Insular Areas Consider Variety of Public Health Related Legislation

August 05, 2021 | Andy Baker-White, Beth Giambrone, Emely Sanchez

USVI-legislature-building_1200x740.jpgEach year, ASTHO tracks and analyzes key legislation that impacts public health, and highlights the emerging trends for our members. The legislation we follow relates to a variety of public health issues, including telehealth, immunization, adverse childhood experiences, tobacco control, substance use, the public health workforce, and more. While the bulk of the tracked legislation arises in state legislatures, ASTHO also follows legislation from the territories and Freely Associated States, jurisdictions collectively referred to as the insular areas. The insular areas often face different challenges than the states, while also sharing many common concerns. Below is a brief look at some of the public health related legislation introduced in the insular areas during their current legislative sessions.

Healthcare Access and Workforce

In March 2021, representatives from the five U.S. territories testified in front of the House Committee on Energy and Commerce, Subcommittee on Health regarding healthcare access in the territories. Their testimony highlighted some of the specific challenges they face. Most notably, territories receive a capped amount of funding per year for Medicaid, as opposed to the unlimited funding received by states. In addition, the federal medical assistance percentage (FMAP) for the territories is statutorily set at 55%, while states receive funding based on per capita income. If territorial Medicaid funding was based on per capita income, territorial FMAPs would likely approach the maximum allowable 83% matching rate. Limited health financing has contributed to several disparities in the territories, including aging infrastructure and residents having to go off-island for specific medical care. At the territorial level, both Guam and the U.S. Virgin Islands recently considered legislation related to healthcare access and workforce.

The U.S. Virgin Islands introduced a bill that would allow the territory to enter the Nurse Licensure Compact (NLC). Currently in use by 33 states, the NLC allows nurses who meet the licensure requirements to practice in any state that is a part of the compact. This multistate licensure also allows nurses to teach and practice telehealth across borders, as well as respond to disasters in other compact states.

During the 2021 session, the Guam legislature introduced several bills focused on healthcare access and infrastructure.

  • Bill No. 13-36 (COR) establishes additional duties of the Guam Board of Nurse Examiners to facilitate licensure of nurses and appropriates additional funding for the NLC.
  • Bill No. 42-36 (COR) establishes the Nurse Recruitment and Retention Fund, which allocates money to the Guam Memorial Hospital Authority to increase differential pay for nurses in the territory.
  • Bill No. 103-36 (COR) provides for telehealth and telemedicine during a public health emergency and ensures insurance providers provide coverage for these services.
  • Bill No. 121-36 (COR) authorizes the financing, design, construction, and long-term maintenance of a new hospital and facilities for the Department of Public Health and Social Services and the Guam Behavioral Health and Wellness Center.
  • Bill No. 158-36 (LS) establishes the Guam Community College as the administrator of the Western Interstate Commission for Higher Education Professional Student Exchange Program. This program provides financial support for Guam residents pursuing a career in healthcare and requires the recipient to engage in full-time practice in Guam for no less than five years.

Polyfluoroalkyl Substances

Polyfluoroalkyl substances (PFAS) are a group of synthetic chemicals used in products such as nonstick cookware, water-repellent clothing, stain-resistant fabrics, cosmetics, and firefighting products. During production and use, PFAS can migrate into soil, water, and air, and can accumulate in humans and animals. Exposure to PFAS can lead to harmful health effects, including an increased risk of kidney and testicular cancer and a decreased vaccine response in children.

A bill in the Commonwealth of the Northern Marianas Islands (CNMI) legislature would establish a combined maximum containment level of 70 parts per trillion for PFAS contaminants in the public water system, a level equal to the U.S. Environmental Protection Agency’s current health advisory for PFOA and PFOS, and directs the adoption of regulations for the standard’s implementation and enforcement. The bill also establishes that if a future federal standard is more protective than CNMI’s standard, the federal standard will become the CNMI’s new standard.

Tobacco Control

The rates for tobacco smoking by territorial and insular area residents can be higher than the U.S. average (14% of adults in 2019). For example, according to the Noncommunicable Disease Hybrid Surveys, Palau reported in 2017 that 20.4% of their residents smoked. In 2018, American Samoa and the Republic of the Marshall Islands reported that 21.5% and 22.5% of their respective residents currently smoked.

One policy intervention to prevent or reduce cigarette consumption is to increase the price of tobacco products. Higher tobacco prices may encourage cessation among existing tobacco users, prevent initiation among potential users, and reduce the quantity of tobacco consumed among continuing users, particularly among vulnerable populations, such as youth and low-income smokers, who are more sensitive to cost. In CNMI, the definition of “cigarette” is vague enough to allow manufacturers to label products as “little cigars” so as to avoid excise taxes on cigarettes, even when the packaging and intended use of the “little cigars” are akin to a cigarette. To combat this, CNMI introduced two bills. HB 22-6 would update the definition of “cigarette” to include these “little cigars” for the purposes of excise taxes, while HB 22-54 updates the definition of “cigarette,” pins increases in tax rates to inflation, and invests the generated revenue into health promotion and disease prevention.


The insular areas have not escaped the impact of COVID-19 pandemic, and in some cases, the legislative bodies are considering proposals related to vaccinations, community mitigation, and public health emergency authority. Puerto Rico has introduced several bills regarding COVID-19. PS 37 declares that any quality, effective, effective, and accessible vaccine to combat COVID-19 will be a public health good and creates a Special Board for the acquisition, management, and distribution of the COVID-19 vaccine. RCC 86 directs the Department of Health to develop and execute a vaccination plan for students of chronological age and physical conditions to receive vaccines prior to the return of students to face-to-face education.

A bill in the U.S. Virgin Islands would establish an eviction moratorium to protect rental tenants from homelessness and the spread of COVID-19 due to the adverse financial impacts of the COVID-19 pandemic.

In Guam, the legislature passed a bill removing the governor’s authority to renew a state of public health emergency declaration and instead giving this authority to the legislature. The bill also gave the legislature the authority to terminate a public health emergency declaration upon the legislature’s determination that the illness or health conditions underlying the emergency declaration no longer exists. After passage by the legislature, the governor vetoed the legislation.

ASTHO is committed to supporting the work of the U.S. territories and Freely Associated States to improve population health, and will continue to track and share legislative proposals that may yield positive health outcomes for their residents.