[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
ASSESSING CURRENT CONDITIONS AND CHALLENGES AT THE LYNDON B. JOHNSON
TROPICAL MEDICAL CENTER IN AMERICAN SAMOA
=======================================================================
OVERSIGHT HEARING
before the
SUBCOMMITTEE ON INDIAN, INSULAR AND
ALASKA NATIVE AFFAIRS
of the
COMMITTEE ON NATURAL RESOURCES
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
Tuesday, July 25, 2017
__________
Serial No. 115-21
__________
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COMMITTEE ON NATURAL RESOURCES
ROB BISHOP, UT, Chairman
RAUL M. GRIJALVA, AZ, Ranking Democratic Member
Don Young, AK Grace F. Napolitano, CA
Chairman Emeritus Madeleine Z. Bordallo, GU
Louie Gohmert, TX Jim Costa, CA
Vice Chairman Gregorio Kilili Camacho Sablan,
Doug Lamborn, CO CNMI
Robert J. Wittman, VA Niki Tsongas, MA
Tom McClintock, CA Jared Huffman, CA
Stevan Pearce, NM Vice Ranking Member
Glenn Thompson, PA Alan S. Lowenthal, CA
Paul A. Gosar, AZ Donald S. Beyer, Jr., VA
Raul R. Labrador, ID Norma J. Torres, CA
Scott R. Tipton, CO Ruben Gallego, AZ
Doug LaMalfa, CA Colleen Hanabusa, HI
Jeff Denham, CA Nanette Diaz Barragan, CA
Paul Cook, CA Darren Soto, FL
Bruce Westerman, AR A. Donald McEachin, VA
Garret Graves, LA Anthony G. Brown, MD
Jody B. Hice, GA Wm. Lacy Clay, MO
Aumua Amata Coleman Radewagen, AS Jimmy Gomez, CA
Darin LaHood, IL
Daniel Webster, FL
Jack Bergman, MI
Liz Cheney, WY
Mike Johnson, LA
Jenniffer Gonzalez-Colon, PR
Greg Gianforte, MT
Todd Ungerecht, Acting Chief of Staff
Lisa Pittman, Chief Counsel
David Watkins, Democratic Staff Director
------
SUBCOMMITTEE ON INDIAN, INSULAR AND ALASKA NATIVE AFFAIRS
DOUG LaMALFA, CA, Chairman
NORMA J. TORRES, CA, Ranking Democratic Member
Don Young, AK Madeleine Z. Bordallo, GU
Jeff Denham, CA Gregorio Kilili Camacho Sablan,
Paul Cook, CA CNMI
Aumua Amata Coleman Radewagen, AS Ruben Gallego, AZ
Darin LaHood, IL Darren Soto, FL
Jack Bergman, MI Colleen Hanabusa, HI
Jenniffer Gonzalez-Colon, PR Raul M. Grijalva, AZ, ex officio
Vice Chairman
Rob Bishop, UT, ex officio
------
CONTENTS
----------
Page
Hearing held on Tuesday, July 25, 2017........................... 1
Statement of Members:
LaMalfa, Hon. Doug, a Representative in Congress from the
State of California........................................ 1
Prepared statement of.................................... 2
Radewagen, Hon. Aumua Amata Coleman, a Delegate in Congress
from the Territory of American Samoa....................... 3
Prepared statement of.................................... 4
Sablan, Gregorio Kilili Camacho, a Delegate in Congress from
the Territory of the Northern Mariana Islands.............. 5
Prepared statement of.................................... 6
Statement of Witnesses:
Bussanich, Thomas, Director of Budget, Office of Insular
Affairs, Department of the Interior, Washington, DC........ 8
Prepared statement of.................................... 9
Questions submitted for the record....................... 10
Faumuina, Taufete'e John, CEO-Director, Lyndon B. Johnson
Tropical Medical Center, Faga'alu, American Samoa.......... 11
Prepared statement of.................................... 13
Questions submitted for the record....................... 14
Young, Sandra King, Medicaid Director, American Samoa
Medicaid Agency, Office of the Governor, Pago Pago,
American Samoa............................................. 17
Prepared statement of.................................... 19
Additional Materials Submitted for the Record:
List of documents submitted for the record retained in the
Committee's official files................................. 36
OVERSIGHT HEARING ON ASSESSING CURRENT CONDITIONS AND CHALLENGES AT THE
LYNDON B. JOHNSON TROPICAL MEDICAL CENTER IN AMERICAN SAMOA
----------
Tuesday, July 25, 2017
U.S. House of Representatives
Subcommittee on Indian, Insular and Alaska Native Affairs
Committee on Natural Resources
Washington, DC
----------
The Subcommittee met, pursuant to notice, at 10:04 a.m., in
room 1324, Longworth House Office Building, Hon. Doug LaMalfa
[Chairman of the Subcommittee] presiding.
Present: Representatives LaMalfa, Gonzalez-Colon,
Radewagen, Bishop; and Sablan.
Also present: Representative Westerman.
Mr. LaMalfa. The Subcommittee on Indian, Insular and Alaska
Native Affairs will come to order. The Subcommittee is meeting
today to hear testimony on the topic of, ``Assessing Current
Conditions and Challenges at the Lyndon B. Johnson Tropical
Medical Center in American Samoa.''
I ask unanimous consent that the gentleman from Arkansas,
Mr. Westerman, be allowed to sit in with the Committee and
participate in the hearing.
So ordered, without objection.
Under Committee Rule 4(f), any oral opening statements at
hearings are limited to the Chairman, the Ranking Minority
Member, and the Vice Chair. This allows us to hear from our
witnesses sooner, and helps Members to keep to their schedules.
Therefore, I ask unanimous consent that all other Members'
opening statements be made part of the hearing record if they
are submitted to the Subcommittee Clerk by 5:00 p.m. today.
Without objection.
STATEMENT OF THE HON. DOUG LaMALFA, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
Mr. LaMalfa. Good morning. The Subcommittee is meeting to
discuss the previously mentioned topic.
The islands of American Samoa joined the United States
through Deeds of Cession back in the early 1900s, and thus
their fate and well-being has been tied to that of our mainland
for the last 117 years. During that time, American Samoa has
had its struggles with maintaining and providing healthcare
services for their growing population.
In 1966, President Lyndon Johnson gave remarks at the
Tafuna International Airport in Pago Pago and his remarks
acknowledged construction of the American Samoa Tropical
Medical Center, the territory's first and only hospital,
``which will provide the finest hospital care in this part of
the world.''
Unfortunately, the President's hopes for the Tropical
Medical Center did not come to fruition, as the hospital is in
a state of disrepair, far below expectations. With this
deteriorating infrastructure and the strain of rising
healthcare costs that plague many of America's rural areas, the
hospital administration is being forced to tackle an expanding
list of challenges: shortage of qualified medical staff and the
remoteness of the South Pacific.
It is, indeed, a struggle to provide this everyday
treatment that is needed. Many have to journey 5 hours via
airplane to Hawaii, instead, to receive proper care. The cost
of travel is a burden for them, and places an incredible
challenge in meeting these costs.
Congress has a responsibility to the territories, and to
review the Federal policies and programs that affect the daily
lives of the Americans living and working in these far-off
places.
The testimony received today will be a crucial step forward
for Congress to review and better understand how our policies
are affecting these Americans at the local level in the
Nation's most remote territories.
[The prepared statement of Mr. LaMalfa follows:]
Prepared Statement of the Hon. Doug LaMalfa, Chairman, Subcommittee on
Indian, Insular and Alaska Native Affairs
Good Morning. The Subcommittee is meeting today to discuss a topic
not many Americans are familiar with, in a place not many Americans are
familiar with, the Lyndon B. Johnson Tropical Medical Center in
American Samoa.
The islands of American Samoa joined the United States through
Deeds of Cession back in the early 1900s and thus their fate and well-
being has been tied to that of our mainland for the last 117 years.
During that time, American Samoa has had its struggles with maintaining
and providing healthcare services for their growing population.
On a visit in 1966, then-President Lyndon Baines Johnson gave
remarks at Tafuna International Airport in Pago Pago. In his remarks,
the President acknowledged the construction of the American Samoa
Tropical Medical Center, the territory's first and only hospital, ``. .
. which will provide the finest hospital care in this part of the
world.''
Unfortunately, the President's hopes for the Tropical Medical
Center did not come to fruition as the hospital is in a state of
disrepair, far below expectations. With deteriorating infrastructure
and the strain of rising healthcare costs that plague many of America's
most rural areas, the hospital administration is being forced to tackle
an expanding list of challenges.
A shortage of qualified medical staff and the remoteness of the
territory's location in the South Pacific make recruitment of vital
medical care providers a daunting task. The struggle to provide
adequate medical treatment is an everyday fight for the hospital's
limited staff and all too often a futile one, as many patients in need
of advanced treatment are forced to journey 5 hours via airplane to
Hawaii in order to receive proper care. The cost of this travel for
healthcare only continues to overburden both the territory and the
Federal programs that are in place to cover a portion of these enormous
costs.
These challenges are ones that the hospital administration and
local government cannot possibly tackle on their own and in today's
hearing we will look at the role the Federal Government has played in
this partnership and if there are ways for improvements to be made,
both in infrastructure and under current Federal healthcare programs.
Congress has a responsibility to the territories and to review the
Federal policies and programs that affect the daily lives of the
Americans living and working in these far-off places.
All too often, it is easy to leave the territories on the fringes
of our Nation's collective dialogue, and what might seem like minor
policy changes to folks here living in the mainland United States can
have very major consequences to those living in our most remote
districts.
I thank all the witnesses that made the roughly 7,000 mile journey
from the South Pacific to be with us here today to share their valuable
expertise and insight as to the conditions at the LBJ hospital. The
testimony we receive here today will be a crucial step forward for
Congress to review and better understand how our Federal policies are
affecting the Americans at the local level in the Nation's most remote
territory.
______
Mr. LaMalfa. With that, I would like to yield time to our
colleague from American Samoa, Mrs. Radewagen.
STATEMENT OF THE HON. AUMUA AMATA COLEMAN RADEWAGEN, A DELEGATE
IN CONGRESS FROM THE TERRITORY OF AMERICAN SAMOA
Mrs. Radewagen. Thank you, Mr. Chairman. I first want to
thank you and the members of the Committee for holding today's
hearing. It has been a long time coming, and I am glad to see
us finally sitting down to tackle this issue that is so
important to my home district of American Samoa.
I also want to welcome our witnesses, who have traveled
halfway around the world to be here, including Taufete'e John
Faumuina, CEO and Director of the LBJ Tropical Medical Center;
Dr. Reese Tuato'o--do I see Dr. Reese Tuato'o?; and Sandra King
Young, Medicaid Director for the territory. Thank you all for
being here today. Your dedication to your work is much
appreciated.
Welcome also to Mr. Tom Bussanich, from the Department of
the Interior.
This hearing is the result of the CODEL that traveled to
American Samoa in February, and I want to thank Chairman Bishop
and the Members who were able to join us. During the visit, the
Members were given a tour of LBJ Hospital, the only medical
treatment facility on the island.
I want it in the record that our doctors and nurses who
work there do an excellent job with the limited resources they
have available, and they should be commended for their efforts
to maintain the good health of our people.
LBJ is approximately a 150-bed facility which opened in
1968 and has since had only minor facelifts, such as new doors
and fresh paint. The capabilities of the facility have largely
remained the same.
Additionally, further adding to the applause we should be
heaping upon our doctors and nurses is the fact that the
facility is drastically under-staffed, as getting qualified
medical personnel to the island has proven to be difficult, an
issue that I hope we can find a solution to through this
hearing and the work that will follow.
The American Samoa Government Operations account, which is
included in the annual Interior appropriations bill, provides
approximately $7 million annually for hospital operations. That
account not only funds a portion of the local hospital, but
also the local judiciary, the Department of Education and local
community college--originated in 1974 at an amount of
approximately $17 million, annually.
Since then, it has been increased only once, in 1986, to
$22.75 million a year, where it sits today. And if one were to
use the standard CPI formula, that amount would now be over $50
million annually. Again, the hospital's take from this
appropriation is approximately $7.5 million.
Compare that to any other facility of the same size here in
the states, and the gap in equity becomes very clear. For
example, this year's total budget for LBJ was about $51
million, while a hospital of the same size in Washington State
has a 2017 budget of roughly $200 million.
