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94–494 PDF 2004

INVESTIGATION INTO HEALTH CARE DISPARITIES

OF U.S. PACIFIC ISLAND TERRITORIES

HEARING

BEFORE THE

SUBCOMMITTEE ON HUMAN RIGHTS AND

WELLNESS

OF THE

COMMITTEE ON

GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED EIGHTH CONGRESS

SECOND SESSION

FEBRUARY 25, 2004

Serial No. 108–160

Printed for the use of the Committee on Government Reform

(

Available via the World Wide Web: http://www.gpo.gov/congress/house

http://www.house.gov/reform

(II)

COMMITTEE ON GOVERNMENT REFORM

TOM DAVIS, Virginia, Chairman

DAN BURTON, Indiana

CHRISTOPHER SHAYS, Connecticut

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

MARK E. SOUDER, Indiana

STEVEN C. LATOURETTE, Ohio

DOUG OSE, California

RON LEWIS, Kentucky

JO ANN DAVIS, Virginia

TODD RUSSELL PLATTS, Pennsylvania

CHRIS CANNON, Utah

ADAM H. PUTNAM, Florida

EDWARD L. SCHROCK, Virginia

JOHN J. DUNCAN, JR., Tennessee

NATHAN DEAL, Georgia

CANDICE S. MILLER, Michigan

TIM MURPHY, Pennsylvania

MICHAEL R. TURNER, Ohio

JOHN R. CARTER, Texas

MARSHA BLACKBURN, Tennessee

——— ———

——— ———

HENRY A. WAXMAN, California

TOM LANTOS, California

MAJOR R. OWENS, New York

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

CAROLYN B. MALONEY, New York

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

CHRIS VAN HOLLEN, Maryland

LINDA T. SANCHEZ, California

C.A. ‘‘DUTCH’’ RUPPERSBERGER, Maryland

ELEANOR HOLMES NORTON, District of

Columbia

JIM COOPER, Tennessee

——— ———

———

BERNARD SANDERS, Vermont

(Independent)

MELISSA WOJCIAK, Staff Director

DAVID MARIN, Deputy Staff Director/Communications Director

ROB BORDEN, Parliamentarian

TERESA AUSTIN, Chief Clerk

PHIL BARNET, Minority Chief of Staff/Chief Counsel

SUBCOMMITTEE ON HUMAN RIGHTS AND WELLNESS

DAN BURTON, Indiana, Chairman

CHRIS CANNON, Utah

CHRISTOPHER SHAYS, Connecticut

ILEANA ROS-LEHTINEN, Florida

DIANE E. WATSON, California

BERNARD SANDERS, Vermont

(Independent)

ELIJAH E. CUMMINGS, Maryland

EX OFFICIO

TOM DAVIS, Virginia HENRY A. WAXMAN, California

MARK WALKER, Chief of Staff

MINDI WALKER, Professional Staff Member

DANIELLE PERRAUT, Clerk

RICHARD BUTCHER, Minority Professional Staff Member

(III)

C O N T E N T S

Page

Hearing held on February 25, 2004 ....................................................................... 1

Statement of:

Camacho, Felix Perez, Governor of U.S. Territory of Guam; Juan

Babauta, Governor, Commonwealth of the Northern Mariana Islands,

accompanied by Dr. James U. Hofschneider, Secretary of Health;

Togiola Tulafono, Governor, American Samoa; Jefferson Benjamin, Secretary of Health, Department of Health, Education, and Social Affairs,

Federated States of Micronesia, Pacific Island Health Officers Association; and Dr. William McMillan, administrator, Guam Memorial Hospital Authority ............................................................................................... 76

Cohen, David, Deputy Assistant Secretary, Office of Insular Affairs, U.S.

Department of Interior; and Nathan Stinson, Jr., Deputy Assistant

Secretary, Office of Minority Health, U.S. Department of Health and

Human Services ............................................................................................ 21

Letters, statements, etc., submitted for the record by:

Babauta, Juan, Governor, Commonwealth of the Northern Mariana Islands, prepared statement of ....................................................................... 91

Benjamin, Jefferson, Secretary of Health, Department of Health, Education, and Social Affairs, Federated States of Micronesia, Pacific Island Health Officers Association, prepared statement of .......................... 124

Bordallo, Madeleine Z., a Delegate in Congress from American Samoa,

letter dated February 25, 2004 .................................................................... 14

Burton, Hon. Dan, a Representative in Congress from the State of Indiana, prepared statement of .......................................................................... 5

Camacho, Felix Perez, Governor of U.S. Territory of Guam, prepared

statement of ................................................................................................... 81

Cohen, David, Deputy Assistant Secretary, Office of Insular Affairs, U.S.

Department of Interior, prepared statement of .......................................... 23

Cumings, Hon. Elijah E. Cummings, a Representative in Congress from

the State of Maryland, prepared statement of ........................................... 150

McMillan, Dr. William, administrator, Guam Memorial Hospital Authority, prepared statement of ............................................................................ 144

Stinson, Nathan, Jr., Deputy Assistant Secretary, Office of Minority

Health, U.S. Department of Health and Human Services, prepared

statement of ................................................................................................... 32

Tulafono, Togiola, Governor, American Samoa, prepared statement of ...... 113

(1)

INVESTIGATION INTO HEALTH CARE DISPARITIES OF U.S. PACIFIC ISLAND TERRITORIES

WEDNESDAY, FEBRUARY 25, 2004

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON HUMAN RIGHTS AND WELLNESS,

COMMITTEE ON GOVERNMENT REFORM,

Washington, DC.

The subcommittee met, pursuant to notice, at 2:05 p.m., in room

2154, Rayburn House Office Building, Hon. Dan Burton (chairman

of the subcommittee) presiding.

Present: Representatives Burton, Watson, and Cummings, and

Delegates Faleomavaega and Bordallo.

Staff present: Mark Walker, chief of staff; Mindi Walker and

Brian Fauls, professional staff members; Nick Mutton, press secretary; Danielle Perraut, clerk; Richard Butcher, minority professional staff member; and Cecelia Morton, minority office manager.

Mr. BURTON. Good afternoon. A quorum being present, the Subcommittee on Human Rights and Wellness will come to order. I ask

unanimous consent that all Members’ and witnesses’ written and

opening statement be included in the record. Without objection, so

ordered.

I ask unanimous consent that all articles, exhibits and extraneous or tabular material referred to be included in the record.

Without objection, so ordered.

Today the subcommittee has the honor of being joined on the

dais by my esteemed colleagues, the Honorable Madeleine Bordallo,

the Delegate to Congress from Guam, whom I had not had an opportunity to talk to when I was over there, but I’m glad she’s with

us today. And the Honorable Eni Faleomavaega, who’s the Delegate to Congress from American Samoa, and a good golfing buddy

of mine when we have a chance to get out and play.

In the event of other Members of Congress joining us at today’s

hearing, I ask unanimous consent that they be permitted to serve

as a member of the subcommittee for the day. Without objection,

so ordered.

I’d also like to take this opportunity to recognize a good friend

of mine, the Honorable Pete Tonorrio, Representative of the United

States from the Commonwealth of the Northern Mariana Islands.

He’s doing a wonderful job for the people of the CNMI here in

Washington, and I hope 1 day to welcome him as a friend and duly

constituted colleague here in the Congress.

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The subcommittee is convening today to examine disparities in

the quality and access to health care experienced by the people of

the U.S. Pacific Island Territories. We’ll be discussing possible solutions that the Federal Government should seriously consider in

order to alleviate these health burdens.

The medical system in the Continental United States prides

itself on the quality of medical services supplied to the millions of

Americans under its care. Unfortunately, there are populations of

underserved American citizens and nationals who do not have the

same access to adequate and proper medical care in other regions

of the world.

These are the citizens of the U.S. Pacific Island Territories;

namely the residents of Guam, American Samoa, the Commonwealth of the Northern Mariana Islands.

In a post-September 11th society, many foreign nationals have

been hesitant to travel to the Pacific Islands, which regrettably has

taken a great toll on the economies of Guam, CNMI and the American Samoas. As a result, this has drastically increased rates of unemployment on the islands, and consequently has left tens of thousands of men, women and children without proper health insurance

or the means for medical care.

Due to these times of economic hardship, coupled with the caps

placed on Federal Government services such as Medicaid, territorial governments are unable to afford the much needed equipment and qualified health professionals required to properly tend

to the medical needs of their people. I had a chance to see that first

hand during our visit over there. It’s unconscionable that we don’t

do more to help those American citizens.

Late last year, I had the opportunity, as I said, to travel to both

Guam and CNMI and witness first hand the deteriorating health

care conditions on the islands. Needless to say, I was extremely

surprised and disappointed by the lack of sufficient medical resources on the islands, and thus was moved to convene this important hearing today to better educate my colleagues and the American people as well as our health agencies on the ongoing plight of

our fellow citizens and nationals.

One of the primary health care concerns encountered by these

territories is the skyrocketing incidence of diabetes. That’s something that should be researched, because there’s no evident reason

why that’s happening, but it is happening. In recent years, the incidence of Type 2 diabetes, formerly known as adult onset diabetes,

has reached epidemic proportions on these islands.

Hundreds of these patients require constant medical intervention

to survive, mainly in the form of dialysis treatments. Unfortunately, the territories are ill-equipped to deal with the ever-increasing demand for dialysis machines and trained technicians to operate them. This has resulted in long waiting lists and late night appointments for people in desperate need of life saving medical attention.

These growing medical concerns place a tremendous budgetary

strain on the already fragile economies of each territory.

To further exemplify the severity of these disparities in health

care, Guam, the largest of the U.S. Pacific Island Territories, has

only one fully functioning civilian hospital to serve its nearly

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170,000 citizens. Currently only about 150 physicians reside on the

island and must care not only for Guamanian patients but also

thousands of patients who are transported to the territory every

year from many of the smaller surrounding islands.

To add insult to injury, the Guam Memorial Hospital Authority recently declared bankruptcy and is currently $20 million in debt.

Although the CNMI has a Commonwealth Health Center, the

lack of proper equipment and health care staff forces thousands of

patients to brave great distances overseas for care during medical

emergency. Consequently, this is at the expense of the CNMI government. I think we had one case where the Speaker of the House

had to be transported all the way to Hawaii for treatment because

they didn’t have any facilities to care for him on the islands.

American Samoa unfortunately also faces these same predicaments, having only one medical center, LBJ Tropical Memorial, to

service the health-care needs of its entire population of 60,000,

much like the CNMI.

Because the main area of concern deals with the shortage of

qualified medical staff, the subcommittee will be receiving testimony from the Honorable Jefferson Benjamin, Secretary of Health

for the Federated States of Micronesia, who will be speaking today

on behalf of the Pacific Island Health Officers Association. Dr. Benjamin will discuss the ever-growing need for properly trained

health care professionals on these islands. We’ll also ask questions

of other professionals from that area who will be part of the third

panel.

To gain further insight into these most important issues, the subcommittee has the honor of hearing today from the Honorable Felix

Camacho, Governor of Guam; the Honorable Togiola Tulafono, Governor of American Samoa; and the Honorable Juan Babauta, Governor of CNMI.

By the way, Governor Babauta, I would like to inform you that

I did receive your letter regarding ‘‘the stateless children of the

CNMI,’’ which we talked about earlier today. We’ve already instructed our staffs to start researching the ‘‘stateless children’’

issue in order to explore how we can best address a case that at

first glance looks to be a meritorious human rights concern. We

thank you for bringing that to our attention.

In addition, the Honorable David Cohen, the Deputy Assistant

Secretary of Insular Affairs at the U.S. Department of Interior will

testify on his personal experiences observing health care disparities

in the territories. I don’t know of anybody that’s better informed

than David is. I had a chance to spend a lot of time with you over

there, David, and we’re really appreciative of you being here and

hearing your testimony.

During my visit to Guam, I had the pleasure of meeting a very

brave man, the Honorable Vincente Pangelinan, Speaker of the

Guam Legislature. He was invited to testify today to share his own

personal story of this recent cardiac medical scare that almost

claimed his life, which may have been avoided if he had the proper

access to immediate medical care. I think he went to Hawaii, as I

said, to take care of that.

Unfortunately, due to continued health concerns the speaker was

unable to come before the subcommittee today. So on behalf of the

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members of the subcommittee, I’d like to wish him well and we

hope that he has a speedy recovery.

The U.S. Department of Health and Human Services has offices

and programs in place to identify and directly assist with underserved populations, such as the residents of the U.S. Pacific Island

Territories. The Honorable Nathan Stinson, M.D., Deputy Assistant Secretary of the Office of Minority Affairs, is with us here

today. He will discuss current HHS initiatives created to help alleviate some of the problems that we’re talking about.

In closing, I’d like to add that the members of this subcommittee

believe that it is one of our highest duties as Members of Congress

to strive to find the best possible public policy solutions for ensuring that all Americans, any place in the world, have access to the

highest quality health-care services.

It’s my sincere hope that the information shared today will help

to provide the necessary assistance for our fellow Americans across

the Pacific Ocean and ultimately alleviate this health care crisis.

As I said to the Honorable Mr. Stinson, I hope that today the

message will be carried back to our health agencies that additional

resources need to be made available for these regions as quickly as

possible, because are in dire need.

[The prepared statement of Hon. Dan Burton follows:]

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Mr. BURTON. With that, Mr. Faleomavaega, would you have an

opening statement you’d like to make?

Mr. FALEOMAVAEGA. Thank you, Mr. Chairman, for your leadership and your sensitivity in calling this hearing this afternoon, as

it pertains to the health care needs of the insular areas. And not

only as the chairman of the full Committee on Government Reform

but also a senior member of the House International Relations

Committee that you and I have served on together, I cannot thank

you enough, Mr. Chairman, for your initiative in calling this hearing to bring to the attention of the Members of the Congress the

problems that we have and health care needs, not only of the

CNMI and Guam, but also American Samoa, although you did not

have the opportunity of visiting my district or territory.

