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After years of advocacy, ASTHO and our partners are celebrating the recently signed Consolidated Appropriations Act.

ASTHO and NAMD Letter Urging Congress to Fully Fund Medicaid and CHIP in U.S. Territories Dear Chair Wyden, Chair Rodgers, Ranking Member Crapo, and Ranking Member Pallone: Strong, sustainably funded Medicaid and Children's Health Insurance Programs (CHIP) are crucial to addressing health care challenges in the U.S. territories. On behalf of the Association of State and Territorial Health Officials (ASTHO) and the National Association of Medicaid Directors (NAMD), we urge Congress to ensure the fiscal stability of the territories’ Medicaid programs by lifting the annual Section 1108(g) allotment cap for all territories and authorizing a permanent 83% Federal Medical Assistance Percentage (FMAP) for Puerto Rico. Robust Medicaid and CHIP are critical components of strong and resilient territorial health systems. The five U.S. territories—American Samoa, Guam, the Commonwealth of the Northern Mariana Islands (CNMI), Puerto Rico, and the U.S. Virgin Islands (USVI)—vary dramatically in population, health care system capacity, and Medicaid program structure. Despite these differences, they share common challenges, including significantly higher rates of poverty (ranging from 16.8 percent in Guam to 54.6 percent in American Samoa in 2019, compared to 10.5 percent in the United States), higher rates of chronic health conditions, and a lack of health care infrastructure. Medicaid and CHIP programs are crucial to addressing these challenges. Chronic underfunding has impaired territories’ capacity to serve their residents, who are U.S. citizens or U.S. nationals. Historically, the territories have faced two statutory funding challenges: 1) A low, fixed FMAP rate that is not tied to per capita income (as is the case in the states), and 2) Annual funding caps. Prior to FY 2023, Congress supplemented low annual funding amounts with short-term additional investments. The short-term nature of this funding limited territories’ ability to plan, undertake large investments, and efficiently deliver services. In the Consolidated Appropriations Act of 2023, Congress permanently increased the FMAP for American Samoa, Guam, USVI, and CNMI to 83% and authorized a 76% FMAP for Puerto Rico through 2027. NAMD and ASTHO applaud and fully support this structural means of addressing longstanding needs. Congress should continue to build on this foundation by extending the permanent 83% FMAP to Puerto Rico to ensure all U.S. territories have access to sustainable Medicaid and CHIP funding. Over and above this FMAP adjustment, Congress must also address the constraints caused by the allotment cap on the territories’ Medicaid and CHIP funding, established by Section 1108(g) of the Social Security Act. When a territory reaches this cap, they are responsible for funding their Medicaid agency solely with local dollars. Due to challenges generating sufficient local funds, many territories have been forced to cut services after reaching these allotment caps, drastically limiting their ability to offer services and destabilizing local health care providers. For example, CNMI expects to hit its FY 2024 cap by July, leaving the CNMI government with more than two months of unmatched Medicaid costs. Congress should eliminate the annual Section 1108(g) allotment cap to ensure sustained access to high-quality public health and health care services in the U.S. territories. Sustainable, equitable funding will allow territorial programs to make long-term, cost-effective investments that support high-quality and innovative Medicaid programs. The Consolidated Appropriations Act of 2023 directed American Samoa, Guam, CNMI, and USVI to develop four-year strategic plans focused on workforce, program integrity, systems development, and financing. The four territories developed comprehensive plans with ambitious goals, including developing electronic eligibility and enrollment, MMIS, and T-MSIS systems, launching initiatives to expand local provider workforces and territory administrative capacity, and strengthening program integrity processes. These plans are evidence of the momentum and energy that territory leaders bring to their reform agendas. Technical assistance from CMS and other agencies will remain a critical resource for capacity-building efforts in the territories. In addition to lifting the statutory allotment cap and providing Puerto Rico with a permanent 83% FMAP, Congress should also consider providing the territories with targeted, project-specific enhancements to their administrative match rates to facilitate necessary technical assistance and change management. These structural improvements will strengthen the impact of Medicaid dollars allotted to the territories. Thank you for your previous support of the Medicaid programs in the U.S. territories and your ongoing attention to this important issue. If you have any questions or require additional information, please reach out to Jeffrey Ekoma (senior director of government affairs at ASTHO, jekoma@astho.org) and Jack Rollins (director of federal policy at NAMD, Jack.Rollins@MedicaidDirectors.org). Sincerely, Joseph Kanter, MD, MPH Chief Executive Officer, ASTHO Kate McEvoy, Esq. Executive Director, NAMD website yes

U.S. Territories Face Healthcare Cuts if Congress Does Not Address Impending Medicaid Financing Cliff ARLINGTON, VA—Association of State and Territorial Health Officials (ASTHO) member Esther Muña, MHA, chief executive officer at the Northern Mariana Islands Commonwealth Health Corporation, and other territorial health leaders from Guam, Puerto Rico, America Samoa, and the U.S. Virgin Islands testified today before the United States House Committee on Natural Resources about the impact that cuts to Medicaid would have on U.S. territory populations. “On the heels of Super Typhoon Yutu, which devastated the Commonwealth of the Northern Mariana Islands’ economy and its people, we face another crisis – our Medicaid program is unable to sustain its operations with the low statutory cap on federal contributions,” says Muña. “Low federal contributions, coupled with the exhaustion of the Patient Protection and Affordable Care Act funds this year, creates a fiscal cliff for our Medicaid program. This fiscal cliff threatens to unweave our substantial improvements over the past ten years in the delivery of healthcare, further erodes our economy, and threatens the health and well-being of our people. “I strongly urge Congress to stabilize Medicaid financing for the territories by raising or eliminating the arbitrary cap on federal dollars to the program so I can continue my work to protect and promote the health our population,” Muña continues. Unless Congress acts, the U.S. territories’ Medicaid programs will become gravely underfunded. Federal funding for Medicaid in territories is capped and it is subject to a fixed federal matching rate. For more information about the hearing, visit the committee’s website. ASTHO Press Release Boilerplate website yes

