Island Areas 101

To improve population and community health, ASTHO supports the work of U.S. territories and freely associated states (FAS), which are sovereign nations that have entered into Compacts of Free Association with the United States. ASTHO's members include the chief health officials of the five U.S. territories and three freely associated states and are collectively referred to as the Island Areas or Island Jurisdictions.

Each island jurisdiction has its own unique context, history, needs, and relationship with the U.S. When working with the island areas, it is important to understand the differences between island jurisdictions and as compared to U.S. states.

Sovereignty is a significant difference between the U.S. territories and FAS. The FAS are independent nations connected to the U.S. through the Compacts of Free Association, under which the U.S. government agreed to provide economic and technical assistance, ensure U.S. military defense support, and allow unrestricted travel to and from the United States for these non-resident FAS citizens. In return, the FAS agreed to give the U.S. Government unlimited and exclusive use of their land and waterways for strategic purposes. So, the three FAS are members of the World Health Organization and vote in the World Health Assembly, but the five territories are not members and are represented by the U.S. delegate.

Other distinctions include citizenship and differences in federal program and funding eligibility such as Medicaid, Medicare, SSI, and Veterans Affairs. The chart below summarizes these differences in political status, citizenship, visa requirements, and Medicaid and Medicare eligibility between the island jurisdictions.