In the interest of time, Mr. Chairman, I would like to submit my

statement to be made part of the record, as I’m quite certain that

our Governor, who will be testifying later, will provide the members of the committee with a very comprehensive overview of the

health care needs of the territory.

I also would like to offer my personal welcome to Deputy Assistant Secretary David Cohen, representing the Department of Interior, and Dr. Stinson, representing the Department of HHS. And

my personal welcome to the Governors of the insular areas, Governor Babauta, my dear friend, who previously served as the representative of the CNMI to Congress, and is currently the Governor

of CNMI. And also Governor Tulafono, my good friend here, I certainly would like to welcome him.

Mr. Chairman, as I said earlier, I will introduce later my Governor when he has the opportunity to testify before our committee.

Again, I want to give you my highest commendation. One of the

very few occasions that committees in the Congress have given specific direction to look into or to focus into this very important area

that is most needful for the insular areas, and I want to thank you

for your initiative in calling this hearing this afternoon. Thank you,

Mr. Chairman.

Mr. BURTON. And I want to thank you for pointing out that

sometimes it’s difficult to say these various names like

Faleomavaega. [Laughter.]

You’ve been kidding me for years about that, and it’s nice to

know you stumble just a little bit once in a while. [Laughter.]

Mr. FALEOMAVAEGA. I must say, Mr. Chairman, we ran a full

schedule today——

Mr. BURTON. Don’t give me any excuses. [Laughter.]

We had a hearing this morning, and hopefully our good friend

Mr. Tonorrio or whoever is going to be elected by the good people

of the Northern Marianas to give full congressional authority to

have a representation by the CNMI.

Also, we had the hearing for which I wasn’t able to make it to

the delegate voting procedure, or hearing that we had in the resources committee. I had to help with Chairman Pombo’s bill to

recognize the 50 years of the Bravo shot, or the unique strategic

relationship that we’ve had with the Republic of the Marshall Islands, which again thank you for your support, and for which

Chairman Hyde and our ranking senior member, Mr. Lantos, and

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the members of our International Relations Committee approved

the bill and the resolution.

Hopefully it will be considered by the full House before March

1st, because that is the day we’re looking at as the basis of which

the resolution was introduced. We ought to recognize the tremendous contributions that the people of the Marshall Islands have

given to our country in the last 50 years. Many of the Americans

don’t even know that one of the best missile testing operations

going on in the Pacific lies in the Marshall Islands. And the fact

that the Marshal Islands also was the home port where we tested

some 67 nuclear devices, which kind of kept us on the go in our

competition with the Soviet Union and defeating communism. I

would be remiss if I did not mention the fact that the people of the

Marshall Islands have made a tremendous contribution, and hopefully, we will have a chance to go and visit those islands again.

Thank you, Mr. Chairman, again, and you can call me John

Wayne any time you want, Mr. Chairman, if Faleomavaega sounds

too complicated. [Laughter.]

Mr. BURTON. You know, that very nice comment that you made

about the Marshall Islands, I thought for a moment you were going

to run for delegate from there.

Ms. Bordallo.

Ms. BORDALLO. Thank you very much, Mr. Chairman.

I want to say this before I begin my very short testimony here,

that the territories have been very fortunate in the past month or

so. We are getting visits from a number of Members of Congress

and most recently the Secretary of Interior. I think that once you

visit Guam, as you have, Chairman Burton, that you will be friend

of the territories forever. Once you get out and visit the Pacific

areas, meet our people, learn about our customs and our traditions,

you will fall in love with the islands.

So the more that we can invite Members of Congress to come and

visit us, I think they will understand more about us and the difficulty we have on many issues.

I want to thank you, Chairman Burton, for holding this hearing

today on health care disparities in the U.S. Pacific Territories. And

I want to especially welcome the Governor of Guam, the Governor

of CNMI and the Governor of American Samoa, Presidents of the

Senate are here, other distinguished visitors from several of our

territories are in the audience today. I want to thank you very

much. And of course, our Secretary David Cohen, who’s been on the

witness stand most of the day today, in different public hearings

and all the others who are here.

Mr. Chairman, as you said earlier, you have visited Guam and

the Northern Marianas, and you have seen first hand the challenges that we face in providing quality health care for our communities. I’m particularly pleased that you had an opportunity to visit

the Guam Memorial Hospital and that you were well briefed by

Hospital Administrator Bill McMillan and the Director of Public

Health on Guam, and the Director of Public Health on Guam, Mr.

Peter John Camacho.

The issue of disparities manifests itself in higher occurrence of

serious and chronic diseases and in mortality rates that exceed national averages. The question here is whether these health dispariVerDate 11-MAY-2000 11:19 Jul 15, 2004 Jkt 000000 PO 00000 Frm 00016 Fmt 6633 Sfmt 6633 D:\DOCS\94494.TXT HGOVREF1 PsN: HGOVREF1
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ties are further enhanced by the lack of adequate Federal funding.

As you are aware, the territories have a Medicaid cap that limits

the amount of Federal Medicaid funding to about 20 percent of actual costs for indigent medical care.

The recent Medicare prescription drug benefit contains a new cap

for the territories, which is a great concern to our constituents.

While Medicare subscribers on Guam pay into the system, their

prescription drug benefit would not be the same as a Medicare subscriber in one of the United States.

We now have a new disparity, Mr. Chairman, in another Federal

health care program. By every health indicator, the territories lag

behind the States, and are now near Third World levels. Perhaps

our distances and our remote locations contribute to this situation.

However, the disparities may in fact be caused by the disparities

in Federal programs, especially where these Federal programs directly impact the indigent population.

The greatest irony is that these are the very same programs that

are meant to extend the benefits of quality health care to the most

vulnerable population throughout the United States. It is not just

unfortunate that Medicaid and SCHIP and Medicare have caps, but

it is tragic for those who depend on those programs for their basic

health care needs.

Mr. Chairman, I want to thank you for your commendable interest in these issues, and I hope the information we learn today from

the territorial representatives will help us to formulate a strategy

to address the caps in Federal health programs, and to put the

Federal resources where they are needed the most.

Mr. Chairman, I would like to enter into the record my full statement, along with a statement from Speaker Ben Pangelinan and

Senator Luli Angararo.

[The information referred to follows:]

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Mr. BURTON. Thank you, yes, we will put your whole statement

into the record, without objection.

Ms. BORDALLO. Thank you.

Mr. BURTON. We will now swear in our witnesses. Will you both

rise, so I can get you sworn? Raise your right hands, please.

[Witnesses sworn.]

Mr. BURTON. Since you’re a friend of mine after our trip over

there, David, I think we’ll start with you, the Honorable Mr.

Cohen.

STATEMENT OF DAVID COHEN, DEPUTY ASSISTANT SECRETARY, OFFICE OF INSULAR AFFAIRS, U.S. DEPARTMENT

OF INTERIOR; AND NATHAN STINSON, JR., DEPUTY ASSISTANT SECRETARY, OFFICE OF MINORITY HEALTH, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Mr. COHEN. Thank you very much, Mr. Chairman. Thank you,

members of the subcommittee and guest members for today.

I’m pleased to appear before you today to discuss health care in

Guam, American Samoa and the CNMI. I would summarize our assessment of health care issues in the Pacific Territories with the

following observations. No. 1, we don’t know enough. No. 2, what

we do know causes us concern. Health care in the Pacific Territories faces many daunting challenges.

One of the greatest challenges is that the last comprehensive

study on health was published in the mid-1990’s by the Institute

of Medicine. The comprehensive health care data we use today are

dated and inadequate. Existing evidence suggests that our own

communities face the likelihood of poor health. Factors that contribute to this prospect are economic hardship, poverty, joblessness

and under-employment, limited primary and specialty care, and the

under-utilization of services.

Health problems are exacerbated by a number of systemic problems. The tradition of heavily subsidized health care in the Pacific

Territories can sometimes impede investment in health care.

Health care management systems have not efficiently allocated the

limited health care resources that are currently available. A perennial lack of funds is a problem for improving facilities, buying up

to date equipment, purchasing sufficient supplies and drugs and

paying for off-island medical referrals, which are very important in

the islands.

Unlike the States, Medicaid reimbursements to the territories, as

the Congresswoman has noted, are subject to caps. They are also

subject to a reimbursement formula that is much less favorable

than what States are eligible for.

Like the general U.S. population, island communities suffer diseases related to the cardio and cerebral vascular system, cancer,

and of course injuries. Nutritional diseases such as diabetes and

obesity are also leading causes of death. Of the serious diseases

faced by the resident of the territories, many are chronic diseases

precipitated by lifestyle choices.

Over the last 50 years, island populations have increasingly

adopted our mainland diet, with its emphasis on processed foods

that are high in fat, high in carbohydrates and low in fiber. Island

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residents have also moved toward more sedentary work. Smoking

is another major risk factor.

The good news is that lifestyle choices can eliminate many of the

diseases discussed above. Educational efforts therefore could

produce positive health results.

The lack of funds dedicated to health care is an overarching

problem. Isolation and distance from metropolitan centers contributes significantly to this deficit in resources. Shipping costs are

vastly increased for all things needed by island health care systems. It’s difficult to attract off-island doctors, nurses and other

personnel to the respective islands on a long term basis. Off-island

medical referrals for specialized treatment consume large portions

of each territory’s health care budget. The acquisition of technical

assistance for solving health care problems usually involves inordinate delays and complications.

In addition, air travel makes the territories vulnerable to infections from the outside. Diseases such as tuberculosis and measles,

which are less controlled in Third World countries than in the

United States, make appearances from time to time in the territories. They must be dealt with on an emergency basis.

Under the compacts of free association, approximately 6,900

Freely Associated State’s citizens are now in Guam and 2,100 in

the CNMI. Respiratory disease seems to be more prevalent in the

FAS than in the U.S. Territories. Marshallese women have five

times the breast cancer rate of Caucasian women in the United

States, and 75 times the rate of cervical cancer. With FAS migration, the health problems of the FAS become the health problems

of Guam and the CNMI.

Over the next 20 years, the Office of Insular Affairs will provide approximately $76 million in assistance to the Federated States of

Micronesia and approximately $33 million in sector grants to the

Republic of the Marshall Islands, under the revised compacts of

free association. This assistance will include as a top priority funds

targeted at improving health of the citizens of the FSM and RMI

in their home countries.

Assuming improved health, education and economic opportunity,

there will be two benefits, we hope. One, fewer FAS citizens may

find it necessary to migrate to Guam and the CNMI, and two,

those FAS citizens who do migrate will likely be healthier.

We also provide now compact impact funds under the compact to

compensate not only for the health effects of migration and the

strain of local health care budgets, but also education and other

types of services as well, $14.2 million this year for Guam and $5.1

million for the CNMI.

The Office of Insular Affairs provides a variety of types of technical assistance funds for a variety of health care needs. These are

summarized in my written statement. Our technical assistance program is well received in the territories and our assistance, along

with HHS grants, can only constitute a small part of each individual territory’s health care financing.

Mr. Chairman, we welcome the subcommittee’s interest in the

territory’s health care challenges, and look forward to working with

you on these important issues. Thank you.

[The prepared statement of Mr. Cohen follows:]

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Mr. BURTON. Thank you, David. I hope you don’t mind me calling

you David instead of Mr. Secretary, since we were traveling together and everything over there.

Mr. COHEN. I much prefer it.

Mr. BURTON. Thank you.

Dr. Stinson.

Dr. STINSON. Thank you very much.

Good afternoon. My name is Nathan Stinson, Deputy Assistant

Secretary for Minority Health and the Director of the Office of Minority Health in the Department of Health and Human Services.

Thank you for the opportunity to testify today on the Department’s

activities on Guam, American Samoa and the Commonwealth of

the Northern Mariana Islands. I will refer to them as the Pacific

Island Territories in our oral remarks. A complete written testimony is submitted to the committee for the record.

I appreciate the committee’s interest in this region. The people

of the Pacific Islands have many serious health problems and are

medically underserved. Let me start with some of the particular

barriers and challenges, many of which, Mr. Chairman, you are

aware. The remoteness of the Pacific Islands, as well as the wide

difference in the time zone redefines the term difficulty in access

to care. The inadequate nature of the basic health infrastructure,

as well as the manpower shortages, are factors complicating their

ability to deliver quality of care to more than 180,000 residents.

In order to better understand the Department’s programs for the

Pacific Island Territories, I would like to mention some of the other

obstacles faced by providers and their patients alike. I will share

with you a few examples of some of the stories that we have heard

as far as issues that complicate their ability to provide the level of

care they are interested in.

There are oftentimes where medicines are in short supply or are

routinely unavailable. For example, we heard the story of lack of

the availability of insulin on American Samoa, that created a situation where a woman who was pregnant and diabetic could not receive the necessary insulin during the time of delivery. Specialists

in tertiary care are severely limited. In Guam, a woman with

breast cancer is much more likely to undergo a mastectomy as opposed to the possibility of breast conserving therapy, such as

lumpectomy and radiation. The breadth of the treatment options

that we have available in this country really aren’t available to

many of the jurisdictions in the Pacific Islands.

Also, the lack of tertiary care generates enormous cost. As was

just mentioned, many patients who need the attention of a specialist must be sent off-island for treatment. This consumes a significant share of the health budget.

As far as the Department of Health and Human Services programs, they really are intended to focus in three specific areas. The

areas of access, the areas of quality of care, and also to help educate and inform individuals on how to take charge of their health

and what are the things they can do to improve their health, such

as exercising and eating the proper diet.

