The day he will take questions from the house intelligence committee. Both open sessions. Mr. Muellers report into russian interference in the 2016 election will air live on cspan3 online at cspan. Org or listen with the free cspan radio app. Much of puerto ricos medicaid funding conspires at the end of september. Puerto rico and other u. S. Territories are on a separate medicaid system nan the rest of the u. S. Congress funds them through block grants. So when the territories are hit by hurricane they go through funds faster and deplete the grants early. The House Natural Resources Committee held a hearing on why states get continuous medicaid coverage while the territories do not. The committees meeting today today to hear testimony on the impact of the end of medicaid funding for the insular areas under the Affordable Care act also known as the insular areas medicaid cliff. And the Committee Rule 4 f any oral Opening Statements at hearings are limited to the chairman and the ranking minority member. Therefore i ask you unanimous consent that all other members Opening Statements be made part of the hearing record if ner submitted to the clerk by 5 00 p. M. Today. I ask unanimous consent that the gentlewoman from the u. S. Virgin islands miss plaskett be allowed to sit and question the witnesses no objection. No objection, so ordered. Good morning again, everyone. And the Mariana Islands which i represent and the four other u. S. Areasry ep face a medicaid ending this year. Supplemental med kald including in the Patient Protection and Affordable Care act or obamacare as we like to call it conspires this year. And i can just recall as if it was onlyyesterday when we enlisted the help of the Congressional Hispanic Caucus and met the president on this issue. And, the senator from new jersey joined us and i think from that meeting we were able to get money because we were not included in the Affordable Care act under the reconciliation process. But, most of that funding puts Healthcare Delivery at risk, not just for medicaid recipients in our islands were for the population at large. This hearing is meant to shine a light on that imminent crisis. I want to thank the directors of the Medicaid Programs for being here as witnesses. Your programs are already short of cash and the cost of coming to washington was not taken lightly. I think we could ask no better spokespeople describe how truly dire the situation is a. I hope we will be able to learn from you what 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 healthcare. Also invited to testify today is the chief executive officer of the Commonwealth Healthcare Corporation. They run the one only hospital in the Mariana Islands and that depends on medicaid for one quarter of its revenue. I hope miss william will be able to tell us what the loss of medicaid funding will mean to the hospitals ability to deliver services and how that will impact not only medicaid patients but all her patients. I think ms. Munez description will help us understand how losing medicaid revenues will hurt Healthcare Providers and private practice as well. So, we are all working from the common set of facts. Let me quickly review the situation. In the state and the district of columbia medicaid is an entitlement program. There is a need for services and to the extent that the state can provide local matching funds, federal medicaid funds are always available. In the five areas this is not the case, up until 2011, we each received a fixed block grant. That block grant i am sorry to say is unrelated to the needs of our areas. It seems to have been set rather arbitrarily decades ago. And the local access to that block grant was set 5050. 5050 is the same matching rate as the wealthiest states, while states swear only matched the rate of 24 federal, i mean 24 local, 76 federal. Obama care provided some relief an extra 7. 3 billion into every medicaid funding and a permanent change in the match 45 federal, 55 local. But the obama care money is no longer available after this year. And all the ancillary areas will revert to their block grants. Using 2018 data means going from 20 million in federal funding to 12 million. For guam from 56 to 18 million. For the marianas from 25 million to 7 million. For the u. S. Virgin islands from 70 million to 18 million. And for puerto rico from 2. 3 billion just under 160 million. We cannot suffer cuts like that and continue to deliver services. The fast or the path forward is unclear. More money is needed at an equitable matching rate. But theres also need for each of the ancillary areas to deliver capacity of 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 ancillary areas to be every bit as good as medical care in the state. I look forward to hearing from the witnesses for their advice and experiences. Lastly i want to report that one of the meetings we do right arranged for the directors will advise the time in washington, some of you already know this prior to coming here. But you met yesterday with staff of the Senate Finance committee and the house Commerce Committee, we also met for you to arrange with cms centers. You asked them of the meeting for obama care section 1323 money to be used in fiscal year 2020 be used before you use the section 11 or eighth annual block grant. I received word last night that they have decided to do what you ask. It will make more money available that otherwise would have been lost. So if we are able to do nothing else i would like to say we will get Something Else done here. I really do believe that todays hearing will have positive results, and i now recognize my colleague, the gentle lady from puerto rico on Opening Statement. Thank you vice chairman and i really appreciate this hearing taking place. I want to thank all for being here today. To discuss one of the most important and Critical Issues currently affecting all the u. S. Territories. The impending expiration of medicaid funding, funds granted by the Affordable Care act and the instability of our healthcare infrastructure, in 2017, 1. 6 million americans living in the territories were enrolled in medicaid. That breaks down to 79 of the population of American Samoa, 21 of the population of guam. 33 of the population of northern Mariana Islands and 37 of the population of rico and 16 of the population of u. S. Virgin islands. The National Average enrollment for the state and the district of columbia was 21 . During the same year the Medicaid Program spent an average of about 1800 dollars a year per territory in relief, in contrast to the National Average excluding the territories that was more than 7000 per relief. Medicaid in the territories is subject to federal matching percentage. What we call fmap, and it varies relatively to each state 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 chair will be increasing up to 83 for the maximum. But if the state and the district of columbia, medicaid provides a guarantee of federal matching payments with no precept limits. And this is the main difference between the treatment to the territories and the rest of the states. However, annual federal funding for medicaid in the territories is subject to this cap. Once a territory exhausts its cap federal funds, it will no longer receive federal Financial Support for the Medicaid Program during that fiscal year. In 2011, the Affordable Care act granted the territories an additional 8. 