In Guam, the delivery of healthcare services is mixed. Services are provided by the Department of Public Health and Social Services (DPHSS) and the Guam Behavioral Health and Wellness Center (GBHWC), formerly known as the Department of Mental Health and Substance Abuse (DMHSA). The Guam DPHSS is organized under five divisions, the Division of General Administration, the Division of Public Health, the Division of Environmental Health, the Division of Public Welfare, and the Division of Senior Citizens.

There are two civilian hospitals on Guam, the Guam Memorial Hospital Authority (GMHA) located in Tamuning and the Guam Regional Medical City (GRMC) located in Dededo. There is a U.S. Naval hospital for the military and their dependents located on the Guam Naval Base. There are also several private clinics located on Guam, including many specialty clinics.

The U.S. Department of Health and Human Services has designated Guam as a Health Professional Shortage Area (HPSA). HPSA status is granted to areas that demonstrate a need in one or more of the following categories: primary care (including family and general practitioners, pediatricians, obstetricians, and general internists in allopathic or osteopathic), mental health, and dental care.

Guam was also designated as a Medically Underserved Area (MUA), which now provides stateside doctors an option to work off a portion of their medical education loans by serving as a physician on Guam. Guam has a mix of public and private providers, including four large private primary care and multi-specialty clinics (all located centrally within a few miles of the public hospital), about a dozen private practice clinics, and a privately-owned birthing center.

There are more than 300 physicians (licensed), 28 dentists, 6 personal and family counselors, and 11 optical centers. When addressing health disparities, it is important not to overlook the mental health of a population. Most of the work done in the Pacific area is not specific to Guam but remains the best approximation until more focused research is done on Guam. Pacific island areas have fewer per capita mental health providers than urban areas substantially. 

Moreover, providers with a higher level of specialization in mental health and greater expertise are extremely scarce.

Medicaid and Medicare programs are available on Guam. There is also a locally funded Medically Indigent Program (MIP) designed to pay for low-income families' medical expenses without other health insurance. Those who don't qualify for assistance may opt for private insurance.  There are several health insurance providers on Guam. Approximately 75% of Guam residents have health insurance. Although Guam has many more medical services available than the other USAPIs, patients still need to go off-island for certain specialty care.

The Compacts of Free Association are joint congressional-executive agreements between the U.S. and the FSM, the RMI, and the Republic of Palau. These agreements establish in part that citizens of the areas may enter, engage in an occupation, and select residence as non-immigrants (a status that typically non-permanent visitors such as tourists or students) in the United States and their territories and possessions.

Pacific Islanders migrating to the United States from the RMI, FSM, and Palau are referred to as COFA migrants. Overall, Pacific Islanders have more chronic diseases and are more likely to be uninsured than non-Hispanic Whites in the United States, with 7.8% of Pacific Islanders uninsured compared with 6.3% of non-Hispanic Whites uninsured. Among Pacific Islanders in the United States, COFA migrants face even greater health disparities and are more likely to be uninsured, with approximately 50% of the uninsured COFA migrant population. Because of a lack of insurance, COFA migrants often cannot access preventive care and have a significantly higher prevalence of type 2 diabetes, hypertension, and other chronic conditions.

Compact of Free Association migrants face barriers to health insurance coverage in the United States. When the COFA agreements were first signed, COFA migrants were eligible for Medicaid as lawfully present migrants. After the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) was enacted in 1996, COFA migrants were excluded from Medicaid because they were not included in the category of “qualified immigrants.” With the enactment of the Affordable Care Act (ACA) in 2010, COFA migrants are required to purchase health insurance. They are eligible for advanced premium tax credit subsidies and are subject to financial penalties for not enrolling in a health plan. Although many meet the Medicaid's income and asset requirements, COFA migrants are not eligible for Medicaid or Medicaid Expansion established through the ACA.

Without health insurance, COFA migrants lack preventive or primary care. While public insurance, such as Medicaid, might expend less on premiums, the consequence is greater costs to the health care system. Patients often suffer complications from unaddressed chronic disease and end up in emergency departments of hospitals. The financial costs are higher and shifted to hospitals, which are often reimbursed by state or federal funding for uninsured care. However, the greater tragedy is that individuals denied preventive and primary care end up getting sicker and dying.

The GAO report also states the Medically Indigent Program pays for healthcare costs of primarily non-U.S. citizens living in Guam, including compact migrants, who do not have other health insurance. "Most Compact migrants in Guam qualify for this program after meeting the six-month residency requirement," according to the GAO report, quoting Guam officials.

Eligibility rules in Guam’s Medicaid program differ in some ways from those in the states. Guam is permitted to use a local poverty level to establish income-based eligibility for Medicaid and is exempt statutorily from requirements to extend poverty-related eligibility to children and pregnant women and qualified Medicare beneficiaries. Guam currently provides coverage to individuals, including children, with modified adjusted gross incomes up to 133 percent of the Guam poverty level. Guam has expanded Medicaid eligibility to the new adult group under the Patient Protection and Affordable Care Act. 

Guam uses CHIP funds as an additional funding source for children in Medicaid after it has exhausted its Medicaid allotment. It does not offer coverage to children whose incomes are above the threshold for Medicaid eligibility.

Federal rules for Medicaid benefits generally apply to Guam, and its Medicaid program provides all mandatory benefits and many optional benefits, including dental coverage and prescription drugs. Guam is the only territory that covers all mandatory benefits, including nursing facility services. Enrollees can receive care outside of the territory with prior authorization, when medically necessary, and when services are not provided in Guam. All Medicaid enrollees under age 21 are eligible to receive early and periodic screening, diagnosis, and treatment (EPSDT) services.

Individuals in the new adult group are enrolled in an alternative benefit plan (ABP), which uses the territory employee plan as a benchmark benefit package. Medically frail members of the new adult group have the option of enrolling in the ABP or the traditional Medicaid plan. Enrollees under 100 percent GPL do not have any cost-sharing, but those over 100 percent GPL, including those enrolled in the ABP, must make small co-payments on prescription drugs.

Guam provides cost-sharing assistance to dually eligible individuals who are eligible for full Medicaid benefits. It does not provide Medicare cost-sharing assistance to individuals who may qualify as partial dually eligible individuals in the states, through Medicare Savings Programs, because of these.

No Medicare Part D plans are currently available in Guam, but dually eligible individuals with cost-sharing for prescription drugs can receive subsidies through the Enhanced Allotment Plan, referred to as 1935(e) funding. The Enhanced Allotment Plan provides additional federal funding allotments to Guam and the other territories to help low-income beneficiaries purchase prescription drugs. The allotment is not countable toward the ceiling on federal financial participation and can only be used for this purpose (§ 1935(e) of the Act).

The Federal Medical Assistance Percentage (FMAP) for Guam and the territories is statutorily set at 55 percent (§ 1905(b) of the Act), unlike that of the states, which are set using a formula based on states’ per capita incomes. Guam’s CHIP enhanced FMAP is 91.5 percent through September 30, 2019. Like the states and other territories, Guam’s matching rate for almost all program administration is set at 50 percent (§ 1903(a)(7) of the Act).