The Medicare and Children’s Health Insurance Programs run

through CMS work closely with the three territories to assure the

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ing for pregnant women, families with children and people with

disabilities. In fiscal year 2003, the Pacific Island Territories received through Medicaid $2.3 million and through the Children’s

Health Insurance Program $1.9 million. The Centers for Medicare

and Medicaid Services, as well as the San Francisco regional office

staff of the Department of Health and Human Services provides ongoing technical assistance to the territories, especially on eligibility,

services and billing. And recently there were discussions around

such priority areas as the provision of screening services, off-island

referrals and the federally qualified health centers.

The community health center program funded through HRSA’s

Bureau of Primary Health Care has established health centers in

Guam and American Samoa. The community health centers experience incredible challenges in the recruitment and retention of providers, especially ones who come from or are knowledgeable of

these communities. Qualified nurses are frequently recruited to

higher paying jobs in Hawaii, as well as other States. And Mr.

Chairman, as you know, even with the continental United States,

we are currently under an incredible shortage of qualified nurses

for our health care system.

To meet these particular challenges, there has been a utilization

of non-physician medical officers on the islands that are utilized for

the provision of health care services, instead of fully licensed physicians. Many of the doctors who have come to the islands have come

through the National Service Corps, which is a program funded

through HRSA.

One of the particularly innovative programs that the Department

has in the Pacific Islands is its Special Populations Network for

Cancer Awareness Research and Training. This is administered by

the National Cancer Institute Center to Reduce Cancer Health Disparities in the National Institutes for Health. The goal is really to

build the relationships between large research institutions and

community based programs to address the burden of cancer in minority communities.

A particular part of this is the Pacific Island Cancer Initiative,

which has assembled a team to articulate the health needs of indigenous Pacific Islanders, and to focus on strengthening and sustaining community capacity and increased involvement of Pacific Islanders in the National Cancer Institute Program and Services is

also envisioned.

The community health centers, through their National Diabetes

Collaboratives, as you mentioned, diabetes is just an incredible

problem of the population in the Pacific Territories, in Guam, approximately 40 percent of the patients have a hemoglobin A1C with

an average of 10, far above the goal of 7. And as a participant in

the diabetes collaborates Pacific West clusters, clinicians in Guam

have made a commitment to improving the quality of diabetes care.

In addition to intense training on the elements of quality treatment, assistance is provided in communication and maintaining

registers, which is important in tracking the development of complications.

The last program I want to mention just very briefly is the State

based diabetes prevention and control program. Again, designed to

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really talk about the ways to prevent the development of the illness

by proper care, proper diet and proper exercise.

In conclusion, I hope this brief overview of the Department’s activities has been helpful to the committee in considering ways to

improve the health care to the Pacific Islands. The task is considerable. But it is doable, and we must accomplish this. If we are willing to accommodate the unique aspects of the region, work with the

territory leaders and residents in their culture and traditions while

respecting the governing entities and policies, I believe that we can

find solutions that will strengthen the capacity of the health care

system and in turn the health status of the people of the Pacific

Islands.

Thank you for the opportunity to testify before you today.

[The prepared statement of Dr. Stinson follows:]

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Mr. BURTON. Let me start the questioning by asking you, Dr.

Stinson, how do the health agencies decide how much money goes

to those territories out there in the Pacific? Is there a formula that

they use, or do you know?

Dr. STINSON. I’m not aware of there being any particular formula, or some type of quota, as it decides on how to utilize the resources that will go to the Pacific Island Territories, as well as

other parts of the other funded programs throughout the Nation as

a whole. The general tendency really has been to try to look at the

development of specific programs, what would be the appropriate

cost of those interventions as well as how you can buildupon the

existing infrastructure and work with other partners to help in

some of those programmatic aspects.

Mr. BURTON. Well, I hope today, this hearing will convey that

back to our health agencies and maybe my colleagues and I can

write a joint letter to the Secretary of Health and Human Services,

our concern about the lack of resources out there. When you go out

there and you see first and people stacked up in the halls to get

dialysis treatment, and they’re running those dialysis machines 24

hours a day, people are coming in the middle of the night, because

they don’t have the capability to take care of all of them, it’s almost

unconscionable.

I was not aware until today that they are second class citizens,

American citizens, second class citizens as far as Medicare and

Medicaid is concerned, as far as the moneys that are available to

them to take care of their health care needs. And our health agency, you know, HHS gets billions and billions of dollars. It’s one of

the largest appropriations of any agency of Government. I think it

is the largest. We need to make sure that American citizens, not

only here in the United States, but in the territories around the

world where we have American citizens, get the same quality of

care or as close as possible to it as they’re getting here in the

United States.

Secretary Cohen, is there anything you think we ought to be

doing that we’re not doing that could help get additional resources

and funding over there for the territories?

Mr. COHEN. I guess I can only speak for my own department.

Mr. BURTON. Well, but you can go on beyond that if you want

to, because you’ve seen first hand the facilities over there, and

you’ve been with me at some of them.

Mr. COHEN. Sure. And Mr. Chairman, I very much concur with

the observations that you’ve made in terms of the lack of resources

for health care in the Pacific. I’m sure we’re going to hear a lot

more about that today.

One thing that we would like to initiate from the Interagency

Group on Insular Areas, and that is an interagency group re-established by Executive order by President Bush in May to have all the

agencies of the Federal Government come together to coordinate

policy of the executive branch toward the insular areas, that’s the

four flag territories other than Puerto Rico, is to have a working

sub-group so that HHS, Interior and others that might have something to contribute to this discussion can, No. 1, see if we can get

better information or create better information on the health care

needs of the territories, get a fuller picture of what the situation

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is building on some of this anecdotal evidence, and trying to get

hard data, which is desperately needed, and then perhaps talk

about solutions to these problems.

But step one has to be getting better data. Of course, we don’t

need better data to see people stacked up in the hallways, or as the

Governor of American Samoa will tell you about the sorry condition

of the hospital there, and its propensity to be flooded, the over-use

of dialysis machines and the lack of trained medical personnel, the

difficulty of attracting proper medical personnel, both for financial

reasons and getting people to remote islands.

So all of these problems are things that I think we would like

to get a better handle on, on the magnitude of them, and then talk

to the various agencies to see if there are ways to work together

to improve the effectiveness of the Federal resources that are

brought out there.

Mr. BURTON. I hope that working group will, and I’m sure you

will be working with the health officials on the islands to make a

recommendation to the administration and our health agencies to

increase the funding. Because I thought it was deplorable, the situation over there. When you go through those hospitals and you see

the problems that they have, it’s just heart wringing in many

cases.

I’d like to ask you one more question on another subject before

my time runs out. There are about 30,000 citizens of Asian countries that are in the CNMI. Can you tell us how that’s affecting the

economic problems over there, and the unemployment?

Mr. COHEN. Well, it’s very complicated situation in the CNMI,

because a lot of industries are almost entirely staffed, as you and

I saw together, by the guest workers. So to the extent that guest

workers are brought in, generally there is a need for them, and

they are taking jobs that the locals, because of the lower pay rates

for these jobs, may not be willing to take.

But it certainly does create an added burden on the health infrastructure, as well as other infrastructures in the CNMI. And certainly the volume of foreign workers is something that has been

very difficult for the health care infrastructure in Saipan and the

rest of the CNMI to adjust to.

And also the different nature, different types of diseases that

may be brought in, there are health checks that are done in connection with granting entry permits. But still, the large migration

of foreign workers does increase, it’s widely believed that it does increase the propensity of certain diseases to show up in the CNMI,

more than would be the case otherwise.

Mr. BURTON. The working group is working on that as well. Yes.

Ms. Watson, you didn’t make an opening statement, so if you’d

like to make an opening statement, that will be fine.

Ms. WATSON. I want to thank you, Mr. Chairman, and I want to

welcome Secretary Cohen and Dr. Stinson. It’s good to see you

both.

I want to thank you, Mr. Chairman, and tell you how pleased I

am that you have traveled to the Pacific Island Territories of Guam

and the Commonwealth of the Northern Mariana Islands. It’s really good when you have a first hand look yourself in this area. I was

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so honored to serve as the U.S. Ambassador to the Federal States

of Micronesia.

I would also like to thank my colleagues, Representative

Faleomavaega of Samoa and Representative Bordallo of Guam, for

being here at the hearing and contributing to the hearing, and

their leadership in the Pacific Island Territories. As well, I’d like

to welcome the Governors of Guam and the CNMI and American

Samoa, and I appreciate your coming this distance to be here

today.

As Americans, we should be aware of all the United States Territories, Guam, the Commonwealth of Northern Mariana Islands,

American Samoa, Puerto Rico and the Virgin Islands. In addition,

the United States has a very special compact with the Freely Associated States of Micronesia, the Marshall Islands and Palau. Due

to the geographic distance from the continental United States,

some aspects of our social responsibility seem to fall through the

cracks. The territories and the Freely Associated States are really

out of our sight, but they should not be out of mind.

As Americans, we take pride in our diversity. And it is our greatest achievement that based upon that diversity, whether it is economic, political, or cultural diversity, we have built a Nation that

is dedicated to providing equal opportunity for all. But much needs

to be done before we can say that we have accomplished that goal,

most notably in the field of health care. Racial, ethnic and geographic minorities too often are denied the high quality care that

most Americans receive.

The Federal Government has recognized this serious problem

and has set a goal of eliminating national health disparities by the

end of the decade. House and Senate Congress Members have introduced legislation, the Health Care Equality and Accountability

Act of 2003, that takes an important step toward making this goal

a reality.

We may have the finest health care system in the world, but too

many of our people receive too little health care and are denied the

right to lead full lives. The reality is that the health care needs of

minority Americans are often greater than those of white Americans. The populations of the U.S. Territories are eligible for Federal assistance and suffer from similar situations to minorities in

the continental United States of America.

Minority populations disproportionately suffer from many varied

diseases. Minority groups have greater rates of acute conditions,

i.e,. tuberculosis and HIV/AIDS, chronic diseases such as diabetes,

heart disease and stroke and many forms of cancer. In addition,

minority women are at a greater risk than White women for pregnancy related complications and their babies are at higher risk of

dying during their first year of life.

Despite a substantial need for health care, minority groups often

encounter obstacles in obtaining health care. Minority groups are

less likely to have health insurance and less likely to receive appropriate health care services.

So the testimony today will provide us with information on the

territories that can be contrasted with trends across this Nation.

According to a study by the Kaiser Family Foundation in June

2003, minority populations have substantially higher uninsured

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rates than white Americans, 12 percent. Hispanics are at 35 percent, Native Americans around 27 percent, and African Americans

20 percent, while Asian and Pacific Islanders are somewhere

around 19 percent.

In addition, while racial and ethnic minorities represent only

one-third of the non-elderly U.S. population, they represent more

than half of uninsured Americans. These numbers are exacerbated

in the islands.

So Mr. Chairman, our focus today on the Pacific Island Territories is a necessary focus. And I’m looking for the testimony from

the Governors of the three Pacific Territories, and from the Pacific

Island Health Officers Association, which can provide us a picture

of the Freely Associated States.

I commend the vision of this subcommittee and the dedication of

this Chair to address and investigate these health care disparities.

The people sitting up here in front of you are the dedicated and

committed ones, to see that not only our citizens but those of you

in our territories are not victims of being neglected. We, some of

us really know the problems personally. And you are here to assist

in telling your story so that we can make the policies that will improve the health care of all Americans, either in the continental

United States or in our territories.

I yield back the balance of my time, Mr. Chairman, and thank

you very much.

Mr. BURTON. Thank you, Representative Watson.

Mr. Faleomavaega.

Mr. FALEOMAVAEGA. Thank you, Mr. Chairman, and I want to

thank Dr. Stinson and Secretary Cohen for their fine statements.

I do have a couple of questions I want to raise. I think it’s important to get a sense of perspective or history on the evolution of how

insular areas have been treated historically by our country, and

what has always been the traditional Federal agency that has been

the chief administrator of the needs of these territories, whether it

be the Pacific or the Caribbean.

And I make specific reference, of course, to Secretary Cohen’s responsibility, a tremendous responsibility in overseeing the needs of

the insular areas. I just wanted to ask Mr. Cohen a couple of questions. There’s no question that the health care needs of the insular

areas are different, perhaps even worse conditions than many of

the areas that we have here in the United States. Testimonies have

borne out this afternoon a reference to distance, sense of isolation

from mainstream America simply because of our location and difficulty in accessibility to services and programs that are easily provided or can be provided if necessary here in the continental

United States.

As Mr. Cohen had alluded to earlier, we have established an

interagency, inter-governmental work group, hopefully, to be composed of chief policymakers of the various Federal agencies that

deal with insular areas or with the Pacific Territories. In fact, it

was just a couple of days ago that we had this meeting with Secretary Norton for which we are very grateful, that we have some

kind of a conduit or a way that we can express what our needs are.

The problem I always have been faced with, this interagency

working group says it’s fine that we talk about the issues, but then

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when it comes to giving some sense of finality or results, this is

where things get lost in the cracks, and then we go back again and

we still discuss the very same issues that we’ve been discussing for

the past several years.

It’s a tremendous gain on the part of the insular areas, we’ve become more politically developed, we’ve elected our own Governors,

we’ve elected our own congressional delegates. We don’t have two

Senators. And for this very sake that we don’t have Senate representation, for those of us who represent the insular areas, Mr.

Chairman, I think we have to work about 10 times harder. A lot

of times it’s been with the compassion and the interest taken by

some, such as yourself, to date to help us bring out the issues, not

only just for public discussion but hopefully to find results.