The people of American Samoa need better access to care
without having to take a flight. The fact is it is beyond time
for a significant increase to the account. The reasoning
provided in DOI's budget report for the lack of any increase to
the ASG operations account over the years is to promote self-
sufficiency on the island, which is all fine and well, but near
impossible when, at the same time, the Federal Government has
closed off large swaths of fishing grounds in the Pacific that
our people have used for a millennium, and long before any
relationship with the United States, and at the same time
imposed federally mandated minimum-wage laws, irresponsibly
putting the territory, which is both economically and
geographically isolated, on the same playing field as the
states.
Mr. LaMalfa. The gentlelady will have to come back to the
rest of your statement a little bit later. Our time has
expired.
Mrs. Radewagen. Thank you, Mr. Chairman. I yield back.
[The prepared statement of Mrs. Radewagen follows:]
Prepared Statement of the Hon. Aumua Amata Radewagen, a Delegate in
Congress from the Territory of American Samoa
Thank you Mr. Chairman. I thank my colleague for yielding her time.
I first want to thank you and the members of the Committee for
holding today's hearing. It has been a long time coming, and I am glad
to see us finally sitting down to tackle this issue that is so
important to my home district of American Samoa.
I also want to welcome our witnesses who have traveled halfway
around the world to be here including: Taufete'e John Faumuina, CEO and
Director of LBJ Tropical Medical Center; Dr. Reese Tuato'o, Chief of
Internal Medicine at LBJ; and Tofoitaufa Sandra Young, Medicaid
Director for the territory. Thank you all for being here today. Your
dedication to your work is appreciated.
This hearing is the result of the CODEL that traveled to American
Samoa in February, and I want to thank Chairman Bishop and those
Members who were able to join us. During the visit, the Members were
given a tour of LBJ Hospital, the only medical treatment facility on
the island. I want it in the record that our doctors and nurses who
work there do an excellent job with the limited resources they have
available, and they should be commended for their efforts to maintain
the good health of our people.
LBJ is a 150-bed facility which opened in 1968, and has since had
only minor facelifts, such as new doors and fresh paint. The
capabilities of the facility have largely remained the same.
Additionally, further adding to the applause we should be heaping upon
our doctors and nurses is the fact that the facility is drastically
under-staffed, as getting qualified medical personnel to the island has
proven to be difficult, an issue that I hope we can find a solution to
through this hearing and the work that will follow.
The American Samoa Government Operations account, which is included
in the annual Interior appropriations bill, provides approximately $7
million annually for hospital operations. That account not only funds a
portion of the local hospital, but also the local judiciary, the
Department of Education, and local community college--originated in
1974 at the amount of approximately $17 million annually. Since then,
it has been increased only once in 1986 to $22.75 million a year where
it sits today. If one were to use the standard CPI formula, that amount
would now be over $50 million annually. Again, the hospital's take from
this appropriation is approximately $7.5 million.
Compare that to another facility of the same size here in the
states, and the gap in equity becomes very clear. For example, this
year's total budget for LBJ was $51 million, while a hospital of the
same size in Washington State has a 2017 budget of roughly $200
million. The people of American Samoa need better access to care
without having to take a flight. The fact is, it is beyond time for a
significant increase to the account.
The reasoning provided in DOI's budget report for the lack of any
increase to the ASG operations account over the years is to ``promote
self-sufficiency'' on the island, which is all fine and well, but near
impossible when at the same time, the Federal Government has closed off
large swaths of fishing grounds in the Pacific that our people have
used for a millennium, and long before any relationship with the United
States, and at the same time imposed federally mandated minimum wage
laws, irresponsibly putting the territory, which is both economically
and geographically isolated, on the same playing field as the states--a
policy that has already forced one tuna cannery to leave the island for
Thailand where they pay their workers a mere fraction of what ours are
required to pay. I recently introduced legislation to resolve this
issue, H.R. 3021, the American Samoa Job Protection and Expansion Act,
and I look forward to seeing congressional action on it.
Regarding LBJ and any improvements to be made following
congressional action, I will be introducing a bill shortly that calls
for a GAO study in partnership with DOI, the VA and HHS to assess the
feasibility of either a new or updated facility, and I encourage my
colleagues to support the measure. It is high-time that we here in
Congress recognize the issues happening in the insular areas, and I am
encouraged by today's hearing and the action it will bring.
Again, I want to thank our witnesses for traveling so far to be
here today. I know that the work they do on the islands is
indispensable and I know that their testimony will provide even more
insight into the issues we are facing on the island in regards to
providing accessible and quality health care for our people. I look
forward to their testimony and moving forward with some real solutions
to improve the health care for the people of American Samoa.
Thank you Mr. Chairman, I yield back.
______
Mr. LaMalfa. Thank you. I would now like to recognize our
Ranking Member, Mr. Sablan.
STATEMENT OF THE HON. GREGORIO KILILI CAMACHO SABLAN, A
DELEGATE IN CONGRESS FROM THE TERRITORY OF THE NORTHERN MARIANA
ISLANDS
Mr. Sablan. Thank you very much, Mr. Chairman, for agreeing
to hold this important hearing. I welcome our witnesses,
particularly those who traveled from American Samoa.
I had the opportunity to visit the LBJ Tropical Medical
Center in American Samoa last year, led by Chairman Bishop and
hosted by my friend, Congresswoman Radewagen. We got a
firsthand look at the hospital, the deterioration of the
physical plant, the lack of equipment and supplies, the
difficulty of hiring and retaining staff. I look forward to
hearing what ideas our witnesses offer, particularly the Office
of Insular Affairs, on how we can make sure the people of
American Samoa get the health care that all Americans have the
right to and that all of us here in Congress enjoy.
But American Samoa is not the only insular area struggling
with health care. As recently as last December, officials at
the Centers for Medicare and Medicaid Services threatened to
decertify the Juan F. Luis Hospital and Medical Center in the
U.S. Virgin Islands, because the hospital failed to meet basic
Federal standards.
In my own district, the Northern Marianas, our only
hospital also faced CMS decertification in 2012. A team from
the U.S. Public Health Service and funding from other Federal
agencies came to the rescue and kept the hospital opened. But
to this day, the hospital has not met all of the standards
required to lift the threat of decertification.
And though the problems at the Marianas hospital were of
long standing, the real catalyst was the decision by the
Commonwealth government in 2008 to cut off funding and create a
quasi-independent Commonwealth Healthcare Corporation. The
corporation has struggled with the costs of delivering
healthcare services to the people of the Marianas. Half are
below the Federal poverty line and one-third have no health
insurance, so patients are often unable to pay for care.
The only reason the hospital has been able to remain open,
the corporation's Chief Executive Officer has said, is because
of the extra Medicaid money that was provided by Obamacare:
$109 million. As we all know, that extra money runs out at the
end of Fiscal Year 2019 or earlier, depending on whether the
Majority repeals Obamacare, as it has promised to do.
Mr. Chairman, 9 years ago the Inspector General of the
Department of the Interior issued a report entitled, ``Insular
Healthcare at the Crossroads to Total Breakdown.'' Insular
governments were unable to provide comprehensive healthcare
services to their citizens, the report stated, because of
shortages of supplies, medicines, specialty physicians, and
because of inadequate, antiquated, or damaged infrastructure.
Sadly, little has changed. This is why any replacement of
Obamacare, which the Majority has promised, must include the
U.S. insular areas. At a minimum, Medicaid must be available to
our areas in exactly the same way it is available to every part
of the country. Beyond that, the federally funded tax credits
that are being proposed in the Majority's Better Care Act, that
will provide help to individuals and families to buy private
insurance, must be available to Americans in American Samoa,
Guam, the Marianas, and the U.S. Virgin Islands.
The President has promised ``insurance for all.'' We are
all waiting.
I look forward to working with you, Mr. Chairman, and all
our colleagues, to fulfill the President's promise, and include
the people of the insular areas fully and equally in our
national healthcare programs.
Thank you, and I yield back.
[The prepared statement of Mr. Sablan follows:]
Prepared Statement of the Hon. Gregorio Kilili Camacho Sablan, a
Delegate in Congress from the Territory of the Northern Mariana Islands
Thank you, Mr. Chairman, for agreeing to hold this important
hearing. I welcome our witnesses, particularly those who traveled from
American Samoa.
I had the opportunity to visit the LBJ Tropical Medical Center in
American Samoa last year, led by Chairman Bishop and hosted by
Representative Radewagen. We got a firsthand look at the hospital--the
deterioration of the physical plant, the lack of equipment and
supplies, the difficulty of hiring and retaining staff.
I look forward to hearing what ideas our witnesses offer--
particularly the Office of Insular Affairs--on how we can make sure the
people of American Samoa get the health care that all Americans have a
right to and all of us here in Congress enjoy.
But American Samoa is not the only insular area struggling with
health care. As recently as last December, officials at the Centers for
Medicare and Medicaid Services threatened to decertify the Juan Luis
Hospital in the Virgin Islands, because the hospital failed to meet
basic Federal standards.
In my own district, the Marianas, our only hospital also faced
decertification in 2012. A team from the Public Health Service and
funding from other Federal agencies came to the rescue and kept the
hospital open. But, to this day, the hospital has not met all of the
standards required to lift the threat of decertification.
Though the problems at the Marianas hospital were of long-standing,
the real catalyst was the decision by the Commonwealth government in
2008 to cut off funding and create a quasi-independent Commonwealth
Healthcare Corporation. The Corporation has struggled to meet the costs
of delivering healthcare services to the people of the Marianas. Half
are below the Federal poverty line and one-third have no health
insurance. So, patients are often unable to pay for care.
The only reason the hospital has been able to remain open, the
Corporation's Chief Executive Officer has said, is because of the extra
Medicaid money that was provided by Obamacare--$109 million. As we all
know, that extra money runs out at the end of Fiscal Year 2019--or
earlier depending on whether the Majority repeals Obamacare, as it has
promised to do.
Mr. Chairman, 10 years ago the Inspector General of the Department
of the Interior issued a report entitled: Insular Health Care ``at the
crossroads to total breakdown.'' Insular governments were unable to
provide comprehensive healthcare services to their citizens, the report
stated, because of shortages of supplies, medicines and specialty
physicians, and because of inadequate, antiquated or damaged
infrastructure. Sadly, little has changed.
This is why any replacement of Obamacare, which the Majority has
promised, must include the U.S. insular areas. At a minimum, Medicaid
must be available to our areas in exactly the same way it is available
to every other part of our country.
Beyond that, the federally-funded tax credits that are being
proposed in the Majority's Better Care Act--that will provide help to
individuals and families to buy private insurance--must be available to
Americans in American Samoa, Guam, the Marianas, and the Virgin
Islands.
The President has promised ``insurance for all.'' We are all
waiting.
I look forward to working with you, Mr. Chairman and our other
colleagues, to fulfill the President's promise and include the people
of the insular areas fully and equally in our national healthcare
programs. Thank you.
______
Mr. LaMalfa. Thank you, Mr. Sablan. Again, I want to thank
the witnesses who have made the 7,000-mile journey that you did
to be here today and provide their expertise. So, let me
introduce them.
We have Mr. Thomas Bussanich, Director of Budget at the
Office of Insular Affairs, Department of the Interior; Mr.
Taufete'e Faumuina, CEO of the Lyndon B. Johnson Tropical
Medical Center; and Sandra King Young, a Medicaid Director,
American Samoa Medicaid Agency, from the Office of the
Governor.
Let me remind our witnesses that under our Committee Rules,
they must have their oral statements limited to 5 minutes, but
their entire written statement will appear in the hearing
record.
Microphones are not automatic, you have to press the button
to begin. The light will then turn green. When it turns yellow,
you have 1 minute to go. When it is red, you know what that
means, I ask you to complete your statement at that point.
I will also allow the entire panel to testify before
questioning by our panel up here.
The Chair will now recognize Mr. Bussanich to testify.
You have 5 minutes.
STATEMENT OF THOMAS BUSSANICH, DIRECTOR OF BUDGET, OFFICE OF
INSULAR AFFAIRS, DEPARTMENT OF THE INTERIOR, WASHINGTON, DC
Mr. Bussanich. Mr. Chairman and members of the
Subcommittee, thank you for the opportunity to speak regarding
the LBJ Tropical Medical Center, the primary healthcare
facility in American Samoa.
The Office of Insular Affairs has been a partner with the
American Samoa government for many years, providing
supplemental funding for the operations and renovation of the
hospital that was beyond the capacity of the local community.
The American Samoa government is a recipient of the
significant share of the annual $27.7 million in capital
infrastructure funding available from the Office of Insular
Affairs. Historically, American Samoa has received at least
one-third of the money in infrastructure funds set aside for
the four flag territories.
For the American Samoa government, the allocation of its
capital funds is conditioned on submission of 5-year capital
improvement plans that outline local priorities for capital
spending. For many years, American Samoa's top priority was
health. And, therefore, the LBJ Tropical Medical Center
received large shares of capital spending.
