot of extra problems to manage the VA facilities and the 

treatment, and the shortage of personnel to attend in that. 

This House of Representatives filed in December of last year a 

Task Force Report on Puerto Rico. And one of the issues in that 

report was the Medicaid situation between the territories. I would 

like to refer to one of the lines in the report—By contrast, in Puerto 

Rico and the other territories, Federal Medicaid funding is subject 

to an annual cap pursuant to the Social Security Act. That cap increases annually according to the change in the Consumer Price 

Index for all urban consumers. 

And the problem in the territories, once that Federal funding cap 

is reached, the territory government is responsible for the remaining cost of the Medicaid services. In our case, our cap in Fiscal 

Year 2016 was more than $335 million. In American Samoa, it was 

$11.1 million. 

The situation with this is that FMAP territories are not based 

on the per-capita income, rather than the fixed in the Federal statute. So, we need to fix the problem itself, and the problem is the 

way we are treated in the Medicaid and Medicare. 

In terms of the ACA, some may say that it helped us a lot, because they gave us some money, one-time money, one-time funding. 

But the problem, it was $7.3 billion, of which Puerto Rico got $6.4, 

and the rest of the territories just got the rest. But the problem is 

that was not a solution. We are still needing to have a permanent 

solution to the ACA or to the healthcare problem for the whole 

territories. 

Once we finish or complete that kind of a task, then we don’t 

have to be here every year asking for money for each of the territories in the Medicaid. 

One of my concerns is that before 2011, we got 50 percent of the 

share of the FMAP. The reality is that the increase to just 55 

percent is below the rest of the states, in terms of the per capita. 

And if we were managing the allocation of money for the territories, including American Samoa, in the per capita as the rest of 

the states, you could be having 83 percent. And that is part of the 

report. 

So, I encourage this Committee to try to have a permanent solution on the Medicaid problem, looking for the inclusion of the territories, the whole territories, in a final solution regarding the cap, 

the FMAP, and the distribution of the funds. Because the ACA, I 

33 

mean the Obamacare, was not a solution, and is still hurting all 

territories, including American Samoa. 

I want to thank the members of the panel for being here today, 

because I know how far it is to come here in this kind of 

Committee. And I would like to yield back the rest of my time to 

Mrs. Radewagen, if the Chairman allows that. 

Mr. LAMALFA. Sure. 

Mrs. RADEWAGEN. Thank you, Mr. Chairman. 

Miss Gonza ́lez, I keep going back to this—I am fascinated with 

your question that you asked earlier about this unspent money. 

And it just seems that my colleagues are still focusing on this 

unspent money, and they—I too want to understand. Because if 

this money became available in 2011, that is 4 years before I was 

even elected to Congress. 

Now, the Medicaid Director here, I am looking at her statement, 

and she is extremely critical of the Obama administration, where 

she says the ACA was passed with no input from American Samoa, 

for us to explain that simply setting aside so much Medicaid funds 

with a deadline for expenditure by 2019 was not logical, as 

American Samoa only had one Medicaid provider, which she did 

explain. 

And the point of it is, in my thinking, that this is about helping 

the local government. It is about helping our economy. But, most 

importantly of all, we are talking about the health of our people. 

I mean I have tears in my eyes when I go to that hospital, people 

cannot get the services they need, and they have to struggle to find 

extra money they don’t have to try to go up to Honolulu. This has 

been going on for years. And quite frankly, I am not convinced that 

the entire answer is right there, that it would take 3 or 4 years 

to negotiate all that was being negotiated in order to—I mean 

somebody should have gotten to Congress, somebody should have 

gotten to the CMS, the Secretary of HHS. 

After all, isn’t that where the money came from? The Secretary 

of HHS put this pot of money out there. I just fail to understand. 

Thank you. 

Mr. LAMALFA. Miss Gonza ́lez, time has expired, but yours is 

starting, Mrs. Radewagen, so I will recognize you for 5 minutes. 

Mrs. RADEWAGEN. You have a comment? To the Medicaid 

Director, can you please comment on this? 

Ms. YOUNG. Sure, thank you, Congresswoman. I think the 

Committee has made a really good point, and has raised this in 

your comments and questions, about some of the challenges that 

we face as a territory. 

I do want to correct that I was not critical of the Obama administration. What I was criticizing is the nature of policy making at the 

Federal level, what oftentimes—and this goes to what Miss 

Gonza ́lez had talked about—overlooks the input from the territories, which is why it is so valuable that this hearing is being 

held. When the 2011 ACA was passed, there was really no relevant 

consideration with the situation in the territories. 

For example, in American Samoa we can barely spend this down 

because we have one hospital. But CNMI needs more money every 

year, because they have dozens and dozens of providers. Guam 

34 

needs more money. Puerto Rico needs more money. We have a 

problem spending our money. 

And you are correct, Congresswoman. Part of the problem is also 

our own Medicaid program in American Samoa, because for 35 

years nothing changed. And I came in 2013, 2014 was when we 

started to look at amending the state plan. 

And it really did take us a few years to negotiate this, because 

before you can change anything with CMS, it requires a lot of 

documentation and financial impact analysis. So, we had to hire 

consultants to do the analysis. The procedures are in place already 

for CMS, and we have a very good relationship with CMS, and they 

understand the issues that we are going through. 

