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Each year, ASTHO tracks and analyzes key legislation that impacts public health, and highlights the emerging trends for our members. While the bulk of the tracked legislation arises in state legislatures, ASTHO also follows legislation from the territories and Freely Associated States, jurisdictions collectively referred to as the insular areas. The insular areas often face different challenges than the states, while also sharing many common concerns. This post contains a brief look at some of the public health related legislation introduced in the insular areas during their current legislative sessions.

Health agencies play a key role in preparing for and responding to hurricanes and other severe weather events.

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

Navigating Public Health Planning with Precision and Purpose Discover examples and best practices for developing strategic plans that enhance community health outcomes. Embarking on the journey of public health planning demands more than good intentions. It requires a meticulous blueprint that encompasses budgetary considerations and strategic timelines, and effectively leverages external support. Across a landscape in which every decision has the potential to uplift entire communities, there are a world of opportunities and details to explore. Included among them are the critical components of crafting a robust plan, the value of engaging contractors, and strategies for optimizing resources. Mining Existing Plans for Insight and Inspiration Organizational strategic plans, Community Health Assessments (CHAs), and Community Health Improvement Plans (CHIPs) can supply guidance and inspiration for comprehensive public health planning. These documents offer both valuable insights into public health initiatives and tangible examples of effective planning frameworks. There are multiple examples of existing plans within health agencies across jurisdictions; when seeking them out, consider various criteria (e.g., population characteristics, geographic location, and specific health priorities). By examining plans tailored to communities with similar demographics or facing comparable health challenges, planners can apply approaches that resonate in their own context. Additionally, understanding the distinctions between strategic plans, CHAs, and CHIPs is essential, particularly for agencies aspiring towards PHAB Pathways Recognition Program or PHAB Accreditation. These plans are separate entities within the PHAB framework, each playing a vital role in shaping public health strategies and fostering community well-being. Strategic Plans Strategic plans outline organizational goals, plans to achieve them, and how to measure success. They drive resource allocation, decision-making, and other priorities organization wide. Examples U.S. Virgin Islands Hawaii Forest County Potawatomi* El Paso County, CO* San Joaquin County, CA* Community Health Assessments Community health assessments offer a complete view of risks, resources, and factors influencing outcomes. Supported by diverse environmental and socio-economic data, CHAs inform health policy, staff protocols, partnerships, program development, funding, resource allocation, and health improvement planning. Examples U.S. Virgin Islands Oneida Nation* Forest County Potawatomi* El Paso County, CO* San Joaquin County, CA* Pierce County, WA* Community Health Improvement Plans Community Health Improvement Plans are strategic, collaborative roadmaps derived from CHAs. They outline how health agencies, partners, and communities will unite to enhance overall health. They guide priorities, resource allocation, and steer project, program, and policy implementation. Examples U.S. Virgin Islands Hawaii Oneida Nation* Forest County Potawatomi* El Paso County, CO* San Joaquin County, CA* Pierce County, WA* *PHAB Accredited Health Department Plan Components, Timeline, and Budget Agencies considering planning processes and examples from other jurisdictions should recognize the diversity in approaches across different agencies and jurisdictions. There truly isn’t a singular “right” way to undertake public health planning. Instead, it’s about tailoring the process to suit the jurisdiction’s unique needs and circumstances. Examples to Guide Plan Development The Kansas Institute of Health’s Strategic Planning in the Public Health Sector Handbook offers a comprehensive breakdown of planning elements and timeframes based on a six-month plan development