As I had mentioned to Secretary Cohen in our meeting with the

IGIA, and I want to ask Secretary Cohen, will the Department of

Interior be willing to work with us as congressional delegates in

crafting appropriate amendments to Federal laws that perhaps are

not helping us? Because I always perceived the Department of the

Interior as our partner in working, in providing the appropriate

forum. Because unless if I’m wrong on this, Mr. Secretary, I would

like a response.

Or in each instance, if we have a problem with HHS, we’ve got

to go to them. In other words, we end up having to go to about 50

or 100 different agencies before we have some sense of finality in

resolving the problems? I wanted to ask Secretary Cohen that.

Mr. COHEN. Sure, thank you, Congressman. You raise a lot of

very good and important points. I think your questions, especially

about the process, now that we have an interagency group on insular areas [IGIA], these are very good questions. I’d like to share

with you some of the optimism I have about how the IGIA can address some of the concerns you’ve raised.

As you pointed out, the Department of Interior has traditionally

been the Department within the Federal Government that is responsible for the day to day relationship with all the territories.

But also, all the agencies have independent relationships with each

of the territories. So there’s sort of a disparity between our knowledge of the territories, because we’re the only office, my office, the

Office of Insular Affairs, is the only office that is focused on the islands 24/7. So it’s a disparity between that and then the other

agencies in the Federal Government that often make very large investments in the territories, but are not focused on the special

needs of the territories.

So it’s always been our task, which has been a very challenging

on, to work with each of the different agencies to try to raise the

profile of island issues in each territory. To do that one agency at

a time is very difficult. So one reason that I’m very excited about

the reestablishment of the IGIA is it creates a forum that’s mandated by the President of the United States for top policy officials,

as you pointed out, from each of the agencies to come together and

focus on the particular needs of the insular areas.

Now, that in and of itself will not result in problems being

solved, as you correctly pointed out. But it addresses the initial

threshold problem of getting insular area concerns, the particular

problems of the islands, on the radar of top policymakers in each

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of the executive branch agencies. That is really a major hurdle, because we have found, when people become familiar with the disparities, and when they become familiar with the particular issues,

just as Congressman Burton, who took his first trip out with me

to Guam and the CNMI, they start to have an understanding of,

No. 1, the uniqueness of the problems, and No. 2, what each agency

can perhaps do to address it.

So the process isn’t complete in that it won’t result, it will not

guarantee that all of these problems will be solved. But we’ll guarantee that all the problems will be focused on and studied.

Mr. FALEOMAVAEGA. Mr. Secretary, my time is running out, I’m

sorry. I just want to cite a classic example. When the Northern

Marianas established this covenant relationship with the United

States, one of the most unique features of this covenant relationship, Mr. Chairman, and thanks to a gentleman that I’m sure all

the insular leaders are well aware of his contributions, for the tremendous help that he gave, was that the Northern Mariana Islands became beneficiary to the SSI benefits, simply because the

late Congressman Phil Burton was very much a key player in

working that covenant relationship, for which NMI, God bless

them, are beneficiaries to the SSI programs.

But American Samoa does not get SSI benefits, Guam does not

get SSI benefits. And every time we’ve made an effort, and Puerto

Rico does not get SSI benefits. And I only use it in the sense of

endearment, you’ve got a 900 pound gorilla with 3.8 million Americans living in Puerto Rico. Every time they put us together with

Puerto Rico, we are dead on the spot.

So for years we’ve been trying to work out, how can these small,

little insular areas, let’s just not discuss Puerto Rico, where we

have tried every way to include American Samoa and Guam for

SSI benefits, but it’s an impossibility. And for some reason or another, we say that they’re not Americans. I suppose I can qualify

that, we’re U.S. nationals, we’re not U.S. citizens. But we do fight

and die in our wars, I suppose that might be a consolation, in our

contributions to our national defense.

But this has been the problem. And I’d like to ask Secretary

Stinson, I’ve introduced legislation to give the Secretary of HHS

discretionary authority that they can work in MOU relationship between Guam and American Samoa, so that in our own unique way,

with 150,000 in Guam and 60,000 in American Samoa, we’re not

asking for the moon. Just enough so that it’s practical and the

services, and we need critically, for example, SSI benefits for many

of our mothers or our residents that have this critical need.

And God bless NMI, thanks to Phil Burton, they got the benefit,

but we don’t. And this is why I wanted to ask Dr. Stinson and Secretary Cohen, will you be willing to help us if we introduce legislation, even if just to give the Secretary of HHS discretionary authority to give us some of that benefit?

I’m sorry, Mr. Chairman, I know my time’s up.

Mr. BURTON. That’s OK, we’ll let them answer the question and

we’ll go to——

Dr. STINSON. Yes, but essentially around the specific around

working with you in relationship to SSI, that’s, you know, SSI is

really part of the Social Security Administration, which is not part

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of HHS any more. There was a time where it was part of it, but

it did become its own separate agency.

But I want to answer the bigger question that you really posed,

and when we look at the needs and what really needs to be done

to improve the health of the people in the Pacific Island Territories,

it really does need to be looked at from a very, very comprehensive

way, and it needs to be looked at across the organizational lines

of the different agencies.

To have the type of discussions and the type of engagement between Interior, Department of Energy also is a stakeholder out

there in the Pacific Islands, HHS, Department of Justice. To sit

down and really determine what are the things, what are all the

components that adversely affect the likelihood that the individuals

there can live a long and healthy life, and put everything on the

table as options and develop some type of strategy, some type of

plan to do it in a very, very comprehensive way. And the Department is very committed to doing that.

Mr. BURTON. Let me, before I yield to the delegate from Guam,

just say that I’d be happy to work with all of my colleagues here

in drafting a letter, we might have to take this one point at time,

but to start off with the health issues and see if we can’t make sure

that American citizens and those who are from a territory that we

control get fair treatment as far as health is concerned. That’s the

thing that bothered me the most when I was out there, seeing the

deplorable conditions.

With that, we’ll go to Delegate Bordallo.

Ms. BORDALLO. Thank you very much, Mr. Chairman.

We’ve spent quite a bit of time on discussing the processes, so I

think I’d like to get to the substance. I’d like to ask you, Mr.

Cohen, would you agree with me that utilization of the Medicaid

program to cover Guam’s providing of health care to citizens of the

Freely Associated States who travel to Guam would be good public

policy worth pursuing? This would and should be outside our current cap and with 100 percent Federal matching assisted percentage. I’d just like to get your views on that.

Mr. COHEN. Sure. As you know, Congresswoman Bordallo, I’m

here representing the administration and would have to do as I always do, work quietly with my colleagues within the administration to actually get an official response to very specific questions

such as that. But the larger point, of course, is that we are aware

of the problems Guam has had for so many years, addressing the

medical needs and other needs of those who migrate from the Freely Associated States pursuant to the compacts of free association.

When I heard that proposal from your staff, I thought it was a

very creative proposal. We would certainly work with you on a proposal like that. I’m very happy that we’ve taken what I think is a

historic major step to addressing compact impact issues and now

having an annual permanent mandatory appropriation of $30 million, of which Guam almost got half this year, and I guess maybe

for the next 5 years, $14.2 million, doesn’t address the concerns

that Guam has raised for going back to the beginning of the compact. But hopefully going forward, we’ll do a much better job of addressing those needs.

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That is one proposal, and you know, we’re certainly willing to

work with you.

Ms. BORDALLO. So would you get back then on that?

Mr. COHEN. Certainly. And of course, this isn’t just something

that Interior would approve, but it would be an administration

wide issue.

Ms. BORDALLO. There is one further followup, Mr. Chairman, if

I could. This is both to Secretary Cohen and Dr. Stinson. I would

appreciate any comment that you could offer to us on the administration’s position with respect to the Medicaid caps. Any thoughts

on how we could best collectively and constructively begin to really

address this disparity in treatment? I’d like to get your opinions.

I suppose you’re going to come back and say that, well, you’ll have

to check with the administration.

Mr. COHEN. I would just say briefly, just because we’ve had a

chance to address this issue through the auspices of the IGIA, that

I guess HHS, well, HHS is here, so I won’t presume to speak for

HHS. But the issues that were raised in terms of linking Puerto

Rico to the equation, which increases the costs by orders of magnitude, is an issue. And of course at the meeting yesterday, some

other ideas were tossed out as interim solutions.

But you know, the initial issue of whether caps are lifted for all

five territories of course presents major cost issues, as I understand

it, from the administration’s standpoint. So if there are other creative solutions, it might provide a better scope for us to work together to address the problem.

Ms. BORDALLO. Dr. Stinson.

Dr. STINSON. Yes, first of all, let me say I’m not an expert in

Medicare and Medicaid. And as we’re all aware, the provisions of

the cap are really grounded in the statutory history here, even if

there have been some modifications over the years. But I would

like to say that clearly, the Department looks at the services that

are provided through the Medicaid program as a mechanism of providing access to care. And it’s certainly interested in the development and the support of solutions that will really maximize the

ability for all U.S. citizens to be able to get the type of care that

they need and that they deserve.

Ms. BORDALLO. Thank you very much. I’m just, when I was listening to my colleague here, Representative Faleomavaega, mentioning the SSI and how our neighbors benefit from this, and of

course Guam, just being a short distance away, we do not have this

benefit, nor does American Samoa nor Virgin Islands. I just wonder

if we consider the three of us alone rather than bringing in Puerto

Rico. They did it with CNMI, so could that be looked at, Mr. Secretary?

Mr. COHEN. I’m sure it could be looked at, and of course, it’s

quite a different issue when it’s framed in that way.

Ms. BORDALLO. Thank you.

Mr. BURTON. Well, we’ll excuse you, gentlemen, but before you

go, I hope that you’ll stick around to hear what the Governors and

the health officials have to say from the territories that we’re going

to be discussing. So if you wouldn’t mind staying around a little bit,

I’d really appreciate it.

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The one thing that I’d like to stress before you leave the table

is that although some of the things we’ve discussed today may take

legislative action to make positive changes, and sometimes that’s

very difficult, especially with the budgetary problems we have,

HHS has a lot of money. And HHS has the ability to put more

money into these territories if they so choose. That doesn’t require

legislative action.

And I hope that the executives at HHS and your working group

get together and say, look, we can’t have these people in American

Territories who are American citizens or live in the American Territories, we can’t have them being second class citizens. They at

least ought to get quality health care, and I’m going to tell you

right now, from first hand visual evidence, I can tell you they’re

not getting it. That’s just not right.

But with that, thank you very much for your testimony.

We’ll now call to the table the Honorable Governor Camacho of

the Territory of Guam; the Honorable Governor Babauta of the

Northern Mariana Islands; and the Honorable Governor Tulafono,

of the Territory of American Samoa. If my colleagues want to make

any kind of introductions for these gentlemen, I’d be happy to have

them do it.

Mr. Faleomavaega.

Mr. FALEOMAVAEGA. Thank you, Mr. Chairman.

I want to offer my apologies, we up here on the dais, I got so

nervous I forgot to even notice my good friend Felix Camacho, and

I want to apologize. But I do want to thank Governor Camacho and

Governor Babauta and Governor Togiola for the beautiful reception

that we recently received, when Secretary North and Chairman

Pombo and several members of our delegation visited these insular

areas.

I would like at this time, Mr. Chairman, to introduce, it’s my

honor to introduce our Governor. This gentleman is a homemade

product, successful in getting his training as a member of the Honolulu police department. He was a law enforcement officer. And

several years served as judge in our territory, and also served as

senator and chairman of the various committees. He has been practicing law for the past 25 years, and a graduate of Washburn Law

School from Topeka, KS. Would you believe, Samoans living in

Kansas, Mr. Chairman?

And due to the untimely death of our late Governor, Governor

Togiola had to take the reins since last April. Mr. Chairman, I’m

very, very happy that he’s here with us, and I look forward to hearing his testimony as it pertains to the health care needs of our territories.

Mr. BURTON. Very good. Would any other Members like to speak?

Ms. Bordallo, do you have any comments?

Ms. BORDALLO. May I introduce my Governor?

Mr. BURTON. Sure.

Ms. BORDALLO. All right, thank you.

My Governor is Governor Felix Camacho, and there are some

very interesting twists and turns to his political life. He served as

the civil service director, I think, correct me if I’m not right, Governor, with the Government of Guam for a number of years as diVerDate 11-MAY-2000 11:19 Jul 15, 2004 Jkt 000000 PO 00000 Frm 00079 Fmt 6633 Sfmt 6633 D:\DOCS\94494.TXT HGOVREF1 PsN: HGOVREF1
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rector. He served many terms and he was my colleague in the

Guam legislature as a Senator.

What makes him most unique is that several years ago, his father, the late Governor Carlos G. Camacho, served as Guam’s first

elected Governor. And now these many years later, we have his son

serving in this very high position.

So Governor Camacho, we welcome you to Washington and we

look forward to your testimony. Thank you.

Mr. FALEOMAVAEGA. Mr. Chairman, I forgot to mention that our

Governor has about a five handicap, if you really would like to play

a round.

Mr. BURTON. I don’t want to mess with anybody with a five

handicap. [Laughter.]

He would own my house.

And I’ll personally introduce Dr. Babauta, who is a good friend

of mine. We had an opportunity to get to know each other in a

more personal way, along with Governor Camacho, when I was visiting in that region. So Governor Babauta, welcome to you as well.

Would you please stand so I can swear you in?

[Witnesses sworn.]

Mr. BURTON. We’ll start with you, Governor Camacho, and just

go right on down the table there. Do you have an opening statement you would like to make? You can read your testimony or

make an opening statement, whichever you would prefer.

STATEMENTS OF FELIX PEREZ CAMACHO, GOVERNOR OF U.S.

