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OP-ED: MOVING OUR SHIP FORWARD, PART 2: HEALTH CARE

Scenario:  Mose makes $10 thousand a year working for ASG, supporting a pregnant wife and six children age 2 to 14. One of the daughters has a heart problem and sees the clinic in Leone every month. One day a visiting heart doctor tells Mose his daughter needs to go to California for treatment. Mose’s wife starts having labor pains a month too early, gives birth prematurely to a son who needs to stay in the hospital until old enough.

The above scenario was posed by “Mose”, pseudonym for a Samoa News blogger, who inquired how such a family would benefit from the Coverage for All in American Samoa (CAAS) Project policy recommendations I have been advocating since 2007. Although hypothetical, Mose’s family is representative of our reality in the territory where 40% of tax filers earn less than $10 thousand per year (the territory’s per capita income per year is estimated at about $6 thousand) and the average household size is 6 people.

I will revisit and briefly discuss the factors of the territory’s health care equation; then address Mose’s question in light of the Obama Care law, current financing system, and policy recommendations we put forth in the CAAS Project Report.

First, our current health care system is determined by several factors; among these are our dependence on the US federal government — US tax payers — for the lion’s share of government revenues, the prevailing perception among the territory’s populace that health care is free per Deed of Cession, (as embodied in the “free medical attention” law), and the underlying and undeniable market forces of supply and demand. 

Free medical care sentiments abound this election year as in previous ones; and politicians will not talk or think amending the free medical attention law even if there’s an urgent need to, as there is now. Moreover, at least one or all of the candidates for governor is of the opinion that free medical care is implied in the Deed of Cession. 

Thus, it’s a fair assessment that free medical care is cemented in the psyche of the average American Samoan, with a lot of help from politicians. We tend to be emotional about what our forefathers meant for us, or what we think they meant for us. We all witnessed and no doubt many felt and shared such deep seated attachment to our forefathers when Governor Togiola delivered his final Flag Day address, when he lamented our political status. 

So health care is what it is, in American Samoa, whether or not our benefactor agrees to it. Notice the Obama Care law is formally known as Patient Protection and Affordable Care Act (PPACA). The key word is “affordable”, free care isn’t implied.

But despite the stamp of local law placed on our ‘free’ health care system, the more potent and omnipresent market forces of supply and demand are determining which direction (north) facility fees move, especially when ASG leaders forget to honor our Deed of Cession-inspired free medical attention law by not paying the hospital subsidy on time or at all. 

The current facilities fee schedule is being challenged in court by a prominent local attorney as “unreasonable” (the current law allows LBJ to charge “reasonable” facility fees but does not define what reasonable is). While the court decision is pending on this case, a new facility fee schedule which prominently “penalized” non-residents is set to go into effect on May 21, 2012.

Secondly, by virtue of our dependency on the US, the Obama Care law stands to impact health care in the territory significantly and for the better (due to the generous financial assistance the law provides) should the Supreme Court rule in favor of keeping Obama Care as is. (The Supreme Court is reviewing the constitutionality of the Obama Care law, and their decision is expected in June of this year). 

Although the US House Committee on Energy and Commerce last week voted to repeal part of the Obama Care law that increases Medicaid funding for the territory, there’s hope the House on the whole would vote in the territory’s favor; but that appears unlikely.  If it fails the House vote, our hopes then rest with the US Senate, where the Democrats hold a slight majority over the Republicans.

Governor Togiola, if you recall, recently decided against establishing an insurance exchange for the territory in favor of expanding the Medicaid program (a choice each state and territory has to make under the Obama Care); well it appears funding for the Medicaid expansion is now in jeopardy. 

If the Republicans were to decide between the two options for the territories, they would more likely vote to lose the Medicaid expansion (because it’s a direct grant) and keep the insurance exchange (because it is a market solution although subsidized).  But we’ll wait to see how the big boys play this one out. Meanwhile, our local big boys should not wait around but prepare for the worse — the Obama Care does not pass the Supreme Court test or the Congress votes against Medicaid expansion for the territories.

What does all this mean for Mose and his family of 9?

If Mose and his family qualify as US nationals, and Obama Care survives the Supreme Court and Congress intact, then Mose and his family are taken cared of for the next seven years (duration of Medicaid increased funding) if ASG allows the territory Medicaid program to benefit the truly impoverished families of the territory for local and off-island health care. 

If Obama Care does not survive, then the new fee schedule slated for implementation on May 21, 2012 will need to be adjusted upward if there’s no funding to replace the reduction in Medicaid, or we face cut backs in health care services, according to the hospital CEO.

Mose and his family qualifies for the LBJ sliding scale fee schedule whether they’re residents or non-residents; given their household income and size, the care may be free of charge to them.

To the extent that they’re US nationals, the free care is paid for by the Medicaid grant and ASG subsidy. If they are residents via living here for at least ten years, the free care is paid for the local subsidy; if non-residents, free care is unfunded or paid for by everyone else. 

This puts tremendous stress on the health care system and if it continues long enough, the system breaks.  And I believe that’s where we’re at now. It doesn’t look good for Mose and his family in this senario.

