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There has been much discussion concerning the future of health care in our country.  As is evident in any “healthy” democracy, views vary widely and opinions on health care reform are persistently tested and tried in our national government.  For example, in the weeks following the U.S. Supreme Court’s (SCOTUS) decision to uphold Obamacare, or as it is officially known as the Affordable Care Act (ACA), the Republican-majority House took its 33rd vote in a two-year effort to repeal either parts of Obamacare or the Act in its entirety. 

The measure passed on a near party-line vote of 244-185.  But just like previous efforts to repeal Obamacare, the bill is certain to be defeated in the Democratic-majority Senate and President Obama has vowed to veto any bills repealing the Act. So, how does this impact American Samoa?

As American Samoa’s Representative to the U.S. Congress, I submit this commentary, in light of recent discourse, to reaffirm my position that I have always been and will continue to be a strong supporter of the ACA because of its comprehensive policies that expand affordable healthcare to all Americans, and more specifically, because of the important benefits it offers to the people of American Samoa. 

Increased Funding and Federal Matching Rate for Medicaid

In American Samoa, the ACA makes the largest impact on the Territory’s Medicaid program, a program jointly funded by the Federal Government and the American Samoa Government (ASG).  Housed under the Governor’s Office, the State Medicaid Office administers the Medicaid program in the Territory under the provision of Section 1902(j) of the Social Security Act.  The provision acts as a broad waiver from State Medicaid requirements and specifies only three constraints: no federal financial participation beyond the federal fiscal cap in Section §1108(f) of the Act, no waiver for the federal medical assistance percentage (FMAP), and no claims allowed outside of certain services specified under Section 1905(a) of the Act.

Therefore, ASG is granted flexibility to design the Territory’s Medicaid Program to suit the unique needs of the population. ASG does not determine Medicaid eligibility based on an individual’s income but instead utilizes a system of “presumed eligibility,” meaning that each year the percentage of the population (excluding tourists and non residents) below 200% of the poverty level is estimated and, after approval of the estimate, the Centers for Medicare and Medicaid Services (CMS) pay expenditures for Medicaid based on that percentage. Currently, the percentage hovers around 88% and the majority of funding is used for services at LBJ Medical Tropical Center (LBJ). 

As noted, American Samoa faces two key challenges in Medicaid funding under the Social Security Act: 1) a statutory funding cap under Section 1108(f); and 2) a statutory limit on the federal matching rate under Section 1905(b), known as the Federal Medical Assistance Percentage (FMAP) which was previously fixed at 50 percent. 

The ACA gave American Samoa a $180 million increase in the Territory’s Medicaid statutory cap over a nine year period, from 2011 through 2019, lifting the overall cap to $285.5 million in Medicaid funding over the nine-year period.  Overall the five U.S. Territories – including American Samoa, Puerto Rico, Guam, the U.S. Virgin Islands (USVI) and the Commonwealth of the Northern Marianas Islands (CNMI) – received an increase of $6.3 billion in the statutory cap from 2011 through 2019.  The law also increased the Territories’ FMAP from 50 to 55 percent federal share. Accordingly, for every dollar of Medicaid funding spent in the Territory, the Federal Government will now pay 55%, matched by a 45% ASG share.

Funding for Health Care Insurance Exchange or Increased Medicaid Funding

The ACA also allowed American Samoa to opt into the Health Care Insurance Exchange (Exchange) which is a centerpiece of the Act’s sweeping health care reforms.  The Exchange increases access to affordable health care through an online competitive insurance marketplace for individuals who do not receive health insurance from their employers.

In March 2011, through the ACA, the Federal Government granted ASG a $1 million Territory Establishment Grant to assist American Samoa in meeting an October 2013 deadline to determine if the Exchange was suitable for the Territory.  If ASG opted in, the ACA would have provided implementation funding starting January 2014.  However, since ASG opted out, according to a March 21, 2012 press release by Governor Togiola, the ACA now permits the funding to instead be distributed towards American Samoa’s Medicaid program from 2014 through 2019.  

While American Samoa’s actual funding allocation is yet to be finalized by the Secretary of USDHHS, Section 1323 of the ACA attributes $75 million to be shared among American Samoa, Guam, USVI, and CNMI. American Samoa could expect approximately $16.5 million if the funding is calculated with the same ratio as the four Territories’ latest Medicaid grants. 

Medicare Prescription Drug Coverage Benefits for Seniors

Another major goal of the ACA that hits home in American Samoa is prescription drug cost relief for Medicare beneficiaries who fall into what is called the “donut hole” coverage gap.  Through various measures, the ACA attempts to close this gap by 2020.  For example, the U.S. Department of Health and Human Services (USDHHS) issued $250 one-time, tax-free rebate checks to assist eligible seniors in American Samoa in purchasing their prescriptions.  

Starting in 2011, eligible beneficiaries in the coverage gap also received a 50 percent discount on covered brand name medications and Medicare also began paying 7 percent of the cost of generic drugs for these seniors.  In 2010 and 2011, more than 5.1 million seniors and people with disabilities nationwide saved more than $3.2 billion on prescription drugs, an average of $635 each.

Support for Consumer Protections, Health Centers, Children’s Health, and Substance Abuse Prevention

Since 2010, the ACA has also provided approximately $4.2 million to American Samoa through four additional programs. First, the ACA provided ASG $1 million through the Grants to States for Health Insurance Premium Review Program, also known as the Rate Review Grant, to help American Samoa protect private consumers from unwarranted premium increases by their insurance provider.

Secondly, the law increased funding towards American Samoa’s community health centers, totaling $1.1 million, towards expanding preventative and primary health care services, creating new sites, increasing patient reach, and/or supporting construction and renovation.  Third, the ACA also gave American Samoa $1.5 million for the Maternal, Infant, and Early Childhood Home Visiting Program which supports children’s health and development through healthcare, early education, parent education, child abuse prevention, and nutrition.

Lastly, the ACA has already provided $600,000 in Prevention and Public Health Fund to enhance American Samoa’s substance abuse prevention efforts. Over a five-year grant period, American Samoa may receive up to $8.3 million towards these efforts through the USDHHS’ Substance Abuse and Mental Health Services Administration (SAMHSA) Screening, Brief Intervention, and Referral to Treatment activities.

The benefits of the Affordable Care Act for American Samoa total over $300 million, not to mention access to crucial program support that enhances delivery of services to our people. 

Over the next eight years until FY 2019, our Medicaid program will have the capacity to benefit from an additional $180 million for the Territory’s health care needs.  The territory will benefit from additional funding to Medicaid in lieu of the Health Insurance Exchange funding, and eligible seniors covered under Medicare will receive much-needed assistance in paying for their prescriptions drugs. 

In addition to the consumer protections in the ACA, funding under the Rate Review Grant will enhance American Samoa’s efforts to protect private insurance consumers from unreasonable, unjustifiable, and excessive premium increases.” 

Furthermore, millions of dollars in supplemental grants will enhance American Samoa’s public health efforts for infants and children, patients seeking primary and preventative care at our community health centers, and individuals who are seeking treatment for substance abuse.  These are all victories for American Samoa.

For these many reasons, I remain a strong supporter of the ACA and give my assurance to the people of American Samoa that I will continue to work with my Congressional colleagues to protect these crucial federal programs for our people.

I once again applaud the Supreme Court for its decision to uphold Obamacare, and most of all, its comprehensive healthcare policy goals that support the health care needs of our Nation and the people of American Samoa.

July 12, 2012