TERRITORY OF GUAM; JUAN BABAUTA, GOVERNOR, COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS, ACCOMPANIED BY DR. JAMES U. HOFSCHNEIDER, SECRETARY

OF HEALTH; TOGIOLA TULAFONO, GOVERNOR, AMERICAN

SAMOA; JEFFERSON BENJAMIN, SECRETARY OF HEALTH,

DEPARTMENT OF HEALTH, EDUCATION, AND SOCIAL AFFAIRS, FEDERATED STATES OF MICRONESIA, PACIFIC ISLAND HEALTH OFFICERS ASSOCIATION; AND DR. WILLIAM

MCMILLAN, ADMINISTRATOR, GUAM MEMORIAL HOSPITAL

AUTHORITY

Governor CAMACHO. First of all, I would like to thank you very

much for inviting me and my fellow Governors, the territorial Governors, here to Washington to provide testimony. We very much appreciate this opportunity, again.

And the mere fact, Mr. Chairman, that you have personally been

able to see for yourself the territories with your visit, to see first

hand the situation of our health care on our islands and the many

challenges we face. I think it makes a big difference. It’s not too

often that we have Members of Congress come out to the far distances in the Pacific to see for themselves the many challenges we

face. We truly appreciate the visit you made there. And with that,

I would like to begin my testimony.

Mr. Chairman and members of the committee, Congresswoman

Bordallo, Congressman Faleomavaega and Congresswoman Watson, thank you for inviting me to participate in your hearings on

the disparities of health care in the Pacific Island Territories. I

would like to express my appreciation to you for providing this opVerDate 11-MAY-2000 11:19 Jul 15, 2004 Jkt 000000 PO 00000 Frm 00080 Fmt 6633 Sfmt 6633 D:\DOCS\94494.TXT HGOVREF1 PsN: HGOVREF1
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portunity to address the needs and concerns of the Pacific Islands

on this most important issue.

Our peoples’ health is one of the highest priorities, and we are

constantly striving to improve the quality of care available on the

islands. However, in addition to facing many of the challenges that

States are grappling with, Guam and our Pacific Island neighbors

also have certain concerns that are unique to our region.

Like many communities, we have difficulty in recruiting and retaining health care professionals, and providing basic health care

in the face of skyrocketing costs and ensuring that every member

of the public has access to quality health care services. But the

challenges we face on Guam go far beyond these issues. Our small

population base, relative isolation and constant mix and influx of

people from areas with even fewer health options are among the

many circumstances that contribute to the serious health care concerns on Guam.

With our Department of Public Health and Social Services, it

provides basic medical care and public assistance to our indigent

population. The Department is additionally responsible for immunizations, health education, disease screening and monitoring, tracking the health status of Guam residents and safeguarding the vital

statistics registry.

Guam’s public health department receives both Federal and local

funding for indigent care. But Federal caps on Medicaid benefits to

the island have resulted in the need for the government of Guam

to bear an unusually large burden for indigent care. In fiscal year

2003, Federal funds paid for just $8 million of the total Medicaid

bill of $15 million. The Government of Guam spent an additional

$17 million on the medically indigent programs that were developed to cover the needs of our poor.

Now, the influx of patients from the Freely Associated States

[FAS], further burdens our public health system. Public health provided more than 188,000 services to residents in 2003. And of these

24 percent were provided to FAS citizens. Citizens from these areas

also have exceptionally low rates of insurance coverage, 29.4 percent of the FAS citizens surveyed in 2003 had no form of health

insurance compared to Guam’s uninsured rate of 21 percent of the

adult population. By comparison, the uninsured rate for the United

States as a whole was 14 percent in fiscal year 2002, the last year

that U.S. statistics are available.

Now, with an economy still struggling to recover from years of

typhoons, geopolitical events, economic problems in Asia, the Government of Guam simply cannot afford to continue over-matching

Medicaid. We must have additional funding to provide the level of

services needed by the population.

I listened with interest, as you had mentioned, Congressman

Faleomavaega, about the need to somehow separate Guam and the

Northern Marianas and American Samoa from Puerto Rico as the

equation. Because you can combine all our islands, land mass, population, even people that come and visit as tourists, and still we

cannot match the level of population and impact of Puerto Rico.

And it’s convenient for policymakers, or those that are responsible in administering the programs to say, well, we simply can’t

give it to you in all fairness, because if we do, then we must also

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give it to Puerto Rico. But I think in all fairness, we understand

the impact of that, but we must be given some reasonable exception to the equation and be separated out in consideration of Medicaid.

This lack of funding has also led to serious deficiencies in our

local facilities which are aging and in need of repair or replacement. These facilities have been built decades ago with the HillBurton funding. And as time has progressed and population has

grown, our public health department is challenged to find adequate

space to provide the myriad of health services it is mandated to

provide.

In May 2003, a local law was passed requiring clients in the

medically indigent program to receive their primary health care

services through the community health services. This was done to

try and alleviate the impact upon our hospital. My administration,

with the support of the Guam legislature, recognizes our obligation

to provide basic primary health care services to our people. And because private health care providers are currently turning MIP and

Medicaid patients away. We must identify a point of access for

these patients.

The need for expanding current facilities and acquiring additional funding for programs provided by our public health and social services department is reflected both in the department’s difficulties and the health of our population. Guam has a high prevalence of both communicable and chronic diseases, as you well pointed out, Chairman Burton, which well funded and aggressive public

programs would best be equipped to address.

Again, you mentioned, Congressman Burton, that our diabetes

rate for adult population ranges from 25 to 46 percent higher than

adults in the United States. And while the Pacific Islands Health

Officers Association meetings in 2003 led to the declaration of a

war on diabetes, the $200,000 budget for that fiscal year seems a

small amount to battle a disease that conservatively affects more

than 10,000 adults on Guam.

Communicable diseases also remain a major concern because of

our proximity to Asia, where many new alarming diseases such as

SARS and the more recent avian influenza outbreak originated.

Despite our vulnerability to such outbreaks, Asian border States

and territories were overlooked during a recent initiative to increase surveillance in border States for bioterrorism agents and

emerging infectious diseases.

With the Guam Memorial Hospital, Guam is served by one civilian hospital, which is a fully autonomous entity of the government

of Guam. As the island’s only hospital, GMH is mandated to provide treatment to every individual, regardless of ability to pay. This

has caused serious financial problems for the institution, as 80 percent of its patients were uninsured self payors, 80 percent of its patients were uninsured in the hospital. They were uninsured self

payors or recipients of medical assistance from the department of

public health.

Our hospital provides 1.1 inpatient acute care beds per 1,000

population, a situation that will deteriorate with 0.92 beds per

1,000 population by 2010. This is still less than half of the 2.1 inpatient beds per 1,000 population in division nine hospitals, according

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to a 2003 American Hospital Association report. The hospital’s

chronic financial problems, combined with challenges inherent to a

relatively small population base, has forced the government of

Guam to limit services available at the facility.

However, unlike mainland U.S. patients who can simply drive to

an appropriate facility, Guam’s patients face the expensive prospect

of flying between 3 to 8 hours to another medical center. You mentioned our Speaker, who had to fly off, and many thousands of others. The discomfort and cost of such trips, to say nothing of the

hardship of such a flight on critically ill patients, makes access to

care extraordinarily difficult for many families. Massive family

fundraising projects are commonplace when a family member needs

surgery or cancer treatment. And some individuals are unable to

get appropriate care because of the high cost.

Honestly, you may have seen it yourself, Mr. Chairman, you’d be

driving down the highway and you’d find in the medians of our

highways by the stop lights people with buckets and hats, and

signs saying, my mother’s sick and she needs a kidney treatment

or open heart surgery, can you donate money. They knock on the

doors of every politician, asking, can you personally help, can you

appropriate money. Everywhere you look on this island, people

have been gravely affected, without the ability to pay for medical

care.

The lack of certain services on Guam is perpetuated by the need for patients to seek care off-island. More than $30 million in local

insurance premiums each year is spent at facilities outside of

Guam, robbing our hospital of the capital needed to develop and expand services. And to date, GHM per capita budget is one-third

lower than district nine Pacific States, leading to an absence of

critical services.

GMH has no radiation oncology, no cardiac surgery, and despite

mortality and morbidity rates that significantly exceed national

averages, we have no kidney donor program or transplant service,

despite higher than average diabetes rates and end-state renal diseases. In addition to the need to expand services and make care

more affordable for all patients, GMH also seeks assistance in

Medicare programs.

A participant since 1986, GMH was granted an exemption from

the prospective payment system. However, our hospital’s reimbursement has slipped from cost based to less than cost, resulting

in the loss of approximately $3 million from Medicare revenues of

$12 million annually. Critical access hospitals receive 101 percent

cost reimbursement, and special mechanisms are available for disproportionate share hospitals, rural referral centers and sole community hospitals. We believe that GMH can meet all of the criteria

for these special categories, if reimbursement regulations can be

modified slightly to recognize Guam’s unique circumstance.

I just have three other categories, and I’m done. Staffing concerns, across the Nation communities have grappled with shortages

of nurses, medical technologists and other medical specialties. This

situation is exacerbated on Guam, where it is often difficult to recruit and retain health care providers.

As an example, I would like to share a brief story that occurred

a few years ago. The island’s only gastroenterologist decided to reVerDate 11-MAY-2000 11:19 Jul 15, 2004 Jkt 000000 PO 00000 Frm 00083 Fmt 6633 Sfmt 6633 D:\DOCS\94494.TXT HGOVREF1 PsN: HGOVREF1
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turn to the U.S. mainland. In the weeks before his departure, his

clinic was crowded until after 11 p.m., and later crowded with

other physicians on-island who rushed in for checkups and treatments before he left the island.

With increasing Federal grant funds to Guam, our geographic

isolation and paucity of human and natural resources contribute to

a higher cost of doing business on Guam. We believe that this cost

could be addressed when Federal grants funds are allocated to

Guam by raising the floor amounts of grants that use them, and

instituting a minimum floor amount for those that do not, and then

applying population based formulas for the distribution of the remainder of the grant funds.

In summary, clearly there are a number of issues that need to

be resolved to place Guam on par with other U.S. jurisdictions. And

there must be a commitment by the Federal Government to help

all Pacific Island Territories deal with the shortcomings that face

each one of us in improving and providing the quality health care

to our people.

I thank you for your attention.

[The prepared statement of Governor Camacho follows:]

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Mr. BURTON. That’s a very, very good statement.

We have two votes on the floor, and I have to run to the floor.

This is unusual to ask this, but I think I’ll ask Mr. Faleomavaega

if he would to conduct the meeting in my absence. I’ll be back in

about 10 minutes, and then we’ll get into questions and answers.

So we’ll go to Governor Babauta, we’ll go to you next, and I’ll be

right back.

Mr. FALEOMAVAEGA [assuming Chair]. Most unusual situation,

that the good chairman has been so kind as to allow the minority

to preside over a hearing. It’s unheard of. But I know for his graciousness, and Governor Babauta, I know you have some very precious statements that you want to share with the chairman. I’m

sure that the good staff director that we have here will take every

word of your statement and make sure that Chairman Burton gets

it.

By the way, Governor, you’ve been here long enough to know

that this is how the Congress and the congressional committees operate, and I know it’s not lack of sensitivity, it’s just the reality of

the nature of the beast. This is how the Members have to be, on

the floor to vote. They cannot vote by proxy.

But please proceed.

Governor BABAUTA. Well, you know, years ago I called you Mr.

Chairman. And although it didn’t work out, I can truly call you

today Mr. Chairman, at least temporarily.

Just as a way of opening remarks, I sat here thinking, when you

and Congresswoman Bordallo were introducing your Governors,

how totally unfair it was that I do not have a delegate up there

to introduce me as well.

Mr. FALEOMAVAEGA. How great an honor you had, in the fact

that the chairman was introducing you, and the congressional delegates certainly don’t have the same rights and privileges. [Laughter.]

I think, Governor, you could not have gotten a better person to

introduce you, in a much higher capacity than us humble congressional delegates. Please don’t feel that bad.

Governor BABAUTA. Let me get back to you on that point.

Today, I’m honored to be accompanied by a number of elected officials from the CNMI. I want to recognize them by name, because

I want their names to appear on the record as having borne witness to this very important hearing that Chairman Burton called

for.

We have the Senate President, Joaquin Adriano, and Senator Joseph Mendula, Senator Henry Senicholas, and Senator Tom

Villagomez, Senator Louie Christastimo, and Congresswoman

Janet Maratita. Just for the record also, Congresswoman Janet

Maratita is the only female representative in the entire legislature.

So we’re very proud of her.

Mr. FALEOMAVAEGA. Governor, I know exactly where you’re coming from. It is annoying at times, when you feel like you’re not really part of the team, or as a full fledged member. Just like when

we have roll calls, we’re left here, and the others get to go vote on

the floor. You feel like perhaps you’re a second class citizen in that

respect, but that’s just the way things are here in Washington. I

know that every Member here doesn’t feel we’re being slighted, it’s

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just the fact that as territorial delegates, we don’t have the full

rights and privileges allotted to Members who represent the various districts from each State. We understand that’s just the way

things are.

As I had raised earlier the question with Secretary Cohen, traditionally the Department of Interior has always been our main advocate, I suppose, over the years, with the Federal agencies, with

the White House, even with the Congress. I wanted to pursue that

line of questioning, wanted to know if there’s any disagreement

with you in that regard.

I know Dave is very good in being elusive and not saying exactly

how he feels about some of these issues. But I was just wanting

to know what your thoughts are.

Governor BABAUTA. Mr. Chairman, I totally agree with you. I

think legislation is part of the equation in addressing a lot of the

discrepancies that the insular areas experience. The Medicaid, for

example, and the equation of Puerto Rico, every time we talk about

the territories, Puerto Rico having a population of about 6 million

people, and the costs associated with the population of Puerto Rico

is just, there’s no comparison to us smaller ones. I think a special

legislation would be absolutely in order for that.

