Much of puerto ricos medicaid funding expires at the end of september. Puerto rico and other u. S. Territories are on a separate medicaid system than the rest of the United States. Congress funds the him to block grants which can be depleted early if theres a hurricane or other Natural Disaster. A hearing on why states get continues medicaid coverage while the territories do not. The committee is meeting today to hear testimony on the impact of the end of medicaid funding for the areas under the Affordable Care act, also known as the use learning areas medicaid cliff. Under Committee Rules, any oral Opening Statements at parents are limited to the chairman and the ranking minority member. Therefore, i ask unanimous consent all of the members statements be made part of the hearing record if they are submitted to the clerk by 5 p. M. Today. I ask anatomist consent the gentlewoman from the u. S. Virgin islands be allowed to sit on the dice and question the witnesses. Hearing no objections, so ordered. Good morning again everyone. The Mariana Islands, which i represent, and the war mac other u. S. Insularity areas all face and medicaid cliff at the end of this year. Supplementing, supplemental funding for the Medicaid Programs and are areas included in the Patient Protection and Affordable Care act, or obamacare, as like to call it, expires this year. I can just recall as if it was only yesterday when we enlisted the help of the Congressional Hispanic Caucus and met the president on this issue. A senator from new jersey joined us, and thats i think from that meeting we were able to get this money because we were not included in the Affordable Care act under the reconciliation budget process. But most of the funded puts Health Care Delivery at risk not just for medicaid recipients in her presence, but for the population at large. This setting is meant to shine a light on that imminent crisis. I want to thank the directors of each of the insularity area of medicaid to being here today as witnesses. Your programs are already short of cash so the kossuth, to washington was not taken lightly i know. I think we could have no better spokespeople to describe how truly dire the situation is. I hope we will be able to learn from you with the loss of medicaid funds will mean to the people you serve, real people, our people, who simply have no other means of getting basic health care. Also invited to testify today is the chief executive officer of the Commonwealth Healthcare Corporation, the one and only hospital and mary alice, the hospital dispense unmedicated for over i hope this way my bill to tell us what the loss of medicaid funding will mean to the hospital ability to deliver services and how that will impact not only medicaid patients but older patients. I think ms. Muna description of how hospital depends on medicaid revenue officers the losing medicaid revenues will hurt after providers in private practice as well. So were all working from a common set of facts. Let me quickly reviewed the situation. In the states and the destitute only medicaid is an atomic program. To the extent there is a need for services and to the extent a state can provide local matching funds, federal medicaid funds are always available. In the five insular areas this is not the case. Up until 2011 we each receive a fixed lock grant. That block grant i am sorry to say is unrelated to the need of each of her areas. It seems to have been set rather arbitrarily decades ago, and the local access was set in law at 5050. 5050 is the same matching rate as the wealthiest states, states as poor as it Insular Affairs only matched at the area 24 federal 24 local, 76 federal. Obamacare provided some relief, an extra 7. 3 billion in temporary medicaid funding, and a permanent change to match 45 federal, state and local. The obamacare money is a longer available after this year, and all the insular areas. Using 2010 data for americans and going from 20 million in federal funding to 12 million. For guam come from 56,000,000 to 18,000,000. For the marianas come from 25 million the 7 million. For the u. S. Virgin islands, 70 million, the 18 million. And for puerto rico from 2. 3 billion just 360 billion. We cannot serve a conflict that i continue to deliver services. The path forward is unclear. Certainly more money is needed and an acquittal matching rate but theres also the need for each of the insular areas to build capacity to deliver care. Because ultimately the goal is not just to have the same funding as states. What we want is medical care for those who need it in the insular areas to be every bit as good as medical care in the states. So i look forward to hearing from the witnesses for their advice and experience. Lastly, i want to report that one of the meetings we arranged for the directors to add value for the time in washington has paid off. Some of you already know this prior to coming here, that you met yesterday with staff of the Senate Finance committee and the house energy and Commerce Committee. We also arranged for you to meet with the Ministry Administration officials of cms. You asked of the meeting for money to be used in fiscal year 2020 be used before you use the section 1108 block grant. I received word last night that cms has decided to what you ask. That will make more money available that otherwise would have been lost. So if we are able to do nothing else, your true appear was rewarded. I would like to say that we will get Something Else done here. But i certainly do believe todays hearing will have positive results. I now recognize my colleague, the gentlelady from puerto rico for an opening statement. Thank you very much chairman and appreciate this hearing taking place. I want to thank all for being here today and to discuss one of the most important and Critical Issues currently affecting all the u. S. Territories are competing expiration of the medicaid funding, funds granted by the Affordable Care act and the instability of our health care infrastructure. In 2017, 1. 