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September 12, 2019 Dear Congressional Leaders: As the chief executives of our respective Territories, we urge Congress to provide the U.S. territories with the same need-based Medicaid funding that is currently available to the fifty states and the District of Columbia. Doing so will ensure that the U.S. citizens residing in the territories will be eligible for fair, equitable healthcare coverage, putting all Americans on an equal footing. Doing so will also • eliminate the arbitrary cap on annual federal Medicaid funding; • increase the federal matching rate for the territories’ Medicaid expenditures; • update hospital reimbursements; and • increase funding for prescription drug coverage to low-income seniors. Background and Rationale Medicaid in the U.S. territories is teetering on the edge of a fiscal cliff. On September 30, 2019, the federal funding provided to the U.S. territories under P.L. 115-123, the Bipartisan Budget Act of 2018 (BBA), and the Affordable Care Act will expire. At this time the Federal Medical Assistance Percentage (FMAP) will revert back to a 55% federal match. This reversion to the earlier status quo will have grave implications for approx­ imately four million Americans living in the U.S. territories of Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands. The challenges surrounding the need to provide health care to low-income adults and children in the U.S. terri­ tories has been exacerbated by long-standing discriminatory treatment under federal Medicaid law. As the fiscal cliff looms, we have requested an extension of 100 percent Medicaid coverage for the next three years so that our citizens in the U.S. territories receive equal treatment under CMS guidelines. If Congress does not act before September 30th of this year, our enrollees may lose their Medicaid coverage and access to compensated care aimed at treating life-threatening diseases and conditions and preventing needless deaths. It is our hope that Congress will work with the U.S. territories to reverse course and resolve the Medic­ aid funding cliff. Failure to do so will constitute a man-made disaster and a blot on the human rights record of the United States. Please also keep in mind that the residents of the U.S. Virgin Islands and Puerto Rico are still recovering from the two back-to-back hurricanes of September 2017, Irma and Maria. The residents of the Northern Mariana Islands as well are still recovering from the strongest storm to hit American soil in over thirty years. Losing their medical insurance is the last thing our vulnerable population needs as they face the ongoing impact of these violent storms on local economies and on their physical and mental health. We look forward to working with you to address this urgent public policy concern. Sincerely, Albert Bryan, Jr. Governor, United States Virgin Islands Lou Leon Guerrero Governor, Guam Lolo Matalasi Moliga Governor, American Samoa Wanda Vazquez Garced Governor, Commonwealth of Puerto Rico Ralph Deleon Guerrero Torres Governor, Commonwealth of the Northern Mariana Islands