Mr. FALEOMAVAEGA. I think Congresswoman has a comment.

Ms. BORDALLO. Yes, thank you, Mr. Chairman.

I’d like to mention to those in the room that we had two Members of Congress who had to leave abruptly, Congresswoman Watson, who was here, and I don’t know if you noticed the gentleman

at the end of the table, Congressman Cummings, who is the chairman of the Black Caucus. They were just called to an emergency

meeting because of the situation in Haiti. I’d just like to say that

they were interested and were present at the hearing. Thank you.

Governor TULAFONO. Congressman, if I could add to that dialog

while we’re preserving the time to assure the presentation by Governor Babauta there in the presence of the Chair, my attitude toward this whole thing is, first, it took a visit from the chairman

to come to grips with the real situation, and with reality that we

live with day in and day out. I think some of the testimonies that

have been offered so far do provide some good suggestions. I think

one of those suggestions is, I think we need to take a comprehensive look at these conditions.

I don’t think there’s any question, and I will say that in my testimony again, that the fact that this hearing is convened and the

recognition of the disparity is sufficient. For the first time in my

estimation, we are here to provide some of the causes that we know

from our respective jurisdictions to try and help the committee

fashion perhaps some of the legislation, or some of the assistance

to help us deal with the situation, help all of us deal with these

situations in our jurisdictions.

I also feel that as a result of what has come up, I think in addition to look at the situation itself, with respect to health care, I

think also we need to look at the mechanism of financing health

care in the territories. We have very unique situations that require

considerations that are not common to everybody else. And I think

that is sufficient reason to want to address those issues in a special

way. I think that comes in the way of fashioning a financial mechaVerDate 11-MAY-2000 11:19 Jul 15, 2004 Jkt 000000 PO 00000 Frm 00091 Fmt 6633 Sfmt 6633 D:\DOCS\94494.TXT HGOVREF1 PsN: HGOVREF1
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nism or financial scheme, so that the issues of the territories are

addressed specifically.

Because if we continue to deal with them in a global sense across

the Nation, they will never be addressed. They can never be addressed. And I don’t know if there’s any way that you can fashion

anything from the existing schemes of today. But I think the fact

that this hearing convened, I think it’s the first time that I am

aware of that a problem is identified, and we are here just to provide information to help, instead of trying to convince Congress

that we have a problem. I don’t think we need to convince Congress

any more that there is a problem.

Mr. FALEOMAVAEGA. You could not have stated it better, Governor. The problem that Madeleine and I have always had over the

years is to have Members interested in issues relating to the territories. This is one of the things we always struggled with, is to get

as many Members to come to our respective districts. Because that

is the only way these Members are going to have some sense of attention, just as the fact that Chairman Burton was able to visit,

and I suppose it wasn’t just Guam and NMI, it was probably part

of an overall delegation that he led to other areas of the Asia Pacific region.

But the fact that this caught his attention, this is just the nature

of how things operate here. I’m just so grateful that Chairman Burton has taken this initiative to do this.

Now, we can make our requests, the fact that finally we’re able

to get the chairman of our House Resources Committee to come

and visit the insular areas, and the fact that some of these Members have never heard of these insular areas, is an accomplishment

in itself. I don’t know how else I could relate to the difficulty there

is in even getting anybody to come down. It’s always a problem

with Members even here in the continental United States to have

other Members come and visit their districts, it’s a very difficult

situation.

So again, our being here, like I said, and thanks to Governor

Babauta and Governor Camacho for really getting the chairman’s

ear on issues related to health care needs of NMI and also Guam

and American Samoa has also become a beneficiary because of this,

and we have a chance to express our feelings about these needs.

I sincerely hope that as a result of this hearing, we’re going to

come up with some strong recommendations, even by way of hopefully maybe even offering amendments to current Federal law that

will be helpful in addressing some of these serious needs that we

have as far as health care needs are concerned.

Governor Babauta, I think Chairman Burton should be here in

another couple of minutes. Maybe you can go ahead and proceed

in that regard. But save your punch line for him when he’s here.

Does that sound OK?

Governor BABAUTA. Sure, that’s perfectly fine.

Mr. Chairman, the names of the elected officials that I enumerated, it is good to have somebody other than myself come to this

hearing to know just how much Chairman Burton means to all of

us for his visit to the islands. This hearing is truly historic, because

I have not seen a hearing in Washington held specifically on health

issues in years that I have been here in Washington.

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Years ago, we had the Hill-Burton dispensaries. These were

dispensaries that were constructed under the federally funded program, the Hill-Burton program. So a lot of dispensaries were built

throughout the CNMI.

Then came Philip Burton, of course, he singlehandedly gave

CNMI the Social Security, the Supplemental Security Income. So

we’re grateful for the late Congressman Philip Burton. Then of

course, Chairman Burton having come out to CNMI and then holding this historic hearing, I just want to say to the chairman that

the people of CNMI are grateful, very grateful to individuals with

the last name Burton. We are very honored and pleased with the

chairman’s visit to the islands. We appreciate his taking the long

flight to the islands.

And when he was there, taking the time to speak with individuals, both elected leaders and health officials and our ordinary people that he met, he took the time to have conversations with them.

That was just extraordinary on his part.

The CNMI has been a U.S. commonwealth since 1976. We had

virtually no health care capacity when we entered the U.S. family

about a quarter of a century ago. At that time, our main hospital

facility consisted of an outdated Naval facility, long abandoned by

the United States. Then in 1982, with the assistance of the United

States, we developed a new hospital facility, that’s the Commonwealth Health Center today. That facility is now 20 years old, overburdened and in need of critical repair, upgrade and expansion. It

provides services to a much higher population of patients than was

ever anticipated.

In addition, our remote location poses other challenges. Our closest U.S. tertiary medical referral center is in Hawaii, some 3,000

plus miles away. We have issues regarding the adequate provision

of health care services to a scattered population on three major islands, Rota, Tinian and Saipan. And occasionally, we have challenges with health care needs in the northern islands. Each island,

although rural in nature, requires the development of a certain

level of emergency and preventive and primary health care services.

Mr. Chairman, we have a diabetes epidemic on our islands. The

No. 1 health issue facing our commonwealth is the treatment of

this disease. The prevalence of a CNMI person having diabetes is

300 percent more than a person in the 50 States, 300 percent more.

We have children developing Type 2 diabetes, and these children

will require treatment for the rest of their lives. We need $3 million in assistance from this Congress to combat and treat this disease.

Mr. Chairman, the advent of September 11, homeland security

priorities and the emerging highly infectious diseases such as

SARS, we have had to cope with upgrading and repair of our rapidly aging hospital facility. We need your assistance in funding $6

million in air circulation and water treatment improvements to the

Commonwealth Health Center. We take issue with the way the

Medicaid funding is provided for the CNMI, just as the other territories do.

We receive millions less in Medicaid reimbursement than we

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tion results in the CNMI being less able than the States to meet

the health care needs of our people, again burdening not just the

way we deliver health care, but our capability in terms of cost. We

want the same Medicaid funding as States enjoy, and we ask, I ask

this committee to end this funding discrepancy.

We also are faced with the fact that many patients with complicated medical problems, such as cardiovascular diseases, must

be referred off-island for definitive diagnostic and therapeutic services. We transport patients to Hawaii and other distant locations

at increasing costs. Patients being referred off-island consume a

significant portion of our health care budget. And with the help of

Congress, we can reduce the cost of health care, and we can do this

by developing a truly reasonable health care delivery system. We

can do it by improving our capacity and with the blessing, with my

good Governor from Guam, we can make Guam a reasonable health

care center for the region.

I ask for this committee’s support in developing this regional

health care program for the people of the CNMI and for the people

of the region.

Thank you, Mr. Chairman. I am accompanied today by the Secretary of Health, Dr. Hofschneider, to answer any specific and detailed questions that you may have. Thank you.

[The prepared statement of Governor Babauta follows:]

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Mr. FALEOMAVAEGA. Thank you, Governor.

Governor Togiola.

Governor TULAFONO. Thank you, Mr. Chairman.

Before I go on, I would like to thank you, sir, for that great introduction, and for conveying a handicap that I can’t very well live up

to. I just wish that number could be translated to some kind of a

formula for obtaining funding to build a new hospital for American

Samoa. I would just be right out of here. [Laughter.]

Talofa to the Honorable Chair Burton and to the temporary

chair, our own Congressman from American Samoa, the Honorable

Faleomavaega. Thank you.

I would also like to especially greet the Honorable Congresswoman Bordallo. It’s been a pleasure serving with you as lieutenant Governors in the NCLG. And I’m very happy to see you in that

chair.

I am very honored to be here, and I would like to thank Chairman Burton for the opportunity and the honor to testify in this

hearing on the issue of health care disparities from a U.S. Pacific

Island territory, in this case American Samoa. The health care and

medical issues faced by small islands such as American Samoa are

insurmountable, due to our isolation and remoteness from specialized services unavailable on-island, retention and recruitment of

medical staff and overburdened and outdated medical facilities.

In addition, our dollars just aren’t worth a dollar any more, especially in a remote location. And also, due to the very low percentage of Federal assistance dollars per capita that we receive in direct assistance.

Mr. Chairman, I sincerely thank you for your humanity and initiative. If nothing else, the preamble to this hearing really is the

recognition of the problem we face. There is a serious disparity in

health care in these U.S. Territories in the Pacific. I would like to

state for the record that in the treaties of cession involving the islands of American Samoa, to take care of the welfare of the people

is a promised recognition that is enshrined in those documents. It’s

sad to say that it’s very difficult for us to deliver and take care of

that welfare when we cannot deliver appropriate medical and

health care services to the people of American Samoa in an adequate way.

It’s always a struggle to meet the rising costs of health care in

American Samoa. Our only hospital, the Lyndon Baines Johnson

Tropical Medical Center, is 40 years old. It has been upgraded and

expanded over the years, but it falls short of meeting the health

care needs of our territory. It is one of the best facilities in the

South Pacific region. However, it falls short in standards compared

to health care in Hawaii and the mainland.

Just May of last year, in 2003, during torrential rain, the whole

facility was covered with mud, even including the patient wards.

The cleanup was done around the patient beds while the patients

were sitting on the bed, to try and remove the mud from the facility. We have unique problems that will require unique solutions to

overcome. And I thank you for this hearing. I believe the recognition that is given to the problem gives us a little easier task today.

That is not to come here to convince you that we have a problem;

rather, we’ve been invited to try and help you recognize why there

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is a problem and try to help foster and forge solutions that will be

beneficial to the U.S. Pacific Territories.

The first of those issues I want to bring up to you is, our own

natural environment, being a tropical climate increases the risk of

diseases subject to natural disasters, as evidenced by recent flooding, mud slides and cyclone Heta in January, and in a very hard

to reach island location.

Second, our health care system is plagued by understaffed agencies, and a portion of staff is underskilled or inadequately trained

to perform up to acceptable standards. Three, even our trained

staff to maintain adequate care levels is difficult to attract, even

at high salary levels, due to our isolated location and limited facilities. A classic example of that is, we offered recently $150,000 compensation package to hire a nephrologist. No one is interested. Nobody is responding.

No. 4, the health care system is not adequately meeting the

needs of the public, because the health care work force is not sufficiently trained to deliver high quality service. As identified by Dr.

Stinson, we’re constantly relying on medical officers to work as doctors, which they’re not qualified to deliver. But that’s the limit of

the ability that we have.

No. 5, medical equipment purchases and maintenance costs and

pharmaceutical supplies are high, and have risen significantly during the last decade. No. 6, funding from local fees and Federal resources is continuing not to be sufficient to meet operational needs

for a sound health care system. And efforts to bring in a reasonable

health insurance program have failed due to low patient volumes

and unreasonable offers from insurance providers. We put out an

offer last year, and only one company responded, offering us a premium of $18 million a year, which is almost more than our whole

health care system.

No. 7, an underlying issue is our high growth rate also in American Samoa, which leads to increasing demands that will outstrip

existing and planned improvements to health facilities. Last, due

to limited tertiary care on-island, there is an unacceptably large

proportion of health care dollars from the territory’s budget absorbed by off-island medical care referral cases, especially to the

State of Hawaii medical centers.

The great percentage of total health dollars are spent on tertiary

care overseas, and too small a sum is spent on preventive health

programs and services in American Samoa. What are some of the

causes of these disparities? It could be summed up quickly by saying that rapid population growth and changes in migration patterns has led to an escalation of immigrant families with greater

health needs coming into American Samoa. That’s document in our

population report of the year 2000. Population growth and increased service demand has resulted in insufficient resources to

meet public demands.

The ever-increasing cost of health care due to inflation and the

emergence of new technologies and equipment to support them are

pushing the LBJ Tropical Medical Center past the point of being

able to support its essential medical services for the community. A

question arises whether improved health services encourages this

immigration, thus helping to cause the stress on facilities and servVerDate 11-MAY-2000 11:19 Jul 15, 2004 Jkt 000000 PO 00000 Frm 00114 Fmt 6633 Sfmt 6633 D:\DOCS\94494.TXT HGOVREF1 PsN: HGOVREF1
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ices. Also, we have improved our health and family planning education programs and services. But with our high end migration pattern, do these programs reach the people causing high birth rates

and result in decline?

A portion of the users of hospital services have limited funds,

and are not able to pay increased fees to support improved health

care. Is our responsibility to continue to provide health services,

even if clients are unable to pay fees? And if we do so, how do we

pay that cost? Only limited local revenue exists to expand our

health facilities, and the territory is increasingly becoming dependent on limited Federal expenditures, such as funds from DOI,

CBDG grants, and the CIP program.