Our saving grace would be for the Obama Care to escape the Justice and Congressional scrutiny unscathed or at least the areas beneficial to the territories would be spared. That would give us room to breathe while we figure out where to go and how to get there from here in terms of health care development.

Finally, let’s explore the initiatives proposed by the CAAS Project report relative to helping Mose and his family.

First, amend the law to reflect the reality of our subsidized health care system (lose free medical attention and reasonable facilities fees) and include the timeliness of the full payment of the subsidy in the law. I don’t believe our forefathers meant to enslave us to a Deed of Cession or its implications. I think if they could lecture us regarding our health care crisis, the message would be for us to use our wise consideration.

Second, legislate a public pre-pay self-insurance pool where everyone pays into, including government and private employees, formal and informal or subsistence employees or self-employed, members of the clergy; in short everyone earning a living. Participation is mandatory except for those who already have health insurance coverage. If the Supreme Court rules the individual mandate of the Obama Care unconstitutional, then participation would be voluntary. 

The plan we proposed is called the American Samoa Health Insurance Plan (ASHIP) to be administered by ASG . Contributions can be either a percentage of wages or a set monthly premium. We proposed the latter to capture the non-formal and non-wage earners. The premium ranges from $25 per month per individual to $50 per month per family of six; premium for a family of more than 6 would be pro-rated based on the rate for a family of 6.

By pooling the risks in the territory, the risk of incurring an uncertain catastrophic outcome (say major illness or accident costing $3000) is transferred into a known small risk ($25 per month premium for an individual or $50 for a family).

Can Mose afford this premium structure? Mose cannot afford not to enroll in ASHIP.

With food stamps and WIC, and the additional child tax credit nullifying the minimum 4% tax and the 2% wage tax, Mose should be able to contribute to his and his family’s health care. To boot, Mose should be given a serious lecture about family planning and financial planning, and a firm kick on the butt forcing him out the door to look for a second part time job in the evening (dish washer or security guard) or start a small business cleaning yards, homes, or contract with ASG to pick up trash and dead animals along the road.  

ASHIP would be open to non-residents, but the premium will need to be adjusted to account for the unsubsidized cost of care. Nominal co-payments need to be figured into ASHIP to control moral hazard (abusing access to care due to availability of coverage) for all enrollees.

Third, an immigration healthcare bond is proposed to cover immigrants’ health care in the territory. Once they find employment and decide to stay for the long term, then they can enroll in ASHIP at non-resident rates.  After ten years, they can re-enroll as residents. 

Fourth, the territory’s Medicaid program needs to be reformed to account for qualified recipients at the lower half of the means criteria (income and net worth); the territory’s millionaire’s are beneficiaries of our Medicaid program as is. Not much can be said at this time as the Supreme Court verdict and Congressional vote are pending on the Obama Care law.  But we need to have this reform dialogue by the end of June, in time for the last Fono session.

Fifth, we proposed to decentralize the delivery of primary and preventive care to outlying district posts, where a physician or at least a qualified nurse practitioner or physician assistant who is experienced in primary care supervises the post. Mose’s family would be able to continue to get the primary and preventative care they need at the Leone clinic.

Sixth, we proposed to reopen the Fiji School of Medicine pipeline to send our prospective physicians to.  Worthy of consideration is Samoa’s Oceania School of Medicine. This human resource development is within our budget and makes sense as graduates from FSM tend to stay and practice their profession in the territory. Hence, there’s assurance that Mose’s children or grandchildren will be taken cared of by trained physicians.  Perhaps one of Mose’s children, the one born a month too early, will one day be one of these graduates.

Finally, ASHIP was proposed to address the local acute health care at LBJ and would not have the resources to underwrite off-island care; unless sufficient seed money is allocated for this purpose and an actuary is engaged to price the off-island insurance properly.

In our report we alluded to referral relationships with teaching hospitals in the states (which are affiliated with medical schools).  LBJ used to have such a relationship with Tripler Army Medical Center and Tripler would take cases from LBJ free of charge. I understand LBJ recently entered into such a referral relationship with a hospital in Oregon which specializes in children’s heart diseases. So here’s a great opportunity for Mose’s daughter who has a heart problem. Teaching hospitals have funds for these cases, thus cost to Mose or LBJ would be minimal if any.

Or Mose can always do what most US nationals do (if Mose and his daughter are US nationals) when the off-island care program was frozen — take the patient and LBJ diagnosis to Hawaii or California and apply for Medicaid assistance there. I don’t know about the legality of such practice, but it has saved a lot of local lives, (thus I don’t condone or condone such practice).  

We need to address our off-island care program properly to include teaching hospitals mentioned above, international medical missions, Obama Care insurance exchange if the opportunity arises again, medical savings accounts and high deductible major medical insurance, and consider an off-shoot of ASHIP to underwrite limited catastrophic risks (with sufficient seed funding) and re-insurance to underwrite amounts above the ASHIP threshold.

Of utmost importance is equity (fairness), that a janitor in Manu’a or a fish cleaner at Star Kist has a fair chance of getting the off-island treatment when needed.

Reaping the benefits of Obama Care would be nice, very nice indeed. But if it doesn’t turn out in our favor, we can still take what we have or have access to and make something happen for ourselves and our people. If anything, that is what our forefathers would have willed for us — the courage and faith to spearhead our ship forward.



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