In the 5-year CIP plan for 2016 through 2020, priorities
changed due to the fragility of the territory's main industry,
tuna canning. The new 5-year plan elevates economic development
to priority number one, and education to number two. Health is
bumped to number three. The allocation decisions are made by
the American Samoa government and are not set by the Office of
Insular Affairs.
The LBJ Tropical Medical Center was constructed in the
1960s. During the past 15 years, CIP funding has been used to
renovate much of the hospital to bring it into compliance with
modern hospital standards. Currently, the labor, delivery, and
surgical wings are under major renovation and expansion.
Construction is ongoing, and when the renovation project is
completed in 2020, approximately 60 percent of the hospital's
physical plant will count as having been rebuilt.
The Office of Insular Affairs also provides operational
funding for the LBJ Hospital from the annual American Samoa
operations grant. In the current fiscal year, the grant totals
$22.7 million. The actual use of the grant is proposed by the
American Samoa government, which is using $7.9 million to
support LBJ in this fiscal year. The remainder of the grant is
used to support general education--$11.4 million; the community
college at $1.4 million; and the high court, at $900,000.
Over the past 15 years, the Office of Insular Affairs has
provided $132 million in operations funding and $30 million in
CIP funding for the LBJ Tropical Medical Center. The Department
of the Interior is proud to have been a partner with the
American Samoa government in improving LBJ Tropical Medical
Center. There is a great deal that still needs to be done, and
we look forward to continuing to work to improve conditions and
serve the people of American Samoa. Thank you.
[The prepared statement of Mr. Bussanich follows:]
Prepared Statement of Thomas Bussanich, Director of Budget, Office of
Insular Affairs, Department of the Interior
assessing current conditions and challenges at the lbj tropical medical
center in american samoa
Chairman LaMalfa, Ranking Member Torres and members of the
Subcommittee on Indian, Insular and Alaska Native Affairs, thank you
for the opportunity to speak regarding the LBJ Tropical Medical Center
in American Samoa.
The LBJ Tropical Medical Center is the primary healthcare facility
in American Samoa. The Office of Insular Affairs (OIA) has been a
partner with the American Samoa government for many years, providing
supplemental funding for the operations and renovation of the hospital
that was beyond the capacity of the local community. Although health
care is not a primary function of OIA, our broad authorities make it
possible to provide assistance in American Samoa.
In recent years, the primary goals of OIA has been to ``Create
Economic Opportunity,'' ``Improve the Quality of Life,'' and ``Promote
Efficient and Effective Governance'' in the U.S. insular areas. Our
assistance for the LBJ hospital is in accord with these goals, as we
provide both operational funding and capital improvement funding to
help improve health care for the American Samoa community.
capital improvements
American Samoa Government (ASG) is a recipient of a significant
share of the annual mandatory $27.72 million in capital infrastructure
funding available from the Office of Insular Affairs. Historically,
American Samoa has received at least one-third of the $27.72 million in
infrastructure funds set aside for the four smaller territories.
2012 $10,089,000
2013 $9,964,000
2014 $10,047,000
2015 $9,297,000
2016 $9,505,000
2017 $9,613,000
2018 (request) $10,321,000
For the ASG, its allocation of capital improvement funds is
conditioned on submission of 5-year capital improvement project (CIP)
plans that outline local priorities for capital spending. For many
years, American Samoa's top priority was health and therefore the LBJ
Tropical Medical Center received larger shares of capital spending.
Normally, between 15 and 24 percent of American Samoa's Federal capital
improvement allotment have been devoted to phased construction at the
LBJ hospital. In the 5-year CIP plan for 2016 through 2020, ASG
priorities changed due to the fragility of the territory's main
industry, tuna canning. The new 5-year plan elevates economic
development to priority Number one and education to Number two. Health
was bumped to Number three. The allocation decisions are made by the
American Samoa government and are not set by the Office of Insular
Affairs.
The LBJ Tropical Medical Center was constructed in the 1960s.
During the past 15 years CIP funding has been used to renovate much of
the hospital to bring it into compliance with modern hospital
standards. Currently, the labor, delivery and surgical wings are under
major renovation and expansion. Construction is ongoing, and when the
renovation project is completed in 2020, approximately 60 percent of
the hospital's physical plant will count as having been rebuilt.
The Office of Insular Affairs also provides operational funding for
the LBJ hospital from the annual American Samoa Operations Grant. In
the current fiscal year, the grant totals $22.75 million. The actual
use of the grant is proposed by the ASG, which is using $7.9 million to
support LBJ in Fiscal Year 2017. The remainder of the grant is used to
support general education ($11.4 M), the community college ($1.4 M),
and the High Court ($.9 M).
For a quick look at both operations and CIP spending over the past
15 years, please see below. It shows that the Office Insular Affairs
has provided $132 million in operations funding and $30 million in CIP
funding for the LBJ Tropical Medical Center in American Samoa.
------------------------------------------------------------------------
Operations CIP Funding to
Fiscal Year Funding to LBJ Fiscal Year LBJ
------------------------------------------------------------------------
2003 $7,721,000 2003 $1,710,000
2004 $7,675,938 2004 $2,000,000
2005 $7,664,000 2005 $1,545,000
2006 $13,264,000 2006 $1,800,000
2007 $13,264,000 2007 $1,736,842
2008 $13,039,906 2008 $1,902,684
2009 $7,652,000 2009 $1,473,684
2010 $7,657,000 2010 $2,000,000
2011 $7,642,000 2011 $7,094,737
2012 $7,645,000 2012 $1,368,421
2013 $7,657,000 2013 $2,631,579
2014 $7,900,000 2014 $2,632,000
2015 $7,900,000 2015 $168,421
2016 $7,900,000 2016 $1,789,474
2017 $7,900,000 2017 TBD
------------------------------------------------------------------------
TOTAL $132,481,844 TOTAL $29,852,842
------------------------------------------------------------------------
The Department of the Interior is proud to have been a partner with
the American Samoa government in improving the LBJ Tropical Medical
Center. There is a great deal that still needs to be done and we look
forward to continuing the work to improve conditions and serve the
people of American Samoa.
______
Questions Submitted for the Record by Rep. Sablan to Thomas Bussanich,
Director of Budget, Office of Insular Affairs, Department of the
Interior
Question 1. Director Bussanich, as you know, Section 2005 of the
Affordable Care Act provided a total of $6.3 billion in additional
Federal funds to the territories. These funds were primarily used to
augment the islands already meager Medicaid programs. Unfortunately,
because the funding for the ACA was for budgetary reasons, only for a
10-year window, the additional Medicaid funding will expire in 2019.
Has OIA (Office of Insular Affairs) or the IGIA (Interagency Group
on Insular Areas)--to your knowledge--been working with the Insular
Areas and their representatives on a strategy for getting these funds
extended? We know that there is a great deal of focus on the impact
that the loss of these funds would have on Puerto Rico because of the
affect it will have on their ability to successfully address their debt
crisis--but it is no less of a big deal for the other islands as well.
Answer. Office ofInsular Affairs (OIA) officials have regularly
discussed the healthcare challenges facing U.S. territories with the
leadership of the insular areas, as well as within the Interagency
Group on Insular Areas. OIA is aware of the shortage of resources for
health care in the territories and would like to find a workable
solution to address the growing healthcare needs of the territories.
OIA continues to reach out and work with our colleagues at the
Department of Health and Human Services (HHS), as the lead agency
responsible for administering the Medicaid program, and will continue
to work with HHS in a cooperative manner to reflect the priorities and
needs of the territories.
Question 2. According to your statement, the LBJ Medical Center has
received almost $30 million in CIP funding from OIA since 2003. Broadly
speaking, can you tell us what these have primarily been used for?
Answer. Please see the following listing of Capital Improvement
Project grants relating to the LBJ Hospital.
*****
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. LaMalfa. Thank you.
The Chair will now recognize Mr. Faumuina to testify.
STATEMENT OF TAUFETE'E JOHN FAUMUINA, CEO-DIRECTOR, LYNDON B.
JOHNSON TROPICAL MEDICAL CENTER, FAGA'ALU, AMERICAN SAMOA
Mr. Faumuina. Thank you for the opportunity to provide
testimony on assessing current conditions and challenges at the
Lyndon B. Johnson Tropical Medical Center in American Samoa. I
am Taufete'e John Faumuina, the Chief Executive Officer of the
LBJ Tropical Medical Center. I would like to also thank the
congressional delegation, CODEL, who visited American Samoa
earlier this year, and had the chance to tour our hospital
facility.
In 1968, LBJ opened its doors to provide patient-focused,
comprehensive, high-quality, and cost-effective health care and
related services that addressed the health needs of the people.
LBJ is the sole hospital providing tertiary services to all of
American Samoa, with a population over 60,000. In order for LBJ
to keep its doors open, we need to retain Medicare
certification through CMS. We must comply to the conditions of
participation.
My testimony will focus this morning on four main areas of
the challenges and needs of our hospital.
First, compliance with CMS standards. LBJ needs to adopt a
suitable budget to address all non-compliance issues pertaining
to medical staffing, nursing staffing, ancillary services, and
supporting services across the board to meet the standard of
care. The need to comply comes with substantial financial
commitment, offer better compensations to recruit qualified
doctors, nurses, certified technicians, and supporting staff,
assign appropriate budget to properly provide maintenance for
the aging facility, and schedule preventative maintenance and
repairs for all equipment.
Second, staffing inequities and workforce development. With
LBJ's 150 beds, we require 95 physicians; we only have 57. We
are required to have 110 RNs; we only have 73. We are required
to have 11 pharmacists; we only have 3. With the radiology
department, we must contract off island services to read our
diagnostics. We do not have a permanent radiologist. We also
contract a nephrologist who visits American Samoa quarterly to
treat the 167 patients with 36 staff to handle a workload of
1,900 treatments per month.
Third, our healthcare facilities. We have struggled to
upkeep the aging facility, acquire new equipment, and to
provide continuous preventative maintenance and repairs. We are
grateful for the CIP funding from DOI that has allowed LBJ to
conduct minor and major renovations to address CMS
infrastructure citations.
Presently, 41 percent of the facility has been renovated to
meet CMS standards. Upon completion of the current labor/
delivery nursery expansion and renovation project, our facility
will be 65 percent renovated. We continue to face the challenge
of increased outpatient visits and high inpatient census. One
of the solutions that we are presently exploring is a new 200-
bed hospital to accommodate increase in population, as well as
inpatient and outpatient visits. Space in the present location
is severely limited, and we are unable to expand the existing
building which, in turn, limits services.
And fourth, our financial conditions--our annual budget
appropriations are quite inadequate. We need to increase
Federal appropriations, explore other revenue sources, lifting
the cap on Medicaid, restructure FMAP percentage favorable to
American Samoa, and extend the expiration of the ACA funds
beyond 2019.
We want to thank you for this rare opportunity given to us.
We are humbled and extremely grateful to be able to share our
challenges and needs with this honorable Subcommittee. And we
hope for your favorable considerations to agree to fund a new
hospital that will meet all quality of care. [Speaking native
language.]
[The prepared statement of Mr. Faumuina follows:]
Prepared Statement of Taufete'e John P. Faumuina, Chief Executive
Officer, Lyndon B. Johnson Tropical Medical Center
Mr. Chairman and members of the Subcommittee on Indian, Insular and
Alaska Native Affairs,
Talofa lava ma fa'afetai lava. Thank you for the opportunity to
provide testimony on, ``Assessing Current Conditions and Challenges at
the Lyndon B. Johnson Tropical Medical Center in American Samoa.''
I am Taufete'e John Faumuina. I am the Chief Executive Officer
(CEO) of the American Samoa Medical Center Authority doing business as
Lyndon B. Johnson Tropical Medical Center (LBJTMC) in the U.S.
Territory of American Samoa.
I would like to thank the Congress Delegates (CODEL) who visited
American Samoa earlier this year and had the chance to tour our
hospital facility. They dialogued with our staff about the limitations,
woes and tribulations we face in providing quality and safe patient
care to the people of our islands.
In 1968, LBJ opened its doors to provide patient focused,
comprehensive, high quality, and cost effective health care and related
services that address the health needs of the people. LBJ is the sole
hospital providing tertiary services to all of American Samoa with a
population over 60,000. In order for LBJ to keep its doors open we need
to retain Medicare certification through the Centers for Medicare &
Medicaid Services (CMS), we must comply with the Conditions of
Participations.
