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