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Op-Ed: An Open Letter to the Governor of American Samoa

Re: American Samoa Health Care, a Legacy of Undermining the Law and Betraying the People's Trust

Dear Governor Togiola:

The routine non-payment or underpayment of the ASG subsidy to LBJ Hospital, undermining the "free medical attention" law of the land, pre-dates your current administration and the establishment of ASMCA (American Samoa Medical Authority) in 1998. These non-payments or underpayments have a compounding effect because the receipt of Medicaid funding is conditional on ASG remitting its subsidy to LBJ Hospital. This year, your administration's failure to pay the balance of the aforementioned subsidy has driven LBJ Hospital to the brink of bankruptcy. The lost revenues, according to media reports, total up to $5.89 million; and that's a very significant percentage of the LBJ budget. Translate that in terms of human capital loss (human suffering and loss of life), the cost becomes immeasurable for life, as you know, is priceless.

Medicaid is a federal insurance program for low income people who meet a certain means test (income and net-worth) and citizenship criteria. Because the majority of the AS (American Samoa) population falls within a pre-determined poverty level, AS's share of the Medicaid benefits, based on a population-sensitive formula, is given as block payments instead of qualifying individuals and families as it is done in the states. As a result, high income earners and high net-worth people, like you and other government leaders and private citizens, become the unintended beneficiaries of the Medicaid program in AS.

This predicament will only get worse if the Census 2010 indeed undercounted the AS 2010 population. This would mean fewer Medicaid dollars will be available to take care of a larger population for the next 10 years. And there's more gloom in the horizon should Washington settle on a national budget policy that calls for reductions in Medicare and Medicaid benefits.

Sadly, it is the poor, the intended beneficiaries of the Medicaid program, who suffer the brunt of the loss of Medicaid funding. As prices of drugs and other services at LBJ increase to reflect the high demand given limited supply of drugs and other health care services, it is the poor who will go without their prescriptions. It is the poor who will forgo necessary clinic visitations and hospital admissions. And many of these folks are living without electricity. (A family in my neighborhood has been without electricity for the past 5 months. Because of that, the children would do their homework outside under trees, when it's not raining, until dusk). But that's another issue, another story.

Why doesn't ASG comply with the "free medical attention" law and pay its annual share of the LBJ Hospital budget revenues in full and on time? Is it lack of government revenues, or is it health care just isn't a top priority of your administration and the ones before it?

Given the ASG's investment in a private cable company, acquisitions of the Foisia boat and the Segaula airplane; distribution of $3 million to the 3 territorial districts (from which one district built a long boat for Flag Day racing); funding of the Samoa Heritage Week in Hawaii; and the recently announced bill to establish a Veterans' Department, I find it difficult to subscribe to the lack of funds argument.

Instead, I am convinced that health care financing is not a priority goal of your administration, like the ones before it. What the AS people have been hearing through flowery speech every two or four years is lip service for political convenience, what the AS people have been getting in terms health care are the realities of ASG priorities and ad-hoc spending.

The lack of attention given to the "Coverage for All in American Samoa Project" report we submitted to your administration in September 2007 further demonstrated the cavalier attitude your administration has towards health care, and the condescending attitude your administration has towards me and the local team who prepared the report.

I understand Lt. Governor Faoa, who was our supervisor, had distanced himself from our work. Perhaps to make you happy, or he didn't really care for our work. Nonetheless Sir, and with all humility, I dare say our report and recommendations therein were worthy of review and consideration by the territory's policymakers - you and your administration and the legislature. And I dare say that if our report was taken seriously and some of the key recommendations debated, improved upon, finalized, legislated, and implemented four years ago or later, we might have been in a better position today to avert the looming severe shortages and corresponding high prices, the greatest impact of which will be suffered by the most vulnerable amongst us - the poor and the socially-unconnected, which is a growing segment of our community.

I cannot help but wonder - why the attention accorded health care by government leaders, who were and still are in positions to affect sound health care policy, so deplorable. Perhaps a glimpse at their profiles would shed some light on this question. I find that most of these leaders are ASG pensioners and retired veterans. The ASG pensioners are of age to receive Medicare insurance coverage, and the veterans have access to VA clinics here and abroad and military hospitals in the states.