My testimony will focus on four main areas of the challenges and
needs of our hospital.
challenges
Compliance with CMS Standards
LBJ needs to adopt a suitable budget to address all
noncompliance issues pertaining to medical staffing,
nursing staffing, ancillary services and supporting
services across the board to meet the standard of care. The
need to comply comes with substantial financial commitment,
offer better compensations to recruit qualified Doctors,
Nurses, Certified Technicians and supporting staff. Assign
appropriate budget to properly provide maintenance for the
aging facility and scheduled preventative maintenance and
repairs for all equipment. For the record, LBJ is currently
operating under a $50 million budget to sustain and provide
the best health care for the people of American Samoa.
Staffing Inequities and Workforce Development
With LBJ's 147 beds, we require 95 physicians, we only
have 57. We are required to have 110 RNs, we only have 73.
We are required to have 11 pharmacists, but we only have 3.
With the radiology department, we must contract off-island
services to read our diagnostics. We do not have a
permanent radiologist.
We also contract a nephrologist who visits American Samoa
quarterly to treat the 167 patients with 36 staff to handle
a workload of 1,900 treatments per month.
Healthcare Facilities
Struggle to upkeep aging facility and acquire new
equipment and to provide continuous preventative
maintenance and repairs.
We are grateful for the CIP funding from DOI that has
allowed LBJ to conduct minor and major renovations, to
address CMS infrastructure citations. The laboratory was
expanded and renovated to provide proper space for new
diagnostic lab equipment to accommodate the increase types
of testing for patient care. The Diagnostic Imaging-
Radiology Department was expanded and renovated to house
more modern equipment such as the radiographic x-ray
machines, CT scans, C-arm X-rays, portable x-rays, etc.
Presently, 41 percent of the facility has been renovated
to meet CMS standards. Upon completion of the current
Labor/Delivery Nursery expansion and renovation project,
our facility will be 65 percent renovated.
With the completed expansion and extensions of existing
infrastructure, we are still struggling to cut down on
patient waiting time in ER and Clinical Services because of
the overwhelming number of patient visits, with ER seeing
an average of over 2,500 visits per month. Patient
admission process is also delayed due to overflow and non-
availability of beds in the wards because of constant high
census.
One of the solutions that we are presently exploring is a
new 200-bed hospital to accommodate increase in population,
as well as inpatient and outpatient visits. Space in the
present location is severely limited, and we are unable to
expand the existing building which in turn limits services.
Financials
Annual Budget--Inadequate appropriation
-- Increased Federal appropriation
-- Explore other revenue sources
Lifting the cap on Medicaid
Restructure FMAP percentage favorable to American Samoa
Extend the expiration of ACA funds
conclusion
We want to thank you for this rare opportunity given to us. We are
humbled and extremely grateful to be able to share our challenges and
needs with this honorable Subcommittee, and we hope for your favorable
consideration to our plea to fund a new hospital that will meet all
quality of care.
Faafetai ma le faaaloalo lava. SOIFUA!
______
Questions Submitted for the Record by Rep. Sablan to Taufete'e John
Faumuina, CEO-Director, Lyndon B. Johnson Tropical Medical Center
Question 1. LBJ hospital is subject to certain standards and
regulations mandated by CMS, the Centers for Medicare and Medicaid
Services. You mentioned that ``these Federal mandates place constraints
and difficulties'' on your operations, even though you welcome CMS'
participation. Can you elaborate on those constraints? What are your
biggest obstacle to addressing them--is it adequate funding?
Answer. The Lyndon B. Johnson Tropical Medical Center (LBJTMC) in
American Samoa presently and continuously embraces CMS' Conditions of
Participation (CoP) for our hospital to retain its eligibility for
Medicare certification. To receive Medicare/Medicaid payment, hospitals
are required to be in compliance with the Federal requirements set
forth in the Medicare CoP. As the sole hospital in American Samoa,
without this Medicare certification to operate, LBJTMC will not be able
to fulfill its critical role in providing access to essential acute
care services to the residents of American Samoa. Although we continue
to face obstacles, difficulties and constraints meeting the CoPs set
forth by CMS, but these requirements are what improve our standards of
practice and allow us to offer quality and safe patient care to our
people. We recognize the value as recipients of CMS.
I will elaborate more on some of the constraints and difficulties
on the operation of our hospital. Please note the following four main
areas of my written testimony from the July 25, 2017 hearing:
1. Compliance with CMS Standards
2. Staffing Inequities and Workforce Development
3. Healthcare Facilities
4. Financials
1. COMPLIANCE WITH CMS STANDARDS
Over the years, LBJ has faced continuous difficulties to be compliant
with the requirements as a provider of services with the Medicare
Program established under Title XVIII of the Social Security Act.
However, we will continue to strive toward improvement as required by
CMS CoPs. In the last year, the recent challenges we have faced with
compliance are:
In June 2014, we were documented non-compliance with nine
(9) CoPs.
A Medicare revisit survey on December 2015, documented
nine (9) non-compliance CoPs.
During our last revisit survey on January 27, 2017, with
financial reserve and resources committed into operations,
CMS identified six (6) areas of substantial non-compliance
for LBJ. These deficiencies have an impact on the integral
function of the four main areas identified in our written
testimony.
2. STAFFING INEQUITIES AND WORKFORCE DEVELOPMENT
For staffing, human resources and workforce development, adequate
staffing is required as part of CMS CoPs, yet we continue to experience
staff shortages hospital-wide due to various reasons. Some causes for
this inadequacy of staffing are: our inability to offer competitive
salaries; our isolated and geographical location; our ability to
recruit and retain; or lack of local pool of qualified, certified or
credentialed prospects in American Samoa. The following critical areas
continue to be a challenge to employ such as, but not limited to:
Medical Staff
-- On-site Radiologist
-- Nephrologists
-- Physicians
Nursing Department/Patient Care
-- Advanced Practice Nurses
-- Anesthetist Nurses
Ancillary
-- Respiratory Therapist
-- Occupational/Physical Therapist
-- Registered Dietitian
-- Medical Laboratory Technologist
Other professionals such as:
-- Infection Preventionist
-- Health Information Technologist
-- Bio-med Technicians
3. HEALTHCARE FACILITIES
As you may recall, this hospital was built in 1968 without the
specification or mandates to meet CMS standards and life safety codes.
While most hospitals in the United States currently have an ``average
age of plant,'' of just less than eleven (11) years, LBJTMC is well
over 50 years old. The routine and preventive maintenance; safety and
testing activities are all part of CoPs for CMS. Maintaining the
hospital throughout the years has been extremely costly.
Although considered modern and state-of-the art at the time it was
built, LBJ was not envisioned and constructed with CMS standards. As a
result, it has become extremely costly to be in compliance with CMS
Conditions of Participation. Therefore, understandably, to continue to
provide quality healthcare services and be in compliance with CMS, a
new hospital would be the most cost effective solution. CoP also
requires that the LBJ hospital be constructed, arranged and maintained
to ensure the safety of the patient and quality of care.
4. FINANCIALS
As depicted in our testimony, one of our continuous challenges and
biggest obstacle in addressing our difficulties and constraints is
funding. Many of the CMS CoPs require constant upgrades of facilities,
increase of medical services, costs of resources to recruit and retain
qualified professionals and overall hospital operations which all
require financial support.
Question 2. You mentioned that 35 percent of your pharmaceutical
budget is for dialysis medications. What is the percentage of your
overall budget is for medications? And, since American Samoa is outside
the customs area of the United States are you able to purchase drugs
internationally, which should provide savings over U.S. sourced drugs?
Answer. The hospital's budget for FY2016 was $46 million. The LBJ
pharmacy's pharmaceutical budget for FY2016 was $5.9 million which is
approximately 12 percent of the overall hospital budget. In our report,
35 percent or approximately $2.06 million of pharmaceutical budget was
spent for our dialysis population in FY2016.
Although, American Samoa is outside of the U.S. customs area, we
cannot purchase pharmaceutical drugs internationally or from foreign
manufacturers as LBJTMC is regulated by the Centers of Medicaid and
Medicare (CMS). The LBJ pharmacy accesses the VA Federal Supply
Schedule (FSS) and PRxO Generic (Pharmacy Prescription Generic
Contract) contract pricing with our pharmaceutical vendor,
AmerisourceBergen Wholesaler (ABC), a U.S. distributor. By using the
FSS program, which is available to Federal and state government, we are
able to procure our pharmaceutical products at a lower cost and
affordability therefore providing savings and best value for our
dollars.
Also, we reached out to the pharmacy department at the Commonwealth
Healthcare Corp (CHCC), Commonwealth of Northern Marianas Islands
(CNMI) hospital to explore opportunities we could share as U.S.
territories. Yet, we learned that we face similar deficiencies in
meeting CMS mandates and difficulties in procuring and maintaining an
inventory level especially with drugs listed on the national shortage.
Furthermore, as regulated by CMS, all of CNMI's pharmaceuticals have to
meet FDA rules and they also procure their drugs through Mckesson
Wholesaler, a U.S. distributor.
As mentioned above, LBJTMC is regulated by the Centers for Medicaid
and Medicare (CMS) and only FDA-approved medications are eligible for
reimbursements. For patient safety, FDA's current position on the
importation of prescription drugs from foreign entities or unknown
sources cannot ensure the safety and effectiveness of products. These
unknowns put patient's health at risk if they cannot be sure of the
products identity, purity and source, therefore, FDA recommends ONLY
obtaining medicines from legal sources in the United States. Drugs sold
in the United States also must have proper labeling that conforms to
the FDA's requirements, and must be made in accordance with good
manufacturing practices. As part of the FDA's high standards, drugs can
be manufactured only at plants registered with the agency, whether
those facilities are domestic or foreign. If a foreign firm is listed
as a manufacturer or supplier of a drug's ingredient on a new drug
application, the FDA generally travels to that site to inspect it.
Here are some of the additional reasons why we cannot purchase from
international manufacturers:
1. LBJ participates in the Medicaid Drug Rebate Program to help
subsidize the cost of medication for the territory. This
program includes CMS, State Medicaid Agencies and
participating drug manufacturers that help to offset the
Federal and state costs of most outpatient prescription
drugs dispensed to Medicaid patients.
Approximately 600 drug manufacturers participate
in this program (all U.S.-based drug companies).
Only FDA-approved medications are eligible for
the Federal Medicaid drug rebate reimbursement program.
2. Benefits of a Closed System
Under the Food Drug & Cosmetic (FD&C) Act, the
interstate shipment of any prescription drug that lacks
required FDA approval is illegal. Interstate shipment includes
importation--bringing drugs from a foreign country into the
United States.
3. FDB (first databank) provides patient safety medication for FDA-
approved medications ONLY
Hospital advantage with offered programs
including drug-drug interactions, drug-allergy, drug-disease
interactions and duplicate therapy flags.
Electronic Health Record and prescription labels
are linked with FDB to incorporate all essential medication
information for both patients and health professionals alike.
4. Early 2017--Drug Importation Bill being proposed to allow U.S.
pharmacies to purchase medications from Canada (see details
below)--has not passed yet, and when it does, it will
definitely provide another avenue to procure medication if
it is cost-effective.
The Affordable and Safe Prescription Drug
Importation Act would instruct the Secretary of Health and
Human Services, within 180 days after enactment of this Act, to
issue regulations allowing wholesalers, licensed U.S.
pharmacies, and individuals to import qualifying prescription
drugs manufactured at FDA-inspected facilities from licensed
Canadian sellers. After 2 years, the Secretary would have the
authority to permit importation from countries in the
Organization for Economic Co-operation and Development (OECD)
that meet specified statutory or regulatory standards that are
comparable to U.S. standards.
Question 3. You indicate that the LBJ pharmacy is constantly faced
with severe shortages of critical drugs and that because LBJ is the
only hospital in American Samoa; you do not have the capability of
reaching out to another facility to procure or acquire essential
lifesaving drugs. What about the America Samoa VA clinic named after
our former colleague Eni Faleomavaega? Do they have a pharmacy on site
that you can utilize to obtain critical drugs?
Answer. This option has been already been explored by LBJ Pharmacy.
At present, the Faleomavaega Fa'aua'a Hunkin Clinic does not have a
pharmacy on site. The essential lifesaving drugs mentioned in our July
25, 2017, written response are the critical medications used in our
hospital and intensive care units for patients who are in their
critical stages and on life sustaining measures.
On the VA Pacific Island Health Care System website, the
``Faleomavaega Fa'aua'a Hunkin Community Based Outpatient Clinic in
American Samoa is to provide primary health care to eligible veterans.
It is a non-emergent care for veterans with stable chronic health
problems or minor acute illnesses. It is NOT equipped to provide
emergency services, and veterans shall seek treatment to Lyndon B.
Johnson Medical Center for emergency services.''