25 dollars billion in federal funds, for the Medicaid Programs, in lieu of establishing a healthcare insurance marketplace. The additional funding for each territory reached from 100. 2 million for the northern marianas, 6. 3 billion for puerto rico, and was available to be drawn down between july 2011 and december 2019. Since then, the spending and puerto rico has. These funds were depleted in february of last year. The last congress, the President Trump acted to avert this crisis and puerto rico Medicaid Program with a temporary increase to 296 million for the fiscal year 18 19. Moreover, as a result, you can see in 2017 again increase the federal cap to 4. 8 billion for the first time 100 federal cost here to the fiscal year 19 to keep puerto ricos Medicaid Program operational. All these additional sources of federal funding for puerto rico and Medicaid Programs will expire september of this year. For my island, medicaid and the fiscal year 2020 will be approximately 375 million. With no additional source of federal funding available. This means that puerto rico will exhaust its federal medicaid allotment in the first three months of fiscal year 2020. And will bear the expense and express excess of 85 of the federal program placing additional pressure on Territory Resources i know this is going to be happening all territories as well. Issues affected by this treatment and equable treatment in healthcare funding in their own way. However, all of the Medicaid Programs are currently conceived are unsustainable. This underfunding contributes to larger problems including lower provided rates and provider shortages. To correct this challenge i have introduced hr 2306, the puerto rico medicaid ask, which seeks to strengthen the Medicaid Program on the island by increasing the cap and removing a subsidiary fmap limitation. Im also the regional cosponsor of hr 1354 the territories held in equity act. This was introduced by the congressman of the Virgin Islands that will face the problem for all tear five territories. Those bills are 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 advancement of those bills. I trust that 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 healthcare in all territories will be severely affected by far reach and repercussion for our nation. Although i recognize that this is not the committee with jurisdiction, i would like to thank the vice chairman 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 long Term Solution of this issue. Thank you chairman. I thank gentle lady for the Opening Statement and recognize the chairman. Thank you so much. No Opening Statement just a thank you for organizing the meeting. I think an excellent panel and i am here to learn something and which direction legislative we are going to go in in terms of dealing with the issue. Thank you so much for this i appreciate it. I was just coming over here, you know when you are chairman of the full committee mr. Gregorio sablan you are conscious, whether people say are not of a possible coup when power is removed and youre thrown off the chair. And having said that mr. Gregorio sablan , of all the people mr. Gregorio sablan i just cant believe it. [ laughter ] with that i yield back. Thank you, tu i for those, i will analyze those comments, but i think he meant well. [ laughter ] thank you i would now like to introduce our witnesses. Ms. Esther muna who is the chief executive officer for the commonwealth of the northern mariana healthcare corporation. Ms. Muna runs our only hospital in the marianas. And, whose revenue is about one quarter, if not more comes from medicaid patients. Ms. Helen sablan who is the director of the commonwealth of the northern Mariana Islands. State Medicaid Agency. Welcome to you. I am going to go ahead and also acknowledge ms. Teresa arcangel, did i say that right . Arcangel. Okay. Who is also the chief administrator of the Guam Division of Public Welfare which runs the Medicaid Programs. And, i would like to ask ms. To introduce her witness. Ms. Aumua amata radewagen to introduce her witness. Thank you mr. Chairman. Our medicaid director and ceo is sandra and she came into the position of ceo and director of medicaid, she has been there for most of the time that the aca funds have been there and she has been working very hard on it. And i want to welcome her to, and her delegation, to town. Thank you. I now recognize the Ranking Member for introduction of her. Thank you mr. Gregorio sablan i would like to introduce ms. Angie abelard she is the executive director of the Puerto Rico Health insurance administration. She is about providing the data related to Health Care System, and coronation with the secretary of health and puerto rico. Alright. Ms. Stacey plaskett, i recognize ms. Stacey plaskett to recognize that the witness from the United StatesVirgin Islands. Thank you mr. Chairman. It is an honor and a pleasure to be here under your leadership. I called the leadership of the subcommittee for mr. Gregorio sablan so please be careful. [ laughter ] this is a really important issue, and i am really grateful to have ms. Rhymer browne 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 here as well as other members of the administration are here, as our governor albert recognizes what a tremendously important issue and the need for this funding is to the people of the Virgin Islands. Thank you. Thank you everyone and, again witnesses are welcome. But under Committee Rules, oral statements are limited to five minutes. But your entire statement will appear in the hearing record. Right in front of you, the microphone will turn yellow when there is one minute left, and then red when you time has expired. I like to keep timeframe. We may, if necessary do two rounds of questioning. But, at the moment we will start with ms. Esther muna. Chairman raul grijalva, vicechairman Gregorio Sablan and testing which 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 a. Chcc is responsible for seeing over my hospital, dialysis services, Mental Health or Public Health services in several outpatient clinics. As one born and raised on taipan i relied on our Healthcare Services long before i became responsible for them. I have seen how begin a remote location poses a host of challenges for our population. For example, in the 1990s a baby with a congenital Heart Disease had to take a total of eight hours and flight 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 the island to manage their complex cancer treatment. A gentleman with a neurological injury waited for days before being transported off the island because the cheapest and safest way for him to receive treatment for his injury was at a hospital in the philippines. And like many u. S. Citizens, he did not own a u. S. Passport. Patients with complex medical issues like this issue are often flown to guam, hawaii, the philippines, and taiwan to receive care. In addition to the challenges with access to care, delivering Health Services in a Remote Island is more costly with high cost of shipping and we are competing with u. S. Hospitals for the same workforce. 15 years ago, with only the inadequate medicaid funding and the undergoing a Major Economic crisis due to several global and u. S. Policy shifts, hospital struggled to hold and stock medical supplies and recruit healthcare workers. The 2007 survey revealed many problems. With