6 million americans living in these territories were enrolled in medicaid. That breaks down to 79 of the population of america samoa, 21 of the population of guam, 33 of the population of northern Mariana Islands and 47 of the population of puerto rico and 66 60 of the population of the Virgin Island. The National Average involvement for the state and the district of columbia was 21 . During the same year the Medicaid Program spend an average of about 1800 a year for territory in rowley. Raleigh. In contrast to National Average, excluding the territories, that was more than 7000. 7000. Medicaid and the territories is subject to statutory federal matching percentage, what we call cliff met. The fmap for the states varies. Relative to each states per capita income. The fmap for the territories is completely different. We are permanently capped by law to 55 . If the formula used to determine the fmap for the states were applied to puerto rico. The federal funding match would increase up to 83 for the maximum. For the 50 states and district of columbia, medicaid provides a guarantee of federal matching payments with no recent limit. This is the main difference between the treatment to the territories and the rest of the state. However, annual federal funding for medicaid in the territories the subject to the statutory cap. Once the territory exhausts its cap federal funds, it is no longer, it won the longer receive federal Financial Support for its Medicaid Program during that fiscal year. In 2011 the Affordable Care act granted the territories an additional 8. 25 billion in federal funds for the Medicaid Programs include of establishing a Health Care Insurance marketplace. The additional funding for each territory range from 109. 2 109. 2 million for the northern marianas, 6. 3 billion for puerto rico, and whats available to be dropdown between july 2011 and september 2019. Since 2011 federal medicaid spending in puerto rico has exceed its statutory cap at using the Funds Available under the Affordable Care act the these funds were depleted in february of last year. During the last congress, 115 congress, the President Trump acted to avert this crisis in puerto rico with a temporary increase of the federal cap to 296 million for the fiscal year 1819. In the consolidated application act of 2017. Moreover, as a result of the state of emergency costs from the hurricanes, we again increase the federal cap the 4. 8 billion for the first time can 100 federal costs here to fiscal year 19 to keep puerto rico Medicaid Program operational. All these additional sources of federal funding for puerto rico in Medicaid Program expired september of this year. For my island medicaid cap set by come in a fiscal year 2020 will be approximately 375 million with no additional source of federal funding available. This means puerto rico will exhaust its federal medicaid allotment in the first three months of fiscal year 2020. And we will bear the expense in excess of 85 of the federal program, placing additional pressure on territory resources. I know this is going to happen in all territories as well. Each territory affected by this treatment in Health Care Funding in their own way. However, all of Medicaid Programs are currently conceived are unsustainable. This underfunded contributes to larger systemic problems including lower provided rates and provider shortages. To correct this challenge i introduce h. R. 2306, the puerto rico medicaid act which seeks to strengthen the Medicaid Program on either by increasing the cap and removing the statutory fmap limitation. Im also a cosponsor h. R. 1354, the Territories Health equity act, legislation introduced by congressman plaskett of the Virgin Islands that addressed to face these problems for all five territories. Both bills are currently under the jurisdiction of the energy and Commerce Committee and i will continue to work with my fellow delegates and the members of that committee to advocate for the dance of those bills. I trust todays testimony will help my colleagues understand the urgent need of action. If we fail to act with the expediency that the situation requires, the provision of health care in all territories will be severely affected by farreaching repercussions for the rest of our nation. Although i recognize this is not the committee with jurisdiction, i would like to thank the vicechairman and members of this committee for this important hearing. Having the witnesses to testify and to be on the record on the impact of the medicaid cliff that will undoubtedly help us as we continue working for a longterm solution of this issue. Thank you, chairman. I think the gentlelady for opening statement. I never can