The clinic ONLY stocks emergency medications in their crash carts
to use in emergency resuscitations for life support. All of the
military retirees and veterans' pharmaceutical needs and their
prescriptions are sent from the VA hospital in Honolulu, Hawaii.
Question 4. What will it mean for LBJ if Congress does not to
extend the 2019 ACA funds?
Answer. At the current LBJ expenditure rate for Medicaid services,
we are only able to tap into ACA funds by the third quarter of the
fiscal year. A new Medicaid methodology for the reimbursement model
process may be an immediate option to assist LBJ and an extension of
the ACA 2019 expiration date. Our current Medicaid state plan
methodology severely limits our ability to exhaust ACA funds.
If the U.S. Congress does not extend the 2019 Affordable Care Act
(ACA) funds expiration date, American Samoa stands the chance to lose
out on optimizing opportunities to assist with a healthcare safety net
to:
1. Insure the medically vulnerable people of American Samoa's low-
income adults and children;
2. To fund long-term services and support for adults and children
with serious disabilities or illnesses who are at risk of
impoverishment as a result of their health.
______
Mr. LaMalfa. Thank you, Mr. Faumuina.
Let's now recognize Ms. Young for 5 minutes.
Thank you.
STATEMENT OF SANDRA KING YOUNG, MEDICAID DIRECTOR, AMERICAN
SAMOA MEDICAID AGENCY, OFFICE OF THE GOVERNOR, PAGO PAGO,
AMERICAN SAMOA
Ms. Young. Thank you.
[Speaking native language]
Chairman LaMalfa, Ranking Member Sablan, and members of the
Committee. Thank you for the opportunity to present testimony
regarding the LBJ Hospital and the role the American Samoa
Medicaid program plays in our healthcare system.
Medicaid is a very complicated Federal-State program, as it
is administered in American Samoa. The American Samoa Medicaid
program has remained unchanged, in terms of provider
eligibility and coverage, over its 35-year history, until the
Lolo administration.
Unlike other states and territories, Medicaid is the only
publicly available health insurance provider in our territory.
And the LBJ Hospital has been the only Medicaid provider until
this year.
Because Medicaid is a state-specific health plan, once we
leave our territory we are no longer covered with a health
insurance plan, should any medical emergency befall us, like
when we are here for this hearing in DC.
As the Medicaid Director, my responsibility is to ensure
that our Medicaid beneficiaries, the people of American Samoa,
have access to medical services, as required under the Social
Security Act. When it comes to challenges that our hospital
faces, the Medicaid agency is most concerned about the
hospital's compliance with the Centers for Medicare and
Medicaid Services, conditions of participation, and compliance
under the American Samoa Medicaid State Plan.
Non-compliance puts at risk Medicare and Medicaid funding
for the LBJ Hospital. The biggest help that LBJ needs to ensure
compliance is the construction of a new hospital. Thus, we
respectfully recommend that the Committee should introduce
authorizing legislation to provide funding for the construction
of a new hospital for American Samoa.
American Samoa has already secured a potential site for
this construction. The LBJ Hospital is a 50-year-old facility,
and it sustained major damage in a 2009 earthquake and tsunami.
While the facility was repaired after the tsunami, the hospital
continues to struggle with infrastructure standards to maintain
CMS certification. It would be more cost-effective to replace
the current facility so that it meets the modern standards for
CMS conditions of participation under a new hospital facility.
In terms of Medicaid funding, the priority of the Lolo
administration and of the territory is to maintain the Medicaid
revenue stream that helps support the LBJ and our entire
healthcare system. Prior to the passage of the Affordable Care
Act in 2011, the LBJ Hospital was insolvent and continually
went into debt to keep the hospital in operation and maintain
needed medical services.
The Medicaid funds under ACA helped to fully fund the
Federal share of the Medicaid program. But, unfortunately, the
expiration of these funds in 2019 weighs heavily over the
territory. The American Samoa Medicaid Agency spent the last 3
years working with CMS to amend our state Medicaid plan to
expand our Medicaid provider network. This year we received
approval to make the federally qualified health centers a
provider, and to enable the off-island medical referral
services to be re-instated directly with off-island providers
through our agency.
Access to the ACA Medicaid funds is critical to fully
implement the Medicaid state plan. If the time to expand the
Medicaid funds provided for in the ACA is not extended, this
would cripple our LBJ Hospital and the rest of our healthcare
system, potentially forcing the territory to cut or suspend
medical services all together.
Looking long-term, after ACA funds are expended, it is
necessary to increase the annual Medicaid block grant for
American Samoa in order to adequately sustain the provision of
medical services, as required under the Social Security Act.
Thank you again for this auspicious opportunity to testify,
and I am happy to take questions from the Committee.
[The prepared statement of Ms. Young follows:]
Prepared Statement of Sandra King Young, American Samoa Medicaid
Director
Chairman LaMalfa, Ranking Member Torres and members of the
Subcommittee, on behalf of American Samoa, I am honored to present
testimony regarding our unique Medicaid program. Thank you for this
prodigious opportunity to share with you the unique features of the
Medicaid program in American Samoa.
American Samoa was granted a 1902(j) waiver in 1983 to administer a
Presumptive Eligibility model for the Medicaid Program. Under this
waiver, American Samoa is the only U.S. jurisdiction where there is no
eligibility and enrollment of individual beneficiaries. Beneficiaries
are presumed eligible for Medicaid if they fall within the 200 percent
U.S. Federal poverty level.
In terms of Medicaid funds and its relation to LBJ hospital, the
priority of the Lolo administration and of the territory, is to
maintain the Medicaid revenue stream that helps support the LBJ and our
whole healthcare system. First, the deadline to expend the Medicaid
funds under ACA must be extended to allow American Samoa to increase
access to medical services for beneficiaries. Second, we must have an
increase of $15 million a year in the regular Medicaid block grant
funds under the Social Security Act regardless of what happens to the
ACA Medicaid funds. This will allow the Medicaid agency to adequately
fund the needs of the American Samoa Medicaid program and avert the
reduction or suspension of medical care services. If ACA is repealed or
replaced without this increase in the regular Medicaid grant, the
consequences would be devastating to the local government and our local
economy, but most of all, it will cripple the LBJ hospital and our
healthcare system so as to deny access to medical care for our people.
One of the most significant challenges that the hospital faces is
the chronic deficiencies with CMS Survey and Certification putting at
risk its Medicare and Medicaid funding. The LBJ hospital was built in
1968 and is located in a tsunami zone and sustained major damage during
the 2009 tsunami. American Samoa needs a modern hospital outside of the
tsunami zone. Continuing to do band aid solutions to renovate the 50-
year old LBJ hospital is not cost effective. American Samoa needs from
Congress an appropriation of $200 million for a state-of-the-art
hospital that would be fully compliant with Medicare Conditions of
Participation and CMS standards for infrastructure.
The Lyndon B. Johnson Tropical Medical Center has been the only
Medicaid provider on island, until February 2017 when the American
Samoa Department of Health's Federally Qualified Health Center (FQHC)
became the second Medicaid provider in the 35-year history of the
program. The 1902(j) waiver under the Social Security Act gives the
American Samoa Medicaid agency flexibility to waive Federal regulations
that are inappropriate and not relevant for its small Medicaid program.
It however, cannot waive three things: (1) the Medicaid cap funding,
(2) the Federal Medicaid Assistance Percentages (FMAP) for local and
Federal match requirements, and (3) the mandatory health services
required under the Social Security Act. All three of these provisions
create inconsistent Federal objectives because (1) and (2) limit
funding for American Samoa thus making number (3) unachievable. In
essence, number (3) becomes an unfunded mandate that the American Samoa
Medicaid program cannot comply with because of inadequate funding.
Unlike the states unlimited access to Medicaid funds, American Samoa
and the territories Medicaid programs operate as a capped block grant.
Further, the FMAP percentage match rate was imposed arbitrarily on all
five U.S. territories--45 percent local/55 percent Federal--and
equivalent to the matching rates of wealthy states like California and
Connecticut. By the third quarter of the fiscal year, American Samoa
generally exhausts the territory's regular Medicaid funds under the
Social Security Act.
The passage of the Affordable Care Act in 2011 provided an
additional $181 million in Medicaid funding for American Samoa plus an
additional $16 million intended for an insurance marketplace. American
Samoa was not able to establish an insurance marketplace because it
does not have health insurance providers on the island--except for
Medicaid. The $16 million was added to the ACA Medicaid funds for a
total of $197 million for American Samoa. The territory benefited from
the additional Medicaid funds and the shortfall of the regular annual
Medicaid block grant was now covered by the ACA Medicaid funds.
Unfortunately, the 2019 deadline to expend the ACA Medicaid funds was
not rationale. The ACA was passed with no input from American Samoa,
for us to explain that simply setting aside so much Medicaid funds with
a deadline for expenditure by 2019 was not logical, as American Samoa
only had one Medicaid provider. The LBJ provides limited medical
services to a small population. Like any health insurance plan,
Medicaid can only reimburse for allowable medical expenses that are
actually incurred by patients seeking treatment at a hospital. Since
ACA, the LBJ hospital remains the only provider on island that can
expend Medicaid dollars, until our local government can appropriate
local funds for our new providers.
The Medicaid agency does not expend Medicaid dollars but ensures
that medical care costs are allowable and that funds for reimbursement
of that care are disbursed to the healthcare providers--in this case
LBJ--in a timely manner. Since ACA, LBJ has only been able to draw on
average an additional $5 million dollars from the ACA account. In 2016,
the LBJ hospital was able to draw $6 million. If we trend the LBJ's
annual expenditures of ACA Medicaid funds, with a beginning balance of
$197 million and an average draw of $5 million a year, it will take LBJ
39 years to draw all of the ACA Medicaid funds. To date our territory
has only been able to draw about 20 percent of the ACA Medicaid funds
because of our limited medical services. It is not possible for the LBJ
to draw all the ACA Medicaid funds by 2019 without additional services
or an expanded provider network. There are options that the Medicaid
agency has successfully pursued to increase access to medical care that
would be covered by the ACA Medicaid funds.
The Medicaid agency after nearly years of development and
negotiations, submitted two major amendments to CMS to change our
Medicaid state plan. The priority was to enable the Department of
Health's FQHC to become a provider. This was approved February 2017.
The second was the Off-Island Medical Referral program that the LBJ
hospital could not implement due to cash-flow problems. This was
approved recently in June. The Medicaid agency is waiting for the local
budget process to be completed and should the agency receive local
match funds, it will be able to draw down ACA Medicaid funds to
reimburse the FQHC and providers of the Off-Island Medical Referral
program.
The Children's Health Insurance Program (CHIP) is up for
reauthorization and is an instrumental part of the funding that
supports the health of the most vulnerable of our population--our
children. We strongly support the reauthorization of this bill and
further request that the cap on CHIP funding for the territories also
be lifted.
I wish to thank you Chairman LaMalfa and the Subcommittee for this
opportunity. Thank you also to our Representative Radewagen and the
Representatives from all the U.S. territories for their support to
strengthen Medicaid for the territories. It is not lost on me the
importance of this opportunity to appear before this Committee and the
attention being afforded to our small island territories. I am most
grateful.
Thank you very much. Fa'afetai tele lava.
______
Mr. LaMalfa. Thank you, Ms. Young. And I want to thank,
again, the panel for your testimony. I will remind the Members
that Committee Rule 3(d) imposes a 5-minute limit on questions
by the Members.
The Chairman will now recognize Members for questions. I
will first recognize myself for 5 minutes.
Let me direct this to Mr. Bussanich. You spoke of promoting
the efficient and effective governments in all island areas,
and then, as it applies to American Samoa and the hospital.
It is designated as a high-risk grantee. So, requirements
of these grantees to comply with special conditions for future
or existing grants. How, so far, has this designation improved
the accountability for Federal funds so that we know that
further investment will be a positive?
Mr. Bussanich. Well, the high-risk designation, it sends
signals in both directions. It sends a signal to the local
government that it needs to focus on improvements in financial
management and practices, and it does serve, to a certain
extent, I would suppose, as a warning. But, certainly, it is a
warning to Federal agencies and others to make sure that the
funds that they are granting are reported on and used
appropriately.
I do think, though, in our case, we have done a lot of
focus on working on audits, improving the outcomes of audits,
and we are also aware that a recent Subcommittee report is also
focusing on this issue.
We certainly believe that American Samoa has the ability to
make the improvements to get itself off the high-risk
designation list.
Mr. LaMalfa. Do you see this designation being revisited
any time soon?
Mr. Bussanich. Yes. It is revisited, certainly, every year.
Mr. LaMalfa. Every year?
Mr. Bussanich. Yes.