Unfortunately, the changes are not happening as fast as we 

would like, but they are changing. So, I think, together with the 

Federal agencies and the Federal Government, having a better understanding of our local situations for all the territories, the need 

to make relevant policies that impact us, but also we recognize that 

internally, not only within LBJ, within the Medicaid program in 

American Samoa, and within our government, we also have problems that we have to take care of. But it does take time. 

Mrs. RADEWAGEN. Thank you, Director. Thank you very much. 

Yes, I can only refer to your statement, which is right here in 

front of me, where you seem to be very, very critical of the Obama 

administration. 

At any rate, the next question has to do with the century-old 

water system. And I think I am going to just give this to CEO 

Faumuina. 

Can you tell us what effect the water system has on the health 

in American Samoa? It has just come to my attention that we have 

lots of these pipes that are lead pipes and what not. 

And does the island’s water infrastructure problems interfere 

with your ability to maintain a sanitary environment for your 

patients at the hospital? 

Mr. FAUMUINA. Yes. We have replaced the water lines to the LBJ 

Hospital with PVC pipings. Unfortunately, we continue to be on 

the watch by ASPA, on the boiling water alerts, which means to 

tell us that the water supplies that come to LBJ are still on a 

watch-out by ASPA. 

So, despite the fact that we have PVC replacements, there are 

other areas of American Samoa that still have that lead piping that 

brings the water through LBJ. 

Mrs. RADEWAGEN. Thank you, CEO. And let’s see, I want to 

thank again the witnesses for traveling all this way, and thank 

you, CEO, in particular, for all you do to try to improve the health 

care of our patients. 

Mr. FAUMUINA. Thank you. 

Mrs. RADEWAGEN. Thank you, Director, on what you are doing 

with Medicare. We want to try to get that solved sooner, rather 

than later. 

Thank you very much. I yield back the balance of my time. 

Mr. LAMALFA. Thank you, Mrs. Radewagen. Thank you again for 

your effort in bringing this to the attention of the Committee, and 

helping to be the driving force on that. 

35 

This is not totally conventional, but, indeed, given the amount of 

travel you made to be here today, Mr. Faumuina, would you like 

to make any kind of a closing statement, or Ms. Young, on this 

issue before we adjourn? 

Mr. FAUMUINA. Thank you, Mr. Chairman. I would like to take 

this opportunity to thank the Committee for extending these invitations to us. We continue to face the challenges until such time that 

we have resolved this CMS survey, as will continue to come down 

hard on us. 

Fortunately, they are very lenient and understandable about our 

challenges. And, as they have cited in their latest reports, we have 

financial, infrastructure, staffing, and all of these challenges that 

we face. But we manage to stay afloat and be very creative in the 

use of our limited resources. 

And we thank you for taking the interest in American Samoa. 

When the CODEL visits came down earlier this year, I took it as 

this is just another visit by the Congress. But, fortunately, I did 

not know that we would come this far, and for me to come and testify before your honorable Subcommittee. 

Thank you very much, and may God bless all. 

Mr. LAMALFA. Thank you. 

Ms. Young? 

Ms. YOUNG. Mr. Chairman and the members of the Committee, 

thank you very much for this opportunity to testify before the 

Committee. I consider it really invaluable that we are here before 

you today, and really wonderful that the Committee took notice of 

American Samoa, and to be able to hold this hearing to hear the 

challenges that we have. 

I would also be remiss if I did not thank the Committee for 

visiting American Samoa in February. I am sorry that we were not 

there when you visited, as we were here for the NGA meeting for 

the governors. But it was extremely important to the Governor and 

to all of us who were not there that deal with the healthcare 

system of American Samoa. 

Having said that, thank you very much for this opportunity, and 

I look forward to working with the Committee in the future, should 

you need any further information from our Medicaid agency. 

Mr. LAMALFA. OK. Thank you. Mr. Bussanich, you don’t get the 

travel award for being here today, but we appreciate your presence 

here as well. 

With that, I just want to again thank you all and the members 

of the Committee that have participated today. If there are any additional questions for the witnesses, we will ask you to respond to 

those in writing. Under Committee Rule 3(o), members of the Committee must submit witness questions within 3 business days following the hearing. The hearing record will be held open for 10 

business days for those responses. 

If there is no further business, without objection, the 

Subcommittee stands adjourned. Thank you. 

[Whereupon, at 11:26 a.m., the Subcommittee was adjourned.] 

36 

[LIST OF DOCUMENTS SUBMITTED FOR THE RECORD RETAINED IN THE

COMMITTEE’S OFFICIAL FILES]

Rep. Bordallo Submission 

— Letter addressed to the Subcommittee on Indian, Insular 

and Alaska Native Affairs from Representative Bordallo in 

support of the Subcommittee’s Oversight Hearing on 

‘‘Assessing Current Conditions and Challenges at the 

Lyndon B. Johnson Tropical Medical Center in American 

Samoa,’’ dated July 25, 2017. 

Rep. Westerman Submission 

— Testimony of Governor Lolo Matalasi Moliga for the 

Subcommittee’s Oversight Hearing on ‘‘Assessing Current 

Conditions and Challenges at the Lyndon B. Johnson 

Tropical Medical Center in American Samoa,’’ dated July 25, 

2017. 

Æ