How the U.S. Virgin Islands is Improving Federal Grants Management astho, association of state and territorial health officials, public health, grant programs, grant management, overall health, health system, improving health, social determinants of health sdoh, grant funding, health outcomes, united states virgin islands, territory of the united states, health community, long term, quality of life, health care, grants management system, u.s. virgin islands. social determinants of health, population health, federal grants, federal grants management, federal grant planning, electronic grants management system Kristin Sullivan Learn about new grants management practices in the United States Virgin Islands. The United States Virgin Islands (USVI) continues to lead the way, making headway on improving key business processes. Last year, ASTHO reported on the beginning of a new "all-of-government" approach in the USVI to more efficiently manage and expend federal grant funding to identify territory-wide social determinants of health and in turn yield population health improvement. Under the leadership of Governor Albert Bryan, Jr., cabinet members from four administrative agencies (Offices of Management and Budget; Property and Procurement; Personnel; and Finance), four programmatic agencies (Health; Education; Human Services; and Justice), and the Governor’s Office comprised a Cross Agency Leadership Team (CALT). After evaluation of the federal grants' life cycle value stream, the team prioritized improving the Federal Grant Planning and Set Up process to prevent bottlenecks and other issues that occur throughout the rest of federal grant lifecycle. During this planning phase, the CALT—along with a project team comprised of key staff in each agency— were oriented to performance improvement basics and participated in Boundary Spanning Leadership workshops where they discussed a unified vision of collaboration to modernize business processes for the benefit of their community. In addition to the benefits to the community they serve, participants envisioned becoming better stewards of funds, increasing respect and trust with funders, increased cross-agency collaboration and communication, and improved job satisfaction due to less rework and urgent requests. "As we promote health equity in our diverse communities, we must recognize operational efficiency as a key driver including our ability to move resources to those most in need. This initiative creates an intentional focus through cross-agency dialogue on saving time, reducing duplication, and building workforce capacity to continuously improve." - Justa Encarnacion, Commissioner, USVI Department of Health Through a series of virtual and in-person workshops, each agency identified the steps in their current process revealing significant commonalities and supporting the feasibility of process standardization across agencies. The full project team worked to uncover the root causes behind process inefficiencies and identified and prioritized solutions. The workshops culminated in a set of recommendations for improvement, which was presented to and vetted by the CALT:   Create one standard process for all agencies documented in a standard operating procedure (SOP). Electronically enable the process (i.e., no paper or emails) using the existing grants management system to track information, facilitate workflow visibility and approvals, and store all information in one common location. Enhance quality and reduce errors through mistake-proof templates and checklists. Work toward removing redundant data entry across financial and grant systems. Streamline information sharing of notice of awards via the creation of general email inboxes. Establish Federal Grants oversight responsibilities in programmatic agencies. Establish Federal Grants Community of Practice (COP) among participating agencies to ensure continual effectiveness and efficiency.   Since then, the project team—with leadership support—has made significant progress developing the recommended improvements, working through challenges, and monitoring progress. To date, one standard process and SOP for all agencies was developed, and four workflows were created to automate the new process within their electronic grants management system, eCivis. Collaboration among programmatic, administrative agencies, and the eCivis vendor resulted in resolution of access issues, better-defined field entries for the automated workflows, and enhanced buy-in on broader system use. 100% of project team evaluation respondents reported improved communication and customer service among participating agencies. Additionally, the COP was established and alternates leading biweekly meetings allowing for the necessary time and space to develop emerging leaders, build capacity of the team, and prepare to sustain collaboration and improvement.  Options to establish federal grant oversight responsibilities in programmatic agencies is under discussion by a subgroup of leadership and COP members. Similar challenges that can be found in other jurisdictions, such as limited staffing capacity and turnover, changes in leadership, and managing daily priorities, affects the speed of which improvements are developed and implemented. These disruptions as well as individual agency process changes that occur over time, will need to be managed with attention given to momentum or resistance experienced, as well as to empowering the project team to adjust. Collaboration and decision making across multiple agencies is not easy. Success lies in engaging all agencies that play key roles in the grants process and strong executive leadership.  These keys to success can be replicated by other jurisdictions similarly interested in improving their ability to procure needed goods and services in a timely manner, efficiently recruit and on-board staff, and effectively manage grants and contracts.  Next Phase and Future Actions There are several critical actions USVI is working to execute prior to moving to full implementation of the new, improved process. Each agency will need to test the new workflows and prepare to roll out training to programmatic and administrative staff beyond the project team. Once completed, the new process will be in place and the COP will monitor process performance including speed and quality, and support ongoing process and system improvements. With reaffirmed commitment and prioritization from Governor Albert Bryan, Jr. and the U.S. Department of the Interior, ASTHO was recently awarded additional funding to continue supporting USVI on its journey to improve its federal grants management. Continual Impact thank you website yes

Medicaid plays a critical role in providing access to health services for low-income U.S. citizens in the five U.S. territories. However, Medicaid financing in the territories has been underfunded compared to states. In this episode, guests discuss the urgent need for a permanent Medicaid solution, drawing attention to the need for equitable health financing for the U.S territories. This funding is necessary to support comprehensive public health and healthcare within these jurisdictions that include expanded prevention, testing, and treatment programs and capabilities.