calendar. Explore Minnesota Department of Health’s Community Health Assessment and Planning Toolkit, a rich resource for navigating the CHA-CHIP process and timeline. Their template includes a detailed approach that considers capacity to accomplish each step within a desired timeline. Given the variation in the depth and breadth of jurisdiction planning processes, it is challenging to pinpoint a specific dollar amount to cover a planning endeavor. NACCHO’s MAPP Budget Template (part of their downloadable MAPP 2.0 process) can help systematically think through the resources necessary for planning processes. Outsourcing Key Support External support—in the form of facilitators, contractors, or other specialized professionals—can play a pivotal role in enhancing public health planning by offering fresh insights, innovative strategies, and diverse perspectives. Such support also allows for full, active organizational participation in the planning process. Moreover, they can provide valuable technical assistance, helping to navigate complex challenges and identify best practices from other contexts. By harnessing external support, organizations can optimize their decision-making processes, foster collaboration, and enhance the delivery of services to communities, thereby promoting better health outcomes for all. Conducting a SWOT Analysis: Contractors can assist in facilitating a thorough analysis of the organization's strengths, weaknesses, opportunities, and threats (SWOT). This structured assessment helps identify internal factors that impact the organization's ability to achieve its objectives and external factors that may affect its operations. Proposing Strategic Priorities: Based on the SWOT analysis and input from stakeholders, contractors can help planning teams crystallize priorities aligned with the organization's mission and vision. These priorities serve as the foundation for developing the plan. Facilitating Steering Committee Meetings: Steering committee meetings are crucial for decision-making and guiding the strategic planning process. External facilitators can lead these meetings, ensuring productive discussions, consensus-building, and alignment with organizational goals. Developing Components of the Strategic Plan: Contractors can support in drafting or reviewing various components of the plan, including vision and mission statements, goals, objectives, and action plans. They may ensure these components are clear, concise, and aligned with the overarching strategic direction. Developing a Draft Implementation Plan: An implementation plan outlines how to achieve strategic goals, including timelines, responsible parties, and resource allocation. Contractors can support an organization to develop a draft implementation plan that outlines actionable steps to translate the strategic plan into reality. Developing Quality Improvement Metrics: Contractors can assist in guiding the development of metrics to measure the effectiveness of the strategic plan. These metrics should be specific, measurable, achievable, relevant, and time-bound (SMART), providing a framework for monitoring progress and making data-driven decisions. Conducting Training Among Organization Staff: To ensure buy-in and understanding of the strategic plan and process itself, contractors can help develop and co-facilitate training sessions for staff members. These sessions may cover strategic objectives, action plans, and their roles in achieving organizational goals. Developing a Communication Plan: Effective communication is an essential key for keeping any strategic plan off the shelf. Contractors can support an organization in developing a comprehensive communication plan that outlines key messages, target audiences, communication channels, and timelines to ensure consistent and transparent communication throughout the organization and with partners. Developing Process Logs, Templates, and Meeting Notes: Contractors can create documentation tools such as process logs, templates for strategic planning documents, and detailed meeting notes. These resources streamline the planning process, capture important discussions and decisions, and serve as valuable references when considering sustainability. In summary, external support brings valuable expertise and resources to public health planning processes, enabling organizations to navigate complexities, engage partners effectively, and develop actionable strategic plans that drive positive health outcomes for communities. OE22-2203 PHIG website yes