Mr. LaMalfa. So, a new, comprehensive look at how
performance is going, and----
Mr. Bussanich. Yes. And a lot of that depends on the
contents of the annual single audits, which----
Mr. LaMalfa. Is there a criteria that is nearly being met
for the designation to be removed?
Mr. Bussanich. Beg your pardon, sir?
Mr. LaMalfa. Is it nearing the point of meeting the
criteria for the designation to be removed or revised?
Mr. Bussanich. I believe so, yes. We are certainly
interested in taking whatever final steps are needed to do
that.
Mr. LaMalfa. OK. I would like to yield the balance of my
time to Mrs. Radewagen for questions.
Mrs. Radewagen. Thank you, Mr. Chairman. I wondered if I
might complete my opening statement, since we had a difference
of opinion as to the time limit.
As I was saying, for example, this year's total budget for
LBJ was $51 million, while the hospital of the same size in
Washington State has a 2017 budget of roughly $200 million.
The people of American Samoa need better access to care
without having to take an airplane off-island. The fact is, it
is beyond time for a significant increase to the account.
The reasoning provided in DOI's budget report for the lack
of any increase to the ASG operations account over the years is
to promote self-sufficiency on the island, which is all fine
and well, but near impossible when, at the same time, the
Federal Government has closed off large swaths of fishing
grounds in the Pacific that our people have used for a
millennium, and long before any relationship with the United
States, and at the same time imposed federally mandated minimum
wage laws, irresponsibly putting the territory, which is both
economically and geographically isolated, on the same playing
field as the states--policy that has already forced one tuna
cannery to leave the island for Thailand, where they pay their
workers a mere fraction of what ours are required to pay.
I recently introduced legislation to resolve this issue:
H.R. 3021, the American Samoa Job Protection and Expansion Act,
and I look forward to seeing congressional action on it.
Regarding LBJ and any improvements to be made following
congressional action, I will be introducing a bill shortly that
calls for GAO study, in partnership with DOI, the VA, and HHS
to assess the feasibility of either a new or updated facility,
and I encourage my colleagues to support the measure.
It is high time that we here in Congress recognize the
issues happening in the insular areas, and I am encouraged by
today's hearing and the action it will bring. Again, I want to
thank our witnesses for traveling so far to be here today. I
know that the work they do in the islands is indispensable, and
I know that their testimony will provide even more insight into
the issues we are facing in the islands in regards to providing
accessible and quality health care for our people.
Thank you, Mr. Chairman. I yield back my time.
Mr. LaMalfa. OK, thank you. We will now recognize the
Ranking Member, Mr. Sablan.
Mr. Sablan. Well, thank you very much, Mr. Chairman. Let me
start with Mr. Bussanich.
According to your statement, the LBJ Medical Center has
received almost $30 million in CIP funding from OIA since 2003.
So, broadly speaking, can you tell us what these have primarily
been used for? Has it been to renovate the facility?
Mr. Bussanich. Yes, sir, I can. And I can show you a list
of all the different projects that we have done since 2003.
But the most significant ones have been a $5 million
project to upgrade the electrical system. We are in the process
of a $5.7 million project to improve the labor, delivery, and
operation room suite. There was $4.7 million spent on a
forensic psychiatry facility, and $3.2 million on a dialysis
unit expansion, among other projects. These have been, I think,
very significant and very useful projects.
Mr. Sablan. Right, thank you. And could we get that
information to the Committee, please?
Mr. Bussanich. Yes, sir.
Mr. Sablan. I appreciate that, because in a previous
hearing I made a statement that OIA should re-examine its
criteria for the capital improvement project funds, and base it
not on the financial criteria, but basically on the public
health needs.
Like, say, for the Northern Marianas, it is the only
municipality in the Nation that does not have 24/7 water, and
there is a public health crisis that is growing from that.
Thank you.
Ms. Young, if I may, you state also that, to date, our
territory has only been able to draw 20 percent of the ACA
Medicaid fund because of our limited medical services. The
inability to draw down the additional ACA Medicaid funds is not
unique to American Samoa. The other insular areas, except for
Puerto Rico, face a similar challenge because of the 55-45
FMAP.
In the Marianas, however, the Commonwealth Healthcare
Corporation, which operates our only hospital, and our Medicaid
managers have been able to meet the FMAP challenge by using a
statutorily-recognized Medicaid financial approach known as
certified public expenditures, or CPEs. And current projections
show that they are on track to use all or almost all of the
Marianas' ACA Medicaid funds before the 2019 expiration date. I
am not an expert on the particulars of CPA accounting, but it
looks like they are successfully using the ACA money.
I also understand, according to Medicaid and CHIP, an
access commission, and a MACPAC, which is a non-partisan
legislative branch agency that advises Congress, that American
Samoa uses CPEs for your local match.
However, I am not sure why you have not been similarly
successful in certifying the use of public funds to support the
cost of providing Medicaid-covered services to allow you to
access more of your ACA Medicaid dollars. Are you familiar with
the approach the Marianas uses with CPEs to access our ACA
Medicaid dollars?
Ms. Young. Thank you, Congressman. Yes, I am. Our
challenges with drawing down the additional ACA Medicaid funds
is due to several factors. But the CPE methodology is probably
not one of them.
CPE methodology is a very good methodology for our LBJ
Hospital. The certified public expenditure methodology was
approved by CMS some years ago, after the hospital had
significant problems with over-billing. The CPE methodology
allows the hospital to do a number of things. It stabilizes
their annual funding, and it also allows them to forecast for
their budgets.
The challenges of drawing down the Medicaid money that is
provided for under ACA is, first, Medicaid dollars can only be
used to reimburse for allowable medical care expenses.
Second, our hospital is the only Medicaid provider, and has
been the only Medicaid provider for 35 years, until this
February, when the FQHC became a Medicaid provider.
And third, we don't have enough medical services on island.
We have not had off-island referral services for the last 10
years, and that normally has taken wind. It was being
implemented, normally took up a lot of medical funds from the
hospital, and it was not sustainable.
Mr. Sablan. Thank you.
Mr. Chairman, my time is up.
Mr. LaMalfa. Thank you. We will now recognize Miss
Gonzalez, our Vice Chair, for 5 minutes.
Miss Gonzalez-Colon. Thank you, Mr. Chairman, and thank
you, the whole panel, for being here today.
I do understand what you are talking about, because I was
part of the CODEL that traveled to American Samoa in February
of this year, and I thank Mrs. Radewagen for making that one of
the main purposes of the trip. But I have many questions. I
will try to direct myself.
Ms. Young, you said in your testimony that a state-of-the-
art replacement hospital in American Samoa will require Federal
appropriation of $200 million. How do you arrive at this
figure?
Ms. Young. That is a number that we have thrown around
amongst ourselves locally, talking about what it would take to
build a new hospital on our wish list. But there is no official
documentation.
I think that Congresswoman Radewagen has suggested a really
great idea to do a report with GAO, DOI, and our local
government to come up with a realistic estimate on how much it
would take us to build a new hospital.
Miss Gonzalez-Colon. So, we don't have any support that
establishes that $200 million as the correct amount, correct?
Ms. Young. Yes, that is an unofficial estimate that we came
up with on our own.
Miss Gonzalez-Colon. Thank you. As part of the territories,
we face the same situation as Mr. Sablan stated with the
Medicaid, so we understand what is going on in American Samoa.
But in our case, we use the money that was allocated in 2012
with the Obamacare.
Ms. Young, American Samoa has so much money that remains
unspent for so long, why? Can you tell us about it?
Ms. Young. Sure. Since 2011, the hospital has been drawing
down on the ACA Medicaid money, but just not as much as we
would like to. Part of that is, like I mentioned earlier,
Medicaid money can only be used to reimburse allowable medical
care services.
And the history of the draw-down--LBJ Hospital is averaging
about $5 million a year in draw-down. And the Medicaid agency
can ask for as much money as we need for the LBJ Hospital. But
through the certified public expenditure payment method, the
way we pay the hospital is based on the Medicare cost report.
The Medicare cost report is the financial statement that the
hospital has to file every year, and it has to be settled and
finalized by a certified CPA firm, and eventually with CMS.
Based on that Medicare cost report, we annualize the
payments for the hospital. Right now, that annual payment
averages about $1.6 million a month for the hospital. We run it
through a calculation formula that is approved by CMS within
our state plan. Usually, the hospital exhausts its regular
Medicaid funding under the Social Security Act by the third
quarter. That is a legal requirement. We have to exhaust our
regular Medicaid funding first, before we can tap into the ACA
funds.
Miss Gonzalez-Colon. Question, Ms. Young. How much is
remaining in that fund?
Ms. Young. It is approximately about $150 million.
Miss Gonzalez-Colon. One hundred and fifty? And it was
allocated at $186 million?
Ms. Young. I believe it was $181 million, with an
additional $16 million from the health insurance marketplace.
Miss Gonzalez-Colon. So, you still have more than $150
million in that account. In our case, in Puerto Rico, when we
have those kind of problems, we fix it by making the changes,
complying with the CMS, to try to get use of that money. I
encourage American Samoa to do the same in the case you can do
it.
Mr. Faumuina, you also touched in your testimony, that in
your opinion, it will make more sense to replace LBJ entirely,
rather than attempt to renovate when that facility is still in
use. Why?
Mr. Faumuina. The renovation project is carried out in
order for us to meet CMS standards. Every time they visit, they
point out deficiencies for us to do certifications of
participation. So, we are forced to do that.
Miss Gonzalez-Colon. Thank you, Mr. Chairman. I yield back.
Mr. LaMalfa. Thank you. We will go ahead and recognize Mrs.
Radewagen for 5 minutes.
Mrs. Radewagen. Thank you, Mr. Chairman. You mentioned this
earlier. My question is for Mr. Bussanich.
The Chairman mentioned OIA has designated American Samoa as
a high-risk grantee. And I think you have more or less
elaborated on how the failure to comply can have this impact on
securing Federal funding. But providing that the Interior
appropriations bill that just passed out of Committee gets
signed into law, we will then see the first increase to the ASG
operations account since 1986. It is my understanding that the
bill report recommends that the increase be used to bring ASG
into Federal compliance.
Can you assure me, Mr. Bussanich, that OIA will commit to
working with ASG to use these funds to meet Federal standards?
Mr. Bussanich. Oh, absolutely. We saw that language and we
were encouraged by it, as well, to be able to use the funds to
work with the government to address specific problems to get
that high-risk designation completely taken off the books.
Mrs. Radewagen. How does this DOI subsidy work? You folks
send it, or it is drawn down by ASG, and then you send it down
to ASG? You don't send it to the hospital directly? Why not?
Mr. Bussanich. Well, generally, I am just checking to make
sure. I am not exactly sure where the draw-down goes. But the
grants are typically made to the government of American Samoa,
and the Treasury there handles the actual draw-downs.
The payments are made on a regular basis, according to a
schedule. As far as I know, there is nothing that has really
gotten in the way of us actually passing money to the American
Samoa government.
Mrs. Radewagen. So, to your knowledge, nothing has been
lost, nothing has been subtracted from that DOI subsidy that is
intended for the hospital?
Mr. Bussanich. I certainly don't think----
Mrs. Radewagen. So, the full amount or installment reaches
the hospital directly. Is that what you are saying?
Mr. Bussanich. It has never been brought to my attention
that it has gone elsewhere. We would certainly look into it and
insist that it goes to the LBJ Hospital if it were brought to
our attention that it was going somewhere else.
Mrs. Radewagen. Thank you, Mr. Chairman. I yield back my
time.
Mr. LaMalfa. Thank you. We will now recognize Mr. Westerman
for 5 minutes.
Mr. Westerman. Thank you, Mr. Chairman, for allowing me to
join the hearing today. I thank the witnesses for being here,
especially the ones who traveled so far. And my colleague, Mrs.
Radewagen, for all the hard work you are doing, representing
American Samoa.
Director Bussanich, in your testimony you list three
primary goals of the Office of Insular Affairs: the first being
to create economic opportunity and the second is to improve the
quality of life. I, too, was on the CODEL that visited American
Samoa, and I can testify it is a long ways from here to there.
It is a very isolated part of the world.
In testimony submitted for the record by Governor Lolo
Moliga, major issues are still lingering from policies of the
Obama administration. And the Governor described those as
Federal over-regulation that has crippled the territory's
ability to develop a strong economy, and thus have stymied
local funding that would otherwise be directed toward the LBJ
Hospital. Those are the Governor's words.
Two of those issues fall directly under the jurisdiction of
this Committee: the national ocean monuments and sanctuary
expansions, and prohibition placed on fishing in the high seas.