The non-veterans who are not of Medicare age yet, most if not all are receiving ASG or private pensions, in addition to their current ASG salaries. So it isn't of much financial consequence to them personally if the Medicaid insurance benefits are lost. If lost, they have access to the aforementioned coverage and access to care, and the financial wherewithal to meet their health care needs. If Medicaid is available, they get to partake in the below market-cost services the "free medical attention law" entails, i.e. $10 per prescription. The odds are stacked in their favor, a win-win situation.

As economic decision makers- maximizing their economic and social benefits while minimizing their costs- I say AS leaders, in their efforts to keep and improve their positions in government, are rational decision makers and would give them an "A+" for their efforts. On the other hand, as conscionable and compassionate leaders and public servants of the territory they were elected and selected to lead and serve, there's much to be desired (at least in the health care area).

Then I wondered about the impact the Church and "Fa'a-Samoa/Fa'alavelave", the two key tenets of the fiber that shapes a Samoan's leadership DNA, has on the aforementioned scarcity of sound, strong, and compassionate leadership in AS.

Have our leaders lost their ways in the midst of modernization and globalization? Or is it the Church and "Fa'a-Samoa/Fa'alavelave" that have lost their way and transformed to the point where AS leaders need to maintain or improve their standard of living at all costs?

I recalled reading about a prominent public leader (who recently became a traditional Samoan chief at the time) negotiating for a higher compensation package, because the prospective public leader couldn't finance the newly acquired traditional responsibilities with the package ASG offered. In the end, the prospective leader became a happy public leader. So there is a functional relationship between the Church/"Fa'a-Samoa/Fa'alavelave" and AS government leaders/public funds; and because such relationship affects the general public, it is worth looking into. But again: that's another issue, another story.

With the Fono allowing your administration and previous ones to short-circuit the Medicaid program over the years, the High Court remains idle to rule on any desired Fono sponsored lawsuits regarding the legality of the perennial non-payment or underpayment of the ASG subsidy to LBJ Hospital, given the existence of the "free medical attention" statute.

The collegial relationship between the administration and the Fono over the years is based on the "Fa'a-Samoa" concept of respect - "Fa'aaloalo" or "Ava Fatafata".

Sadly it is the poor, in this incident, who pay the price of maintaining this "respect".

The triangular foundation of democracy (executive, legislature, and court system) designed to promote and protect the interest of the people have been routinely rendered useless by our leaders' observance of the "respect" part of our "Fa'a-Samoa". And again: that's another issue, another story.

Given the glaring reality of this picture, who else can the poor and the AS people in general turn to as advocates for their health care? I think the AS health care problem has reached the boiling point where mere mortal advocates are of no useful value. This job requires a revolutionary paradigm shift that only Divine Intervention can deliver.

When I think of Divine Invention, two Icons come to mind - Mother Teresa of our time and Moses of Biblical times. The Divine-inspired humility and compassion of Mother Teresa drove her to dedicate her life to taking care of the poorest of the poor of the world. And the Divine-inspired rock fortitude of Moses saw Moses leave the comfort environ of an Egyptian prince to lead God's people home from slavery in foreign land.

Therefore, let us all bow our heads and pray for Divine Intervention for AS. Let us pray to God to bless you, Governor, and leaders and members of the Fono; that God anoint you all with Mother Teresa's humility and compassion to serve and Moses' rock fortitude to lead God's people of American Samoa.

Further, when you and the Fono convene next month to address the AS health care problem, I pray that the forthcoming solutions will not be of mere episodic and reactive nature, only to take care of the current shortfall and avoid the looming increase in fees.

God's people deserve a solution package that addresses the current shortfall and ascertains that ASG observes the law and pays the ASG subsidy in full and on time; but most importantly, addresses for the long term the sustainability of the AS health care system as it exists today, and make the necessary changes to ascertain a sustainable health care system for God's people tomorrow (as discussed in our report, discarded by your administration).

What happens next month will set the tone for AS health care in the future-maintain status quo or take the necessary steps towards change. As Governor, you are in a position of power to set that tone next month, or opt to take the easier road and "kick the can down the road" - letting the next Governor worry about it.

Given the lag time it takes the next governor and his administration to effectuate public policy, your taking the "road less travelled" now will save a lot in terms of human suffering and loss of life among God's people. The opportunity cost of not taking up the challenge head on now is just too high, Governor.

In fact the cost is immeasurable-as life, as you know Governor, is priceless.



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