In 1996 to 2000, the expenditure was $40 million, or $8 million

per year. Presently, we receive $12 million for health care, $10 million from DOI and $3 million from Medicaid. Medicare provides at

a one to one ratio to the mainland, even though the costs are much

higher in American Samoa. The reality is that our government collects much less than it expends, and we face a serious dilemma on

how to finance our needed service providers, and an expanded infrastructure to support our health delivery system.

The lack of health and medical insurance in American Samoa

further compounds our financial dilemmas in operating the services

to the territory. All the respondents to our last offer, RFP, came

from off-island. There are no insurance companies available on the

island.

The current financing method is both socially inequitable and

unsustainable as the hospital authority can no longer support

health care to a level that meets public expectations, standards of

quality and scope of services. If health care costs are increased further and the health system continues to divert a large proportion

of health care dollars for off-island tertiary care, the hospital will

ultimately have to raise fees to the point that low income individuals will find basic health services inaccessible and essential health

services will become eroded due to a lack of funding.

Our remoteness and expensive, infrequent air service between

American Samoa and Hawaii also adds to the difficulties in medical tertiary care. The passing of our late Governor Sunia last year

is a case or testament of not having adequate tertiary care on-island, limited medical resources and flights that could have abated

his untimely demise. He was forced to catch a flight to a foreign

country to catch a flight to try and reach Honolulu in time. He

passed away enroute.

To meet the causes of these disparities, we have taken a number

of actions in American Samoa. However, the reality is that it is difficult to provide quality health care in this environment, to deal

with our natural disasters and overcome the attraction of being a

U.S. territory to our neighboring countries. The late Governor

Sunia formed a task force to investigate the effects of the rapid

population growth we are experiencing. This included impacts and

ways to overcome these problems, including those to our health delivery system. We have a committee to address population growth

issues through implementing the recommendations of that population task force report in 2000.

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We need to work with our environment and the climate and natural disasters to which we are subjected. I ask you to understand

that our challenge is greater than in other locations, and our needs

are also greater. Remember that American Samoa represents the

United States in this region. It is important that we put our best

face forward.

We look for assistance in terms of funding, but it is not just

about money. We need help to recruit qualified health professionals, incentive programs to attack our staffing problems, and enable us to attract qualified physicians to come and provide the

services so needed in the territory. We also need to develop and implement a health and medical insurance program in American

Samoa to subsidize health care in order to operate, upgrade and

deliver top health care to our residents.

Finally, I cannot also negate the need to reevaluate and assess

the current facilities if the capacity and staffing issues are resolved

for much needed upgrades to medical buildings, technological improvements and to develop high tertiary care services to be made

available to all residents of American Samoa.

I hope this information will give you a perspective of the issues

that we confront in American Samoa, as other Pacific Island Territories. It is my hope that you can assist us in the areas I have outlined that continue to plague us in providing health care services

to all who reside in the territories.

Thank you for your attention and I appreciate this opportunity

to be here with the committee and share a perspective from a U.S.

territory in the South Pacific. Again, we thank you for convening

this hearing, and thank you for having us today.

[The prepared statement of Governor Tulafono follows:]

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Mr. BURTON [resuming Chair]. Thank you. I want to thank Representative Faleomavaega for carrying on while I was gone.

Let me just ask a few questions, then after they ask their questions, we’ll go to your medical experts and try to find out exactly

what in the way of money and other things we can do to help solve

this problem.

I’m just curious, Governor Tulafono, what did your predecessor

die from? You said he died on the airplane.

Governor TULAFONO. Yes, he did. He was being evacuated to

Honolulu because our hospital could not continue to treat his illness.

Mr. BURTON. Was it a heart condition, or cancer?

Governor TULAFONO. Well——

Mr. BURTON. If you’d rather not go into it, that’s OK. But it was

something that could have been treated had they had the facilities

on the island?

Governor TULAFONO. I think he eventually suffered from a heart

failure. But it was due to other medical conditions.

Mr. BURTON. And is it pretty certain that had they had the proper facilities on the island, he would have been able to survive?

Governor TULAFONO. That’s correct. If the facilities had adequate

treatment and physicians competent to treat his condition, he

would have survived.

Mr. BURTON. That’s really a tragic story, chief executive of a territory like that not even being able to get adequate treatment.

Governor Camacho, your island had I guess a problem with the Guam Memorial Hospital Authority. They had a $20 million debt

and they had to declare insolvency, I guess. Can you tell me a little

bit about how that happened, how that occurred?

Governor CAMACHO. I have our hospital administrator, Bill McMillan.

Mr. BURTON. We can wait until the next panel. I think he’s going

to be testifying, is he not?

Governor CAMACHO. Yes, the hospital has not filed for bankruptcy.

Mr. BURTON. Oh, that’s not true.

Governor CAMACHO. They’re still financially solvent.

Mr. BURTON. But they’re having a tough time right now?

Governor CAMACHO. Yes, the government had to step in and take

money out of our general fund, and I believe even a portion of some

grant money and money that we had available and bailed them out

a couple of times for them to even make payroll.

Mr. BURTON. Is that right. The request that I presume you’re

going to be making, along with the other territories, will talk about

how that can be dealt with?

Governor CAMACHO. Yes, sir.

Mr. BURTON. I think you said, Governor Camacho, that over 24

percent of the 188,000 medical services were rendered to patients

from the Freely Associated States who are not American citizens

or nationals. How do you compensate, how do you take care of

those expenses?

Governor CAMACHO. That’s a very good question, Mr. Chairman.

Basically it has to be absorbed by our medically indigent program.

In fact, the amount of money owed to the hospital for uninsured

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services provided to our citizens and also others from other countries is absorbed by the general fund. Part of the problem or reason

why they have not been able to make payroll or come close to not

making payroll or paying their obligations, it’s a burden that’s been

absorbed by the hospital and public health. And certainly it is a

growing problem.

We have, because it’s only one civilian hospital, there is a responsibility we have to accept all patients, no matter what. And the

funding and the payment for their care and services leaves a big

dent and big hole in the hospital’s finances. Their accounts receivable amount has been tremendous, and I give a lot of credit to our

board and Mr. McMillan in his administration of the hospital.

They’ve made great strides in running it as it should be run.

But there are some problems that simply cannot be overcome.

How do you tell a person, sorry, we can’t provide services for you

because you have no insurance or you have no way of paying for

it. We simply take them in and somehow or other we will eventually try and find payment out of the general fund. But we have a

growing problem under what’s called the medically indigent program. Again, government and policymakers come forward with

every good intention to provide for the needy and those that cannot

afford medical care or medical insurance. And somehow or other,

it’s the government that has to bear that cost.

Mr. BURTON. And the Medicaid ceilings there are below what

they are on the mainland?

Governor CAMACHO. Definitely. Much, much lower. We have a

cap and we continue to pay over and above. We’ve spent an additional $17 million just on the indigent care program, for those that

don’t have any insurance.

Mr. BURTON. Let me ask one more question to Governor

Babauta. That diabetes Type 2, I think you alluded to that in your

statement. I wasn’t here, but I think I read that in your statement.

Did you refer to that?

Mr. BABAUTA. Yes, Mr. Chairman.

Mr. BURTON. What I wanted to find out, CNMI is third in the

world among populations with that kind of diabetes, it’s one of the

worst places in the world as far as that’s concerned, and what exactly do you need to compensate for that or deal with that?

Governor BABAUTA. We definitely need to complete the extension

of the hospital that is now under construction, adding additional 27

units for dialysis to treat the overflowing dialysis center that we

now have, and making sure that the entire extension of the new

hospital is well equipped with air circulation suitable for patients

that are critically ill.

Mr. BURTON. And the total cost of that would be about how

much?

Governor BABAUTA. We’re looking at a total cost of about $12

million, Mr. Chairman, all in all.

Mr. BURTON. That would be a one time cost for the expansion

and taking care of the air handling and everything else?

Governor BABAUTA. Yes, sir.

Mr. BURTON. Mr. Faleomavaega.

Mr. FALEOMAVAEGA. Mr. Chairman, listening to the statements

from our Governors, I think there is a common thread here in

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terms of the health care issues that we have, sharing together with

the territories. I think diabetes, hypertension, and obesity are probably among the three or four top killers as far as the health care

situation that we have. I can certainly speak on behalf of American

Samoa, we have the same situation.

And I don’t have any questions for the Governors, except I want

to commend them for their statements. As I’ve said earlier, Mr.

Chairman, the issues and the problems are out there. And as you

have expressed an interest in saying, funding is critically needed

to provide for these, to take care of the problems that we have, and

hopefully somewhere, somehow, we might be able to provide some

assistance in that regard.

Again, I want to thank our Governors for their fine statements

and being here with us this afternoon to share their statements.

Thank you.

Mr. BURTON. Ms. Bordallo.

Ms. BORDALLO. Thank you, Mr. Chairman.

I too would like to thank the three Governors for their testimonies, and as I listened intently to each of the problems, it just

seems so bleak. Certainly we in Congress will have to address this.

I want to mention, there’s someone in the audience, I think, who

hasn’t been introduced. That’s Ambassador Jesse Marholou from

FSM. He’s been sitting through the entire afternoon. Ambassador,

welcome to the hearing.

Mr. Chairman, I just for the record want to mention that since

we’ve heard all the problems, what are we doing. Well, there is

some legislation that’s been sponsored and is moving through the

process here in Congress. One is H.R. 675, that’s a bill that was

introduced by Congresswoman Christensen and co-sponsored by

Eni and myself. The territories are all in this together. That has

to do with lifting the Medicaid cap. That’s H.R. 675.

Then we have H.R. 3459, it’s called the Health Care Equality

and Accountability Act. This was introduced by the gentleman that

came for a moment but was called away, Congressman Cummings,

and co-sponsored by the members of three minority caucuses. That

addresses health disparities of our minority population, which includes specifically the Medicaid caps for the territories.

Then the third one is H.R. 3750, that’s the Pacific Insular Areas

Rural Telemedicine Act that I recently introduced, which is also

sponsored by our sister territory, which would enable the Pacific

Territories greater access to funding for telehelp and telemedicine

applications. So I just want you to know that there is some movement now, but certainly it’s just the beginning, it’s the tip of the

iceberg. We’ve got to continue to work very hard.

And Mr. Chairman, I was hoping that maybe when we see these

bills move through, that your support of them would certainly be

helpful as they move along in the process. And of course, anything

else that we can develop after this public hearing.

Again, thank you to the three Governors, all very good friends

of mine and it’s nice to see you. Welcome to Washington. I know

you’re anxious to get home to warmer weather. Thank you.

Mr. BURTON. Thank you. Let me just say that I’ll sure take a

look at the legislation to see if I can be of help. During a time of

severe budgetary problems like we’re facing in the Congress, getVerDate 11-MAY-2000 11:19 Jul 15, 2004 Jkt 000000 PO 00000 Frm 00123 Fmt 6633 Sfmt 6633 D:\DOCS\94494.TXT HGOVREF1 PsN: HGOVREF1
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ting new legislation passed that is going to have a price tag attached can be rather difficult.

What I would like to see, and maybe with all of us working together we can get it accomplished, is to talk to Health and Human

Services initially and get them to get off the dime and appropriate

the moneys that are necessary for the immediate problems, expansion of the hospitals, the dialysis treatment centers, and whatever

else is needed, so that we can make sure that the quality of health

care is improved very quickly. Then as far as the legislative proposals are concerned, we’ll work on those as well.

Ms. BORDALLO. Thank you.

Mr. BURTON. So with that, Governor, did you have one more comment you wanted to make?

Governor CAMACHO. Yes, I wanted to thank you, Mr. Chairman,

and Congressman. As I listened to all our problems again, there

are many common themes. In talking to Governor Babauta and

talking to President Tommy Remegasal, Governor Oraecho from

Yap, Peter Christian and also president from FSM, we all agree

that we’re trying to find ways, we understand as leaders that we’re

problem solvers. We’re trying to find solutions and find ways to

make things happen.

So we have agreed that one approach we’re taking is to try and

work and help each other together as a region in the western Pacific, with the limited resources we have, we’re going to find ways

to help each other out, one way or the other. We have pride, we

have dignity of our people.

As we come to you, and as we come to Congress, it’s with the

idea that we’re not necessarily blaming anyone, we’re simply here,

as my colleague Governor Tulafono had mentioned, we’re here to

express that yes, we do recognize the problems, but we’re also trying to find solutions and help you in that way. From our perspective, we can point out the key areas where we definitely need the

help and how you can help in legislation, working together we can

resolve a lot of things.

But we do have our pride, we do have our dignity. And working

together as a region, we’re going to make things happen. So we’re

doing everything we can on our end. We do need a little help from

this end, too.

Mr. BURTON. We really appreciate that attitude. But I have to

tell you that every State in the Union, every city in the Union, they

come here on a regular basis with problems that need to be addressed to help their constituencies. It’s not out of line for you to

ask for fair treatment as well, any of you. So I think it’s imperative

that we do what we can while you’re doing what you can to help

make this thing work better.

Let me now have the next panel come forward. I want to excuse

this panel, thank you very much for your testimony. We’ll have the

Honorable Jefferson Benjamin, M.D., the Secretary of Health for

the Department of Health and Education and Social Affairs for the

Federated States of Micronesia. He’s speaking for the Pacific Island

Health Officers Association. I guess he’s going to be the spokesman.

But I’d also like to have Dr. Stevenson Kuartei, public health officer, Palau, come forward; Dr. William McMillan, who’s the administrator of the Guam Memorial Hospital Authority; and Dr. James

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Hofschneider, Secretary of Health for CNMI, who’s with Governor

Babauta.

Mr. FALEOMAVAEGA. Mr. Chairman, I have to go with my Governor right now, but I will come right back.

Mr. BURTON. Oh, sure. We’ll receive his testimony.

Gentlemen, will you raise your right hand? I’d like to have you

sworn before answering questions.