Strengthening Long-Term Care Capacity in Island Jurisdictions Through Policy Using Policy to Strengthen Islands' Long-Term Care Capacity Lana McKinney Explore policy levers island jurisdictions can use to strengthen long-term care capacity like payment flexibilities, workforce, and collaborative partnerships. Acute care facilities in U.S. territories and freely associated states experience significant strains on capacity, driven by: Difficulty transitioning medically stable patients to the next appropriate level of care. Insufficient staff to meet patient needs. Limited transitional or extended care facilities. This creates a bottleneck that compromises the efficiency and stability of health systems. However, there are policy levers available to island jurisdictions that can support appropriate care for patients requiring institutional or home-based services and supports. These include payment flexibilities, workforce initiatives, and collaborative partnerships. Current State Infrastructure Island jurisdictions have limited hospital and long-term care (LTC) facility capacity. While many have government-run hospitals, three jurisdictions — American Samoa, the Commonwealth of the Northern Mariana Islands (CNMI), and Palau — have only one hospital, the Federated States of Micronesia has one hospital per state, and the Republic of the Marshall Islands and the U.S. Virgin Islands (USVI) each operate one hospital in both of their most populous islands. Additionally, Guam has just one Medicare-certified skilled nursing facility with 40 Medicare beds, operated by the Guam Memorial Hospital Authority, while Puerto Rico has nine Medicare-certified nursing homes for a population of more than three million people. Without LTC facility capacity, hospitals lack appropriate options for discharge. Geographic isolation, difficulties with recruitment and retention of sufficiently skilled staff (i.e., nursing staff), and supply chain challenges are additional obstacles to establishing and maintaining LTC capacity. Reimbursement Federal health care programs also influence the availability of LTC services in the territories. Medicare and Medicaid may cover LTC services under different circumstances; however, federal funding restrictions limit Medicaid in the territories compared to the states. Unlike the annually calculated, income-based Federal Medical Assistance Percentage (FMAP) for states, the territories have a fixed FMAP. The current permanent FMAP for American Samoa, Guam, CNMI, and USVI is 83%, while Puerto Rico’s is 76% through FY2027. Medicaid funding for the territories also operates under a statutory cap allotment, meaning once the federal allotment is exhausted, the territory must cover all subsequent service costs with local funds. This frequently results in territories expending federal funding mid-year, which leads to service restrictions for residents and financial instability for providers. Finally, while the territories have additional financing restrictions, CNMI and American Samoa are able to operate their Medicaid programs under a special waiver authority. Policy Strategies A number of policy strategies may limit the strain on acute care facilities, address LTC needs, and support the provision of appropriate levels of care in island jurisdictions: Workforce Development Recruitment and retention of health care workers is a challenge in island jurisdictions, but public health and rural health care workforce strategies may help address staffing needs and capacity. Encourage employers and educational institutions to partner with local colleges, vocational schools, and community centers to develop apprenticeship programs and formal career pathways that support skills development, professional advancement, and patient and community needs. Identify available educational programs across the region to support a pipeline for students entering medical, nursing, pharmacy, and behavioral health careers. Promote and support dedicated in person recruitment opportunities as well as broader strategies that support local candidates and students. Develop cross-jurisdictional workforce agreements that allow training completed in one island jurisdiction to be recognized in another. Explore workforce training opportunities through commissions (e.g., Western Interstate Commission for Higher Education), universities (e.g., the Pacific Islands Geriatric Workforce Enhancement Program), and public health associations (e.g., Equipping Community Health Workers to Address Alzheimer’s) as well as curriculum exchange and workgroups (e.g., USAPI Health Workforce Development Technical Working Group). Support partnerships among island jurisdictions to share resources and learnings related to facility development, financial models, and reimbursement strategies. For public employers, decentralize HR functions to create a more efficient hiring process. For jurisdictions with professional schools and programs, develop additional training models (i.e., short-term or extended rural placements) or blended learning. Medicaid and Other Federal Health Programs U.S. territories can also consider Medicaid policies that encourage community supports over institutional care or pursue other program flexibilities through waivers or state plan amendments. For example, states and territories can provide Home and Community-Based Services and use different authorities to achieve their policy goals. Implementing a Section 1115 demonstration allows for significant flexibility but must be budget neutral. In addition, the Money Follows the Person demonstration supports community-based services over institutional care. CMS awarded time-limited planning grants to Puerto Rico and American Samoa for this initiative. Additionally, the Program of All-Inclusive Care for the Elderly helps older adults remain at home and offers comprehensive medical and social services to eligible individuals. Supported Care Transitions Several models support patients moving from hospital to home to control chronic conditions, limit readmissions and emergency department visits, reduce costs, and improve outcomes overall. This includes the Care Transitions Intervention, a short-term training program for patients and caregivers to navigate the move home. The coach’s credentials are flexible and can include nurses, social workers, community health workers, or other professionals. Meanwhile, the Transitional Care Model, provides ongoing care management and is led by an advanced practice nurse. Collaboration Strategic partnerships can drive policies that support healthy aging or aging in place. For example, USVI established a commission on aging, while Guam enacted a senior citizens housing task force, both with multi-sector representation. And in December 2025, American Samoa’s Governor issued an Executive Order establishing a Home and Community-Based Services Commission as part of its Money Follows the Person plan, which includes representatives from a number of governmental agencies and areas of expertise. Legislation Island legislatures have also explored strategies that support older adults and those with complex health care needs and their families: Guam (No. 31-38 (COR)) would establish a regulatory framework for assisted living facilities with the goal of facilitating their development and operation. In 2023, USVI 35-0119 authorized mobile integrated health programs to leverage health care personnel for in-home services and prevent costly hospital readmissions. CNMI considered a resolution to explore several policy strategies, including leveraging Medicaid flexibilities, and prioritizing collaboration and financial support to meet the needs of elderly residents. In 2026, Puerto Rico enacted legislation to improve access to information about the benefits and services available to older adults. Reviewed by - Baker-White, Kearly, Sands Leavitt, Wheatley article yes

As the Association of State and Territorial Health Officials, ASTHO is committed to the T in our name. The health officials from the territories and freely-associated states are valued members and we are committed to advocating for the unique policy needs and priorities of the Pacific and Atlantic jurisdictions. The insular areas face unique challenges locally but also require a specific strategy here in Washington, D.C. Funding approaches and requirements set for states do not always translate to the unique context of the insular areas.