The U.S. Senate is expected to vote Monday on a resolution that would raise the debt ceiling. But one lesser-known provision is significant for the health care of residents of America’s five island territories.

The provision would extend Medicaid reimbursement rates for U.S. territories through Dec. 3. If the proposal doesn’t pass by Thursday, reimbursement rates for the public health insurance program serving low-income patients would revert to previous lower levels.

The congressional vote approaches as federal officials are implementing an administrative way to avert a Medicaid fiscal cliff. Several territorial government officials said that they learned recently that President Joe Biden’s administration is reinterpreting an existing law in a way that would provide more Medicaid funding for territories.

But officials still are pushing Congress to extend higher reimbursement levels to avoid any effect on what health services patients in U.S. territories may access.

Esther Muna is the executive director of the only hospital in the U.S. Commonwealth of the Northern Mariana Islands, home to about 57,000 people.

She said it’s still important for the Senate to approve the higher reimbursement levels in order for territories to be able to take advantage of the federal funding that the Biden administration wants to provide.

Reverting back to the lower match would require territories to come up with more local dollars in order to take advantage of the federal funding, something that’s so challenging in the current economy that she expects that the CNMI would be forced to offer less health services to low-income patients.

Muna said 70% of the hospital’s patients are on Medicaid.

The uncertainty about Medicaid funding has become a ritual for territorial governments, which have been pushing Congress for years to provide more health care support.

States don’t have a limit on Medicaid funding and their reimbursement levels are determined by per capita income. Territories, meanwhile, have fixed Medicaid reimbursement rates regardless of the need, and often find themselves advocating for more funding in front of Congress — where they lack votes — to make up for shortfalls.

“Parity — that’s all we’re asking for,” Muna said.

But that is still a difficult ask. Increasing Medicaid reimbursement rates in U.S. territories would cost millions and force cuts elsewhere. The resolution facing a vote on Monday would cut $96 million from the Medicare Improvement Fund to afford more money for the territories.

There’s no guarantee the continuing resolution will pass. It faces opposition from senators who oppose other spending priorities in the measure, in particular raising the debt ceiling.

Some congressional officials from territories have praised the Biden administration for finding a creative solution to the problem, including Congressman Gregorio “Kilili” Sablan from the Northern Mariana Islands and Congresswoman Jennifer Gonzalez from Puerto Rico, where 1.5 million people rely on Medicaid funding.

But Gonzales told The Weekly Journal that she’ll continue to push for higher Medicaid reimbursement rates “so that our Health Card recipients have access to all the benefits that the program establishes.”

Pandemic And Disasters

The debate over health care funding comes as U.S. island territories grapple with the global coronavirus pandemic.

Most are doing well, in part by sacrificing tourism dollars. As of Sunday, Puerto Rico, the CNMI and American Samoa had the lowest Covid daily case counts per capita in the nation, with the U.S. Virgin Islands not far behind. But Guam had the sixth-highest rate of Covid-19 cases per capita in the nation, according to The New York Times.

Even before the pandemic, accessing health care has been a struggle for residents of U.S. territories, who often need to fly to U.S. states or other countries to get medical care.

In the Northern Mariana Islands, when Medicaid patients need health care that’s not available in the islands — such as an MRI or a cardiology appointment — a committee meets to determine whether they should be sent off island to Guam, Hawaii or the Philippines.

Before Medicaid reimbursement rates to territories were increased in 2017, it was typical for 300 patients from the CNMI to fly to Guam and Hawaii each year for cancer treatments.

But Muna said the pandemic has made many people reticent to leave the commonwealth for medical care because they are afraid of catching Covid-19.

Robin Rudowitz, co-director of the program on Medicaid and uninsured patients at the Kaiser Family Foundation, said it’s important to realize the pandemic comes on the heels of a series of national disasters that have stressed the island governments’ health systems.

It’s common for territorial governments to struggle to come up with enough funding to meet the needs of Medicaid patients in the absence of more federal support, Rudowitz said.

That’s true in American Samoa, says Sandra King Young, who runs the Medicaid program there. She said last year the territory returned $59 million in federal funding after being unable to come up with enough matching local funds.

“It’s not that they don’t need it, we do,” she said.

The uncertainty of funding also makes it difficult for territorial governments to hire and retain staff.

“If Medicaid funding is low, it’s hard to support reimbursement rates to providers that helps attract and maintain providers,” Rudowitz said. “There’s also a number of services that might not be provided.”

Benefits of More Funding

A recent uptick in the Medicaid reimbursement rate for territories allowed Puerto Rico to provide patients with access to Hepatitis C drugs that previously weren’t available there, Rudowitz said.

In the U.S. Virgin Islands, recent higher Medicaid levels allowed the territory to enroll 20,000 more residents, Congresswoman Stacey Plaskett said in a press release Wednesday.

She said Monday’s resolution would avert “a sharp decline in the rate of federal Medicaid funding to the Virgin Islands.”

Muna says the higher Medicaid reimbursement rate and funding recently allowed the local hospital to hire its first-ever oncologist.

The hospital still has no radiation services, but patients are coming in earlier to get cancer diagnoses and treatment plans. They’re also less afraid that they’ll be told they have to fly off island, leaving behind their jobs and families to seek care, she said.

Without consistent Medicaid funding, patients are faced with the choice of dying at home or going off island for care and potentially dying there, said Muna, who finds the funding disparity between states and territories unnecessary and unfair.

“These are Americans,” she said.