As we consider the effects of racism on the health of Black, Indigenous, and People of Color (BIPOC) and how the COVID-19 pandemic underscores these health disparities, we must remember the unequal treatment to which the U.S. subjects the predominantly-BIPOC residents of American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and U.S. Virgin Islands.
The Trump administration has recently ramped up efforts to convert the open-ended Medicaid entitlement in the 50 states to block grants or per-capita-caps, which would set a limit on the amount of federal dollars available to states and effectively reduce spending, leading to cuts in eligibility and benefits.
The best indication of the disastrous consequences that such a move would have is the dire state of the health care systems in the territories, where Medicaid federal financial participation (FFP) has been capped since the inception of the program in 1965. This cap, coupled with the fact that the territorial Federal Medical Assistance Percentage (FMAP) is set at 55% despite high poverty rates, make it harder for territories to prepare for and respond to public health emergencies, such as the COVID-19 pandemic.
As a result, low-income territorial residents often experience difficulty accessing services, diminished quality of services, and higher rates of chronic conditions that make them vulnerable to COVID-19.
Because of limited federal dollars, Medicaid in the territories traditionally has not offered the same level of eligibility or covered the same benefits as in the states. As a result, low-income territorial residents often experience difficulty accessing services, diminished quality of services, and higher rates of chronic conditions that make them vulnerable to COVID-19. While Congress has periodically increased the territorial FMAP, the current temporary fix is only effective for two years and will revert back to 55% in 2022, at which point territories will have to make even deeper cuts to eligibility and benefits.
Moreover, low levels of federal funding prevent territories from implementing long-lasting policy changes that would enable them to better address emergencies. For example, territories could improve system capacity by investing in higher provider rates to attract more providers, prevention services, and needed infrastructure like ventilators and intensive care beds.
But without sufficient and permanent federal funding for system capacity, some territories have had to rely on extreme lockdown measures, at the expense of their already weakened economies, to prevent the spread of COVID-19 and avoid collapse of their health care systems.
Although the Families First Act temporarily increased the cap and FMAP for each territory, the FFP cap remains in place. As such, territories cannot afford major COVID-19 outbreaks that would require considerably higher investments in health. Because Medicaid provides coverage for over 35% of the territories’ population (a number certain to increase with job losses), successful response to an emergency of such magnitude would likely require federal dollars in excess of these caps.
In fact, experts agree that open-ended Medicaid funding is essential for an appropriate response to emergencies and economic downturn because it allows local governments to make the necessary coverage adjustments.
The unequal treatment towards territories regarding Medicaid funding is no accident. It is part of a pattern of discriminatory and racist policies, sanctioned by the U.S. Supreme Court through the Insular Cases, that have been imposed on territorial residents since overseas U.S. colonization began in the 19th Century. For example, one of these cases (Downes v. Bidwell) concluded that territories “belong” to the United States, and yet, a lower level of Constitutional protections applied to residents of territories “inhabited by alien races”; while full protections were afforded to “contiguous territor[ies] inhabited only by people of the same race or by scattered bodies of native Indians.”
More recently, these policies have been justified by the false and disproven assumption, steeped in stereotypes, that territorial residents pay less in federal taxes than their state counterparts (a federal court of appeals recently held that disparate SSI payments in Puerto Rico are unconstitutional in part because federal income taxes in the territory exceed those in some states).
As our nation undergoes necessary reevaluation of structures that perpetuate systemic racism and oppression, we should acknowledge the need to do away with disparities in health care access for Black, Latinx, Pacific Islanders, and other POC residing in the territories. What better time to do so than in the middle of a pandemic that has disproportionately impacted BIPOC and that has laid bare the fragility of territorial Medicaid?