I know that when we were there, the issue of fishing on the
high seas was discussed, and there were questions about whether
that was even doing anything to help the tuna population, as
other countries were coming in and over-fishing those areas.
Do you agree with the Governor's claim that if the Federal
over-regulations still lingering from the previous
administration are left in place, that the territory will be
unable to develop a sustainable economy, and thus will be
forced to continue under-funding the LBJ Hospital?
Mr. Bussanich. Actually, sir, I think that is a question
kind of beyond the view of my office. I mean the example you
gave about fisheries, while it was certainly a subject of the
Obama administration, was not part of the Office of Insular
Affairs.
We certainly are an advocate for American Samoa within the
current administration. And if tasked to look at this, we would
certainly give our opinion.
Mr. Westerman. Can you share with the Subcommittee any
efforts that OIA has begun during this new Trump administration
to review policies regarding marine monument expansion in
American Samoa?
Mr. Bussanich. I would have to deflect that to the
appropriate bureau or office, because the Office of Insular
Affairs itself does not participate in those regulatory
schemes.
Mr. Westerman. OK. Shifting gears a little bit, we
obviously visited a hospital while we were there, and also
visited the VA facility. As an observer from far away, and I
represent a very rural district in Arkansas, but I can probably
count up at least a half-dozen hospitals in my district that
have had a lot more capital put into them and are much more
advanced than the hospital on American Samoa, as far as the
infrastructure and facilities there.
But, obviously, there were some very dedicated healthcare
professionals there doing the best they could with the
facilities they have. In my district, there are a lot more
hospitals, and there are much larger, nicer hospitals just a
few hours away from some of these small, remote hospitals.
Also, at the VA facility, we saw that people were having to
be air-evacuated to Hawaii for major health concerns. And it
dawned on me, shouldn't the VA and the local hospital be
working together, and maybe some of that money the VA is
spending to airlift people could go toward having a better
hospital there on the island that everyone could take advantage
of.
Ms. Young, has there been any work between the VA and the
hospital on the island, trying to coordinate and provide, or
pool the efforts so you could provide better services?
Ms. Young. I know that our agency does not get involved in
those discussions. That is a high-level discussion usually done
between--I know that we have had cases in the past where our
governor has been in touch with our Congresswoman to assist in
triggering those types of services and assistance to the
territory.
This is a followup to Congresswoman Colon's question--the
Medicaid state plan has not been changed until now, and it took
us almost 3 years in negotiations with CMS to make some of
those changes. One of those changes, which is very key to the
off-island referral program, is to allow our agency to
reinstate the off-island medical referral program directly with
our agency. That would allow my agency to contract directly
with the air carriers, as well as hospitals in the United
States, as well as in New Zealand.
Under the Medicaid state plan, the Medicaid funding can be
used for transportation services. Currently, the hospital does
use some of that for nominal transportation airfares. But
because the LBJ Hospital has not implemented the off-island
referral program for nearly 10 years, they cannot draw down
transportation Medicaid funds.
We will be able to do that starting in the new fiscal year,
once the local government provides local funding. When that is
done, we hope that we can better resolve the issues of air
transportation, including air ambulance services to the United
States through the Medicaid program, which will also allow us
to draw down our Medicaid additional ACA funding provided
through the ACA law.
Mr. LaMalfa. Thank you, Mr. Westerman. I recognize Chairman
Bishop for 5 minutes, if you so wish.
Mr. Bishop. Thank you, I appreciate that. I appreciate you
holding this hearing. I was with all of you--most of you,
anyway--at this hospital. And it was an enlightening spot.
Mr. Westerman, I would actually like to follow up on where
you were going with that. Would you like a couple minutes to
continue on with that? The issue of VA spending especially, as
we have the CHOICE Act--if indeed the services can be there at
the island, or if everyone still has to fly, does the Medicaid
you are talking about, does that solve this particular issue?
Can I yield to you a couple of minutes to continue on with
that?
Mr. Westerman. Well, you are heading right down the line of
questioning. And would you care to address that more?
Ms. Young. Sure. We have approached that. Three years ago,
when Governor Lolo came into the administration, his mandate to
our office, as well as to the CEO and to the Director of the
Department of Health, was for us to pursue every avenue to see
how we can better improve the delivery of healthcare services
in American Samoa, which included reaching out to the VA.
And we have done that, and it is something that--the
Medicaid agency is under the purview of CMS and the HHS. So, as
a separate department, it requires partnership at a higher
level with the VA. I don't think we are precluded from
continuing to pursue that, but it always comes down to funding,
availability of resources, and the separate jurisdictions of
our departments.
We came in February of 2015, and one of the initiatives
that the Governor wanted us to pursue was to also approach the
Uniformed Services University for health services to see what
they could do to help us with our workforce development for the
medical care workforce. And we----
Mr. Westerman. Being mindful of the Chairman's time, one
other issue I remember was--and correct me if I am wrong--but
the VA clinic indicated that the hospital did not meet
standards for the VA care, so the hospital would have to be
brought up to standards before the VA could use the hospital.
Is that correct?
Ms. Young. That is my understanding. And I want to share
the USU contact allowed the Governor and the President of the
University to sign an MOU to allow graduate students of nurse
practice to be located and assigned on TDY to the FQHC in
American Samoa to help us with that. And the preceptors will
come from both the LBJ Hospital and the FQHC. We hope that is a
segue for us to develop an inroad to work more closely with the
VA.
But you are correct, sir, in saying that the VA cannot at
this time utilize the LBJ Hospital. But they may be able to
utilize the FQHC for VA services.
Mr. Westerman. I yield my time back.
Mr. Bishop. Mr. Faumuina, can I have you address that same
particular issue? Is Medicaid funding going to be the solution
to this, or do we have to do other things--you have a whole
bunch of veterans in Samoa--to make it possible for them to
come back and stay?
Mr. Faumuina. I really don't have a clear answer for that,
your honor.
Mr. Bishop. Well, OK. I don't either.
Mr. Faumuina. I probably don't understand the question.
Mr. Bishop. It was simply what we were talking about here,
these two issues again, the ability of actually being able to
provide services there at LBJ, and does an upgrade need to be
there, and also does the upgrade need to take place?
And the second one was does Medicaid funding, if you are
looking at those funds in the future, does that solve the
problem of transportation back to Hawaii, or to the mainland?
Mr. Faumuina. At this point we are using our local funds to
provide transportation only, and no medical care bills for
outside providers.
Mr. Bishop. My gut feeling is that Medicare or Medicaid, by
itself, will not solve that problem, will not be enough to meet
the need that is actually there. Am I wrong with that gut
feeling? Either way, anybody? Westerman, you can answer that.
Whomever.
[Laughter.]
Ms. Young. Chairman----
Mr. Faumuina. With respect to Medicaid funding, we are
really at the mercy of the local Medicaid office to determine
what LBJ is eligible for and what LBJ is not eligible for. We
do submit our report to them, and they will process it through
the system, and we get reimbursed for what is due to us.
Mr. Bishop. Thank you. My time is over. Once again, I do
appreciate you being here, traveling this distance to come to
talk about this issue. It is important.
Mrs. Radewagen has been continuously telling us how
important it is, and it is. So, I appreciate her bringing this
to our attention all the time, too.
Mr. LaMalfa. Thank you, Mr. Chairman.
All right, we will open it up for a second round of
questions here. I would start off again, back to Mr. Faumuina.
In previous testimony, you did mention that there has been
discussion about a new facility, a 200-bed facility. But I
wanted to roll back to the staffing difficulties there has
been. You mentioned the number of pharmacists--I think the
numbers were--11 would be required, and you have 3. On the
nursing ratio it was about, I think, 120 or so and you have
about 70. And doctors, I cannot quite remember those numbers.
But you have had a real challenge with staffing.
So, I guess relating--how would you get the staffing level
up to what you have with the current facility, let alone a
newer, larger facility? What is the magic, the silver bullet
for getting that done? What do you see as the way to accomplish
that?
Mr. Faumuina. The staffing is always a challenge for us
because of the difficulty of recruiting the right or qualified
personnel to take over the positions for doctors, nursing, and
other technical assistants.
When the CMS comes to do their assessment of our patient
care, they discover that there are times that we do not have
enough physicians to attend to the needs of the patients. The
same goes with our registered nursing staff. In those areas,
when they go through the charts and the forms, they discover
that we do not have enough staff.
And the problem with management, we cannot recruit when we
do not have the resources to recruit them.
Mr. LaMalfa. Where is the recruiting, how far do you have
to cast the net for recruiting?
Mr. Faumuina. We recruit from everywhere. We go as far as
the Philippines, Fiji, and the Pacific, but most importantly we
try to recruit from the United States. But it is so difficult
for them to--they are interested to come to the Pacific, but at
the end of the day, the salary issue becomes prohibitive for
them to make a decision.
Mr. LaMalfa. Are there any other comments you would like to
make, with the remaining time I have, on the issue in general?
I again respect the amount of travel you had to be here. Are
there any other issues you would like the time to cover a
little bit?
Mr. Faumuina. [No response.]
Mr. LaMalfa. Sorry I caught you on the spot. Let me throw
that to Ms. Young here, too.
What areas would you like to emphasize in front of this
Committee today that we may have fallen short on for time?
Ms. Young. Thank you, Mr. Chairman. I believe that in our
testimonies we have laid out the priorities for our government
and for the territory, which is the need to extend the timeline
for us to expend the ACA money.
But also, because DOI is here--and this is not a comment
that would help answer the question of why it is that we cannot
draw down enough of the money, besides the fact that we only
have a small population, we have limited medical services, we
have only one hospital provider--I think what needs to also
happen is the Department of the Interior--and this is my
recommendation--is to provide technical assistance to the
hospital to allow the hospital to better capture, and more
effectively capture, the cost of doing business in the
hospital.
Capture the costs. Because only then can we help increase
their draw-downs through their certified public expenditure
payment method through the Medicare cost report. It would be
very helpful for DOI to hear that, that LBJ Hospital would
benefit greatly, but because the hospital has not had enough
funding, and their cash-flow is a problem, they have been
unable to consult with a Medicare cost report expert to better
capture the cost of doing business, as a hospital. Thank you
very much.
Mr. LaMalfa. Thank you. On my remaining time, Mr.
Bussanich, is it realistic for OIA to expect the Samoan
government to be able to promote efficient and effective
governance while still Federal regulations are hindering,
really, the growth of the territory?
Mr. Bussanich. Well, from our point of view, given that we
are working under whatever statutes and regulations are in
place throughout the United States, I think, we take those as a
given. We also recognize, as we were speaking of, the relative
isolation, kind of the economic isolation of a territory still
makes it very difficult.
I think we are always in a dialogue with the governors, all
of the territories, looking at similar problems, and trying to
represent them in what Councils that we can to ensure that the
environment that they work in for economic development is as
suitable as possible.
Mr. LaMalfa. OK. I better stop there. Let me recognize Mr.
Sablan for 5 minutes, thank you.
Mr. Sablan. Thank you very much. Let me go back again.
Ms. Young, on the issue of the certified public
expenditure--I know you are an attorney, and I am not an expert
on the particulars, but the Northern Marianas have one
hospital. You have 57 doctors, 93 RNs, and 3 pharmacists. I am
envious, because you have more doctors than we do.
Yet, the cost of medical referral that is incurred by LBJ--
and they are going to say hospitals in Hawaii that meet CMS
standards. They are paying for it already. Then that cost
should be used as the CPEs, the certified public expenditures,
so that draw-downs on Medicaid could be done.
Are you doing it for LBJ?
Ms. Young. That is a really good----
Mr. Sablan. I need to ask this, because here we are, trying
to find a way to continue funding after 2019 for the
territories. And Puerto Rico at 2019 will spend 128 percent of
its money. The Northern Marianas would have spent 93 percent.
And it hurts our effort when somebody points and says,
``Wait,'' because they see this as a pot of money. And they
said, ``Look, you have''--the way we are going now means we
would have spent 53 percent of the total pot of money. And they
are going to say, ``You have money left over on the table,''
because I need to protect the Northern Marianas, too. So, why
aren't you using that public expenditure, since they are
qualified as CPEs?
Ms. Young. Very good question. American Samoa is very
different from CNMI. American Samoa has no private providers.
CNMI, I talk with your Medicaid Director every year, and am
always consulting with her to say how do you, how can we help
ourselves expend our Medicaid funding more from ACA.
And the problem is, we only have one Medicaid provider, the
LBJ Hospital. That means we can only pay LBJ.
Mr. Sablan. Right.
Ms. Young. We have no private doctors that are Medicaid
providers and we don't do off-island referral. The off-island
referral that we do right now over the last 10 years, is simply
partial payment of airfare.