ask the chairman of the full committee, chairman grijalva. Thank you very much. No opening statement, mr. Chairman, just a thank you for organizing the being. I think an excellent panel and im here to learn something in which direction legislative we will go in terms of dealing with this issue. Thank you very much, mr. Chairman burr i appreciate it. I was just commenting that when you are chairman of the full committee, mr. Sablan, you always a little conscious with people the people say are not of a possible coup or your power is removed and are thrown off the chair. Having said that, mr. Sablan come up all the people, mr. Sablan, i just cant believe it, you know . Without i yield back. Thank you. Thank you for those, im going to analyze those comments but i think he meant well. [laughing] and thank you. I would now like to introduce our witnesses. Ms. Esther muna who is the chief executive officer of the commonwealth of the northern mariana healthcare corporation. Ms. Muna again runs are only hospital in the marianas, and whose revenue is about one quarter if not more of the medicaid patients. Ms. Helen sublime, who was the director of the commonwealth of the northern Mariana Islands state Medicaid Agency. Welcome to the two of you. Im going to go ahead and also acknowledge ms. Theresa arcangel. Arcangel. Did i say that right . Who is also the chief administrator of the Long Division of Public Welfare which binds the Medicaid Program. And i would like to ask ms. Radewagen to introduce her witness. Thank you, mr. Chairman. Our medicaid director and ceo is sandra king young, and she came into the position of ceo and director of medicaid. Shes been there for most of the time that the funds have been there and shes been working very hard on it and i want to welcome her and her delegation to town. Thank you. I will now recognize the Ranking Member for introduction of her. Thank you mr. Sablan. I would love to introduce miss angela b lee, executive, puerto rico state Health Insurance administration. We held a panel yesterday and shes the one provided the data related to help our system in accordance with the secretary of health of puerto rico. All right. And miss plaskett, recognize mse witness from the United StatesVirgin Islands. Thank you, mr. Chairman. Its an honor and a pleasure to be here under your leadership, mr. Grijalva, ill have you know i call the leadership of the subcommittee for mr. Sablan, so please be careful. [laughing] this is a really important issue and im really grateful to have ms. Michal rhymerbrowne who is the assistant commissioner of the United StatesVirgin Islands department of Human Services, which does tremendous work and is managing this issue as well. I do note that the governor has his chief of staff year as well as other members of the administration are here. Because we recognize and our governor recognizes what is a tremendously important issue and the need for this funding is to the people of the Virgin Islands. Thank you. Thank you everyone. Again, witnesses are welcome. Under Committee Rules oral statements are limited to five minutes but your entire statement will appear in the hearing record. The lights in front of you will turn yellow when there is one minute left, and the red, and then read when the time is expired. I like to keep timeframe. We may if necessary due to backgrounds of questioning, but we will start with ms. Esther muna, please. Chairman grijalva, Ranking Member bishop, vicechairman sublime and distinguished committee members, thank you for the opportunity to appear before you today. As chief executive officer i oversee the work of the Commonwealth Healthcare Corporation known as chcc. See htc is responsible for the sole hospital, Dialysis Service committal health, Public Health services and several Outpatient Clinics on saipan. As one born and raised on saipan i relied on her Health Care Services long before i became responsible for them. I have seen have been in a remote location poses a host of challenges our population. For example, in the 1990s a baby with a congenital Heart Disease had to take a total of eight hours inflight time to receive care costing 1 million accumulated in a year. Several residents that are my neighbors, my relatives and my friends are unable to return home because we do not have an oncologist on island to manage the complex cancer treatment. A gentleman with a neurological injury waited for days before being transported off island because the cheapest and safest way for them to receive treatment for his injury was at hospital in the philippines. Unlike many u. S. Citizens, did not own a u. S. Passport. Patients with complex medical issues like this gentleman are often flown to guam, hawaii, the philippines and taiwan in order to receive care. In addition to these challenges access secure, delivering Health Services in a Remote Island is more costly with high cost of shipping, and were competing with u. S. Hospitals for the same workforce. 15 years ago with only the inadequate medicaid financing my undergoing a Major Economic crisis due to several global and u. S. Federal policy shifts, the hospital struggled to stop medical supplies and recruit health care workers. In 2007 survey revealed many problems. With no funny improvements, paydays were missed, doctors and nurses left the island. In september 2012, cms issued a