[Witnesses sworn.]

Mr. BURTON. Be seated.

Since you’re the spokesman, Dr. Benjamin, we’ll let you give the

overview, and then we’ll go to questions.

Dr. BENJAMIN. Thank you very much, Mr. Chairman. My name

of course is Jeff Benjamin. And of course with me are Dr.

Hofschneider, Dr. Kuartei, members of the PIHOA. We are Pacific

Islanders who live in the Pacific and are here on behalf of the Pacific Island Health Officers Association.

PIHOA is the association of the ministers, secretaries and directors of health for the U.S. Pacific Island jurisdiction, which includes Guam, American Samoa Commonwealth of the Northern

Mariana Islands, Federated States of Micronesia, Republic of the

Marshall Islands and the Republic of Palau. I want to thank you

for this opportunity to tell the Pacific story.

The U.S. Pacific insular areas are unique because of the challenges posed by the fast and isolated geographical setting, an area

of the Pacific the size of the continental United States. At least

nine distinct ethnic cultures, with varied socioeconomic and political conditions. A population of about half a million people, scattered over five time zones.

Most of the things discussed are health indicators that are associated with health disparities in the region such as the rate of people living on the poverty line, which ranges from 25 percent in

Guam to as high as 91 percent in the FSA. Infant mortality rate,

some as high as 37 per 1,000 compared to 6.8 per 1,000 in the

United States. Life expectancy is about 7 years lower than in the

United States, and in some areas, the difference is 10 years or

more.

All of the U.S. associated Pacific island jurisdictions are going

through a state of transition, health morbidity and mortality. We

stand in double jeopardy, having to do with illness of antiquity,

such as leprosy and elephantiasis, as well as having to deal with

issues of modernity, diabetes, heart disease, stroke and others.

With globalization, our borders can no longer protect us from

SARS, avian influenza and the ever-present threat of terrorism and

global warming.

These islands are also vulnerable to natural disasters. Because

many of them are located along the Pacific Ring of Fire and the Pacific typhoon belt, which predisposes them to earthquake and typhoons.

I am told that the U.S. Pacific Island jurisdictions score up to a

maximum of 25 on the health professional shortage area score,

something we are not proud of. This shortage is significant because

the access to health is not only dictated by remote geography and

limited financial resources, but also the lack of appropriate service

delivery, availability such as basic primary health care.

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To further develop our population base and primary care services

in this jurisdictions will require a realistic development and allow

for them to attain an even playing field in terms of competing for

Federal assistance with those of the U.S. based health care services.

All tertiary care patients are referred out of the region for treatment. This does not only drain the jurisdiction’s limited health

budget, but also causes significant sociocultural dysfunction in the

health care delivery for these patients who access such services. In

some years, up to 30 percent of the country’s health budget has

been spent on tertiary care, out of the region to Hawaii or the Philippines. Less than 1 percent of the population uses tertiary care,

and yet this 1 percent consumes up to 30 percent of the total

health budget, which places a significant burden on primary population base health care services.

The disparities in health in the U.S. affiliated Pacific jurisdictions becomes more intense when it is eclipsed by the stagnated

education system that is unable to produce students who are able

to matriculate in health related fields, such as medical, dental,

nursing and allied health schools. The shortage of physicians, dentists, nurses and allied health necessitates the recruitment of expatriates, which is not only expensive, it retards sustainable human

resource development in health. The disparity is also exacerbated

by the shortage of qualified health care managers and administrators.

The application of domestic Federal health program requirements through this U.S. affiliated Pacific Island jurisdiction sometimes retards the appropriate progress in health care development

as it tends to create inappropriate models of health care in the region.

The digital divide even further isolate these islands through the

lack of adequate communication capabilities. The Freely Associated

States, FSA, Marshall and Palau Islands are adversely affected because they are not considered insular areas by the Federal Communications Commission and therefore, ineligible for the discounted

telecommunication rates for health and communication offered by

the universal service fund.

The extreme distances and travel time not only among the jurisdiction but also distance to the U.S. complicates this digital divide.

For example, Palau is one complete day, 13 time zones away, and

22 flight hours by commercial jet travel from Washington, DC.

Appropriate and timely health information systems continue to

play an integral role in failing to describe the full extent of these

mentioned disparities. While there have been improvements so that

now we are quoted as Pacific Islanders and not others, there continues to be a significant health information disparities in research

and information collection analysis and translation.

To this end, the Pacific Island Health Officers Association is

grateful to the Department of Health and Human Services through

HRSA, CDC and NIH and the Department of Interior Office of Insular Affairs, for all of their direct and indirect support for PIHOA.

PIHOA is also grateful for the resources provided through the Department of HHS and its program, which includes the community

health centers, National Health Service Corps, Community Action

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programs, human resources development programs, such as area

health education centers and health career opportunity programs,

and the many condition-specific programs, such as HIV/AIDS, STD,

diabetes control and collaborating, tuberculosis, immunization, cancer prevention and control, and last, bioterrorism resources that

come from CDC and HRSA.

While there remain significant health disparities in the U.S. Pacific Island jurisdictions, there has been some tangible improvement. For example, in some of the jurisdictions, while the infant

mortality rate is still high compared to the United States, there

has been as much as six to one person reduction of infant mortality

rate over the past 13 years.

In conclusion, Mr. Chairman, PIHOA and the many indigenous

populations of the Pacific jurisdiction thank you for this opportunity to tell our story. At the end of the day, we request that our

quest for self-sufficiency in health be at the cornerstone of your delivery today and in the future.

I thank you specifically for allowing me, a Pacific Islander, from

the Pacific, to testify on this occasion. Because that in itself is a

benchmark of your efforts to eliminate disparities among the U.S.

affiliated Pacific jurisdictions, and the spirit of the Pacific peoples.

Thank you for your attention, and I will submit the prepared

statement for the record.

[The prepared statement of Dr. Benjamin follows:]

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Mr. BURTON. Thank you very much, Dr. Benjamin.

I guess the only real question I have of you, and it was pretty

much the same question we had of the Governors, what are the

needs, immediate needs of each one of the territories, and how

could we best help you solve that problem. I think what I would

like to have you do, if you would, is to give us that in writing, so

that we can draft a letter and send it to the organization that the

President has appointed where various agencies get together and

try to come up with solutions of problems of the territories.

We’ll also send a letter to the head of HHS urging them to take

positive action on the financial requests that will take care of your

needs. That I think should be the focus of our hearing today. My

colleagues who have been with us today have legislative proposals

which may or may not reach fruition. We may or may not get them

passed because as I said before, we have these budgetary constraints that are very severe.

But at the same time, I think that if we collectively write a letter

to as well as personally contact the people on this commission that

the President has appointed, as well as the Secretary of Health and

Human Services, we might be able to shake loose the funds that

are necessary to get your various territories over the hump as far

as immediate health care needs are concerned. I think that’s the

first thing that needs to be done. Then we can work on the legislative proposals that they talked about.

And with that, do any of you have any comments you’d like to

make to add to what Dr. Benjamin said? Dr. Hofschneider, do you

have any comments you’d like to make?

Dr. HOFSCHNEIDER. Thank you, Mr. Chairman, for this opportunity. I’m here to elaborate more on the issues, especially affecting

the CNMI and to give you more details about our needs. I also support the statement as a member of the Pacific Islands Health Officers Association, I support the statements and the priorities that

have been discussed by Dr. Benjamin.

Mr. BURTON. When I met with you in Saipan, we went through

your hospital, I think you pointed out some of the things you felt

were necessary. You don’t really need to go through them again

with us today. What I really need, and what we really need is to

have it very succinctly stated in writing what is needed, when it’s

needed, how much money is needed and why we need to get on

with that as quickly as possible. I think that would probably be the

best thing we could get. Then I’ll try to get other Members of Congress who are not with us today to sign on to this letter and try

to use their influence to shake loose the funds that are necessary.

HHS has the money. It’s just a matter of getting it allocated in

the proper way so you folks are getting what needs to be allocated.

Dr. McMillan.

Mr. MCMILLAN. Mr. Chairman, thanks for the promotion. It’s

just Mr. McMillan.

There are two things I’d like to bring to your attention, sir.

Guam’s hospital is a Medicare participating hospital. And in my

written testimony, we identify that our Medicare reimbursement is

still subject to a TFRA count, because we’re not part of the prospective payment system. And a very specific and actual thing to do

would be to either re-base our TFRA count, that’s the least popular

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alternative in my book. Second would be to either just eliminate

the TFRA count completely for the hospital, or, and this would require a little bit of legislative work, allow Guam Hospital to be declared a critical access hospital. Those hospitals are reimbursed at

101 percent of the cost based reimbursement.

Prior to coming here, I gave Governor Camacho a list of 107 specific Federal funding vehicles, either grant programs or grants or

loan guarantees that we intend to rebuild our hospital with. I’ll be

happy to supply some specific recommendations for your committee

to pass on to the HHS.

Mr. BURTON. What we’ll do, when we write and contact the

health agencies regarding the requests that are being made today

is we’ll cite all the various avenues that could be followed to get

that money. And so I would like to have, did you say 107?

Mr. MCMILLAN. Yes, sir.

Mr. BURTON. If you give us a list of 107, I’ll make sure that it

is attached to the letter as an addendum, saying you figure you

can’t take it out of your general budget over there, here’s 107 other

ways you can do it.

Mr. MCMILLAN. Sir, there’s one other thing I’d like to mention.

We’re very heavily dependent on foreign health care workers. Wage

scales are a little low and we’re kind of far from home for not only

physicians but also nurses and allied health practitioners. The cap

on the H1B visa program severely limits our ability to bring in the

nurses, x-ray techs and that sort of thing. There’s an H1C visa program that if Guam was written into that specific visa program, we

would be allowed to recruit a lot more nurses.

Mr. BURTON. That would probably now be under Homeland Security, I believe.

Mr. MCMILLAN. Yes, sir.

Mr. BURTON. It’s either State Department or Homeland Security

Act. Can you guys write that down, and let’s check on that and see

if we can’t contact them about maybe changing the visa policies, so

they can get more health professionals in there.

Mr. MCMILLAN. I realize that’s not your purview, but I’m getting

my licks in when I can.

Mr. BURTON. That’s fine. It is, if it refers to the health care problems of the area. We certainly would like to help.

[The prepared statement of Mr. McMillan follows:]

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Mr. BURTON. Dr. Hofschneider, I cut you off. I apologize. Did you

have more you wanted to say, sir?

Dr. HOFSCHNEIDER. Thank you, Mr. Chairman.

I just wanted to sort of reiterate that we have submitted testimony, written testimony to your subcommittee outlining the needs,

the requests that we have in three specific areas. One is the funding for us to enhance our prevention and treatment of diabetes. As

you know, as Governor Babauta noted earlier, our prevalence of

kidney failure is five times compared to the national prevalence.

We are the third in terms of, worldwide, for prevalence of Type 2

diabetes. Only the Pima Native Americans and Narauns have the

higher prevalence that the indigenous people of the CNMI.

So we will be asking for funding for prevention, as well as for

treatment, including the treatment of the kidney complications. In

addition, because of our aging infrastructure we need to upgrade

our water system. Our water system, the water that is fed into the

hospital is not suitable for medical uses, and it has to be treated.

The system is now almost 20 years old and needs to be upgraded.

The demands have increased.

In addition, we have a problem with our air conditioning and

ventilation system. And in this age of SARS and anthrax, we need

to upgrade that.

Last, a big burden and really, this has been mentioned several

times, is the Medicaid cap. Currently we spend $13.5 million, that’s

the total obligation of the local government, the Federal Government gives us $2.5 million, which is 90 percent, this is Medicaid

and SCHIP. And I think this burden is preventing access to proper

care. We give the care anyway, we don’t deny any services to the

poor. But we really need some relief, especially at this time when

we have a downturn in our economy.

In my recent statement, I also noted that we have a 21 percent

increase in our Medicaid population since last year. This issue of

inadequate funding is very important. We have been in a situation

where we have to practically beg Hawaii hospitals or California

hospitals to take our sick child or a person with multiple medical

problems, take them so they can get adequate medical care. So

really, we can never bring Hawaii closer to us. What was expressed

earlier by our Governor and the Governor of Guam is the idea of

having some regionalization as part of the long term strategy.

So we ask for your support for this request, and thank you very

much again.

Mr. BURTON. Well, like I said, if we have that in writing, and I

think the Governor mentioned part of that, we’ll certainly—that regionalism you’re talking about I think makes a lot of sense. It

might help us when we’re trying to get resources if we say that

they’re cooperating in a way to, because you know, for instance,

Guam and Saipan are not that far apart. If there was some way

you could eliminate some duplication and use funds for other areas,

it would be helpful when we’re talking to HHS about more money.

Dr. Kuartei, did you have a comment you’d like to make, sir?

Dr. KUARTEI. Thank you very much, Mr. Chairman, for the opportunity to be here. Dr. Benjamin actually spoke on behalf of the

PIHOA. I can only say that as a Pacific Islander, sitting over here

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today, it’s probably a benchmark for a moment that’s probably positive. Thank you very much.

Mr. BURTON. Well, we really appreciate your being here and the

Governors being here. We will not drop the ball on this. I can’t

guarantee how much money we’re going to be able to shake loose

and how much of the problem will be solved, but I promise you that

I as the chairman of this subcommittee will push very hard, and

I’ll try to get other Members besides those who are here today to

likewise push hard to get some of these things done.

With that, thank you very much for being here. It’s been nice

being with all of you.

We stand adjourned.

[Whereupon, at 4:42 p.m., the subcommittee was adjourned, to

reconvene at the call of the Chair.]

[The prepared statement of Hon. Elijah E. Cummings and additional information submitted for the hearing record follow:]

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