We do not do individual claims. The CPE is a monthly, one
day, one sheet of paper that comes to our Medicaid agency that
basically shows us, in aggregate, in line item, all the
different departments of the hospital and what they expend. And
that is what we pay. We don't pay individual claims, we don't
track. We cannot track individual referrals off-island, because
we don't do them.
When people go for off-island referral, the hospital simply
captures that off-island airfare in the Medicare cost report,
and then the patient is left on their own to pay out of pocket,
so we have no way in our system to track the expenses of off-
island referral patients that take themselves for off-island
care in Hawaii or California.
And it is a problem. We recognize that. But it is going to
take us a while to resolve those system issues. We have started
doing that since the Lolo administration came in, but it has
taken a number of years for us to negotiate those changes in
our Medicaid state plan. It cannot happen and does not happen
overnight, but we are getting there. We just got an FQHC
approved, we have the off-island referral approved. And
hopefully, in the next year, we will see a substantial draw-
down in our ACA funds.
Mr. Sablan. Let me ask, Mr. Faumuina, what will it mean for
LBJ if Congress does not extend the 2019 ACA funds?
Mr. Faumuina. Well, the experience that we have now is that
the present Medicaid appropriations, which LBJ is eligible for,
is always exhausted on the third quarter of every fiscal year.
So, on the fourth quarter of the fiscal year we kind of rely on
this ACA fund. Without that, then, we have to be very creative
in coming up with other revenue sources to make up for that
loss.
Mr. Sablan. Yes. Some people will tell me that you guys
just have too much money, if you are leaving 80 percent on the
table unspent.
Mr. Bussanich, I need to ask this. Either OIA or IGIA, to
your knowledge, have they been working with insular areas and
their representatives on a strategy for getting these funds
extended? You said you are continually working with the
territories. When is the last time you contacted a
congressional office from the four insular areas on ACA?
Mr. Bussanich. Well, I must say I don't know the answer to
that.
Mr. Sablan. Well, Steve may. He is right behind you. When
is the last time, because you said you continually work with
us.
Mr. Bussanich. I don't think we have spoken about that,
sir.
Mr. Sablan. And you know it is a cliff, it is a funding
cliff that will hurt critically needed--this is a public health
issue. You are our foremost advocate in the executive branch,
and it is 2017. And you know that 2019 will be a funding cliff.
And you have not raised a finger, as far as you are telling me,
and yet you testify that you are continually working it.
I don't want to put you on the spot, but it is a matter of
your testimony. Yet, you tell me that you don't remember.
My time is up, Mr. Chairman.
Mr. LaMalfa. Thank you, Mr. Sablan. Let's recognize Miss
Gonzalez for 5 minutes.
Miss Gonzalez-Colon. Thank you, Mr. Chairman. We have a big
problem here, and the treatment the territories are receiving
in Medicaid. That is the bottom line of the problem.
And, of course, being American Samoa in the Pacific, that
triggers a lot of extra problems to manage the VA facilities
and the treatment, and the shortage of personnel to attend in
that.
This House of Representatives filed in December of last
year a Task Force Report on Puerto Rico. And one of the issues
in that report was the Medicaid situation between the
territories. I would like to refer to one of the lines in the
report--By contrast, in Puerto Rico and the other territories,
Federal Medicaid funding is subject to an annual cap pursuant
to the Social Security Act. That cap increases annually
according to the change in the Consumer Price Index for all
urban consumers.
And the problem in the territories, once that Federal
funding cap is reached, the territory government is responsible
for the remaining cost of the Medicaid services. In our case,
our cap in Fiscal Year 2016 was more than $335 million. In
American Samoa, it was $11.1 million.
The situation with this is that FMAP territories are not
based on the per-capita income, rather than the fixed in the
Federal statute. So, we need to fix the problem itself, and the
problem is the way we are treated in the Medicaid and Medicare.
In terms of the ACA, some may say that it helped us a lot,
because they gave us some money, one-time money, one-time
funding. But the problem, it was $7.3 billion, of which Puerto
Rico got $6.4, and the rest of the territories just got the
rest. But the problem is that was not a solution. We are still
needing to have a permanent solution to the ACA or to the
healthcare problem for the whole territories.
Once we finish or complete that kind of a task, then we
don't have to be here every year asking for money for each of
the territories in the Medicaid.
One of my concerns is that before 2011, we got 50 percent
of the share of the FMAP. The reality is that the increase to
just 55 percent is below the rest of the states, in terms of
the per capita. And if we were managing the allocation of money
for the territories, including American Samoa, in the per
capita as the rest of the states, you could be having 83
percent. And that is part of the report.
So, I encourage this Committee to try to have a permanent
solution on the Medicaid problem, looking for the inclusion of
the territories, the whole territories, in a final solution
regarding the cap, the FMAP, and the distribution of the funds.
Because the ACA, I mean the Obamacare, was not a solution, and
is still hurting all territories, including American Samoa.
I want to thank the members of the panel for being here
today, because I know how far it is to come here in this kind
of Committee. And I would like to yield back the rest of my
time to Mrs. Radewagen, if the Chairman allows that.
Mr. LaMalfa. Sure.
Mrs. Radewagen. Thank you, Mr. Chairman.
Miss Gonzalez, I keep going back to this--I am fascinated
with your question that you asked earlier about this unspent
money. And it just seems that my colleagues are still focusing
on this unspent money, and they--I too want to understand.
Because if this money became available in 2011, that is 4 years
before I was even elected to Congress.
Now, the Medicaid Director here, I am looking at her
statement, and she is extremely critical of the Obama
administration, where she says the ACA was passed with no input
from American Samoa, for us to explain that simply setting
aside so much Medicaid funds with a deadline for expenditure by
2019 was not logical, as American Samoa only had one Medicaid
provider, which she did explain.
And the point of it is, in my thinking, that this is about
helping the local government. It is about helping our economy.
But, most importantly of all, we are talking about the health
of our people.
I mean I have tears in my eyes when I go to that hospital,
people cannot get the services they need, and they have to
struggle to find extra money they don't have to try to go up to
Honolulu. This has been going on for years. And quite frankly,
I am not convinced that the entire answer is right there, that
it would take 3 or 4 years to negotiate all that was being
negotiated in order to--I mean somebody should have gotten to
Congress, somebody should have gotten to the CMS, the Secretary
of HHS.
After all, isn't that where the money came from? The
Secretary of HHS put this pot of money out there. I just fail
to understand. Thank you.
Mr. LaMalfa. Miss Gonzalez, time has expired, but yours is
starting, Mrs. Radewagen, so I will recognize you for 5
minutes.
Mrs. Radewagen. You have a comment? To the Medicaid
Director, can you please comment on this?
Ms. Young. Sure, thank you, Congresswoman. I think the
Committee has made a really good point, and has raised this in
your comments and questions, about some of the challenges that
we face as a territory.
I do want to correct that I was not critical of the Obama
administration. What I was criticizing is the nature of policy
making at the Federal level, what oftentimes--and this goes to
what Miss Gonzalez had talked about--overlooks the input from
the territories, which is why it is so valuable that this
hearing is being held. When the 2011 ACA was passed, there was
really no relevant consideration with the situation in the
territories.
For example, in American Samoa we can barely spend this
down because we have one hospital. But CNMI needs more money
every year, because they have dozens and dozens of providers.
Guam needs more money. Puerto Rico needs more money. We have a
problem spending our money.
And you are correct, Congresswoman. Part of the problem is
also our own Medicaid program in American Samoa, because for 35
years nothing changed. And I came in 2013, 2014 was when we
started to look at amending the state plan.
And it really did take us a few years to negotiate this,
because before you can change anything with CMS, it requires a
lot of documentation and financial impact analysis. So, we had
to hire consultants to do the analysis. The procedures are in
place already for CMS, and we have a very good relationship
with CMS, and they understand the issues that we are going
through.
Unfortunately, the changes are not happening as fast as we
would like, but they are changing. So, I think, together with
the Federal agencies and the Federal Government, having a
better understanding of our local situations for all the
territories, the need to make relevant policies that impact us,
but also we recognize that internally, not only within LBJ,
within the Medicaid program in American Samoa, and within our
government, we also have problems that we have to take care of.
But it does take time.
Mrs. Radewagen. Thank you, Director. Thank you very much.
Yes, I can only refer to your statement, which is right
here in front of me, where you seem to be very, very critical
of the Obama administration.
At any rate, the next question has to do with the century-
old water system. And I think I am going to just give this to
CEO Faumuina.
Can you tell us what effect the water system has on the
health in American Samoa? It has just come to my attention that
we have lots of these pipes that are lead pipes and what not.
And does the island's water infrastructure problems
interfere with your ability to maintain a sanitary environment
for your patients at the hospital?
Mr. Faumuina. Yes. We have replaced the water lines to the
LBJ Hospital with PVC pipings. Unfortunately, we continue to be
on the watch by ASPA, on the boiling water alerts, which means
to tell us that the water supplies that come to LBJ are still
on a watch-out by ASPA.
So, despite the fact that we have PVC replacements, there
are other areas of American Samoa that still have that lead
piping that brings the water through LBJ.
Mrs. Radewagen. Thank you, CEO. And let's see, I want to
thank again the witnesses for traveling all this way, and thank
you, CEO, in particular, for all you do to try to improve the
health care of our patients.
Mr. Faumuina. Thank you.
Mrs. Radewagen. Thank you, Director, on what you are doing
with Medicare. We want to try to get that solved sooner, rather
than later.
Thank you very much. I yield back the balance of my time.
Mr. LaMalfa. Thank you, Mrs. Radewagen. Thank you again for
your effort in bringing this to the attention of the Committee,
and helping to be the driving force on that.
This is not totally conventional, but, indeed, given the
amount of travel you made to be here today, Mr. Faumuina, would
you like to make any kind of a closing statement, or Ms. Young,
on this issue before we adjourn?
Mr. Faumuina. Thank you, Mr. Chairman. I would like to take
this opportunity to thank the Committee for extending these
invitations to us. We continue to face the challenges until
such time that we have resolved this CMS survey, as will
continue to come down hard on us.
Fortunately, they are very lenient and understandable about
our challenges. And, as they have cited in their latest
reports, we have financial, infrastructure, staffing, and all
of these challenges that we face. But we manage to stay afloat
and be very creative in the use of our limited resources.
And we thank you for taking the interest in American Samoa.
When the CODEL visits came down earlier this year, I took it as
this is just another visit by the Congress. But, fortunately, I
did not know that we would come this far, and for me to come
and testify before your honorable Subcommittee.
Thank you very much, and may God bless all.
Mr. LaMalfa. Thank you.
Ms. Young?
Ms. Young. Mr. Chairman and the members of the Committee,
thank you very much for this opportunity to testify before the
Committee. I consider it really invaluable that we are here
before you today, and really wonderful that the Committee took
notice of American Samoa, and to be able to hold this hearing
to hear the challenges that we have.
I would also be remiss if I did not thank the Committee for
visiting American Samoa in February. I am sorry that we were
not there when you visited, as we were here for the NGA meeting
for the governors. But it was extremely important to the
Governor and to all of us who were not there that deal with the
healthcare system of American Samoa.
Having said that, thank you very much for this opportunity,
and I look forward to working with the Committee in the future,
should you need any further information from our Medicaid
agency.
Mr. LaMalfa. OK. Thank you. Mr. Bussanich, you don't get
the travel award for being here today, but we appreciate your
presence here as well.
With that, I just want to again thank you all and the
members of the Committee that have participated today. If there
are any additional questions for the witnesses, we will ask you
to respond to those in writing. Under Committee Rule 3(o),
members of the Committee must submit witness questions within 3
business days following the hearing. The hearing record will be
held open for 10 business days for those responses.
If there is no further business, without objection, the
Subcommittee stands adjourned. Thank you.
[Whereupon, at 11:26 a.m., the Subcommittee was adjourned.]
[LIST OF DOCUMENTS SUBMITTED FOR THE RECORD RETAINED IN THE COMMITTEE'S
OFFICIAL FILES]
Rep. Bordallo Submission
-- Letter addressed to the Subcommittee on Indian, Insular
and Alaska Native Affairs from Representative
Bordallo in support of the Subcommittee's Oversight
Hearing on ``Assessing Current Conditions and
Challenges at the Lyndon B. Johnson Tropical
Medical Center in American Samoa,'' dated July 25,
2017.
Rep. Westerman Submission
-- Testimony of Governor Lolo Matalasi Moliga for the
Subcommittee's Oversight Hearing on ``Assessing
Current Conditions and Challenges at the Lyndon B.
Johnson Tropical Medical Center in American
Samoa,'' dated July 25, 2017.
[all]