The Department of Public Health and Social Services is responsible for public health policies. Guam Memorial Hospital, which is located in the village of Tamuning, provides a broad range of health-care services to residents and people from neighboring islands, such as the Commonwealth of the Northern Mariana Islands and the Federated States of Micronesia. The United States Naval Hospital Guam provides health services primarily to military personnel, but also provides voluntary community services to the civilian community. The Guam Regional Medical City, a private hospital, started its service in 2015 in the north of Guam.

Understanding gaps in the delivery of health care is critical to addressing many of the focus area of the Title V Block Grant. In 2012, the Guam Department of Public Health and Social Services (DPHSS) conducted an island wide community health assessment to identify gaps in public health services and to align resources and island wide efforts to improve population health. Based on the assessment, DPHSS released the Guam Community Health Improvement Plan (CHIP) 2015-2020, a strategic approach to addressing the top public health priorities. Through stakeholder input, public health priorities were selected based on the magnitude of the problem, severity , potential to impact, cost effectiveness, existence of evidence-based models, political feasibility, community readiness, disparities, current trends, and quality of life. Based on outcomes from the prioritization process, the Guam CHIP focuses on the following health issues: 1) Vaccine Utilization; 2) Diabetes and Cardiovascular Disease Mortality; and 3) Cancer Screening (Lung and Cervical Cancer).

Implementation of the CHIP and ongoing assessment of its progress served to identify those barriers in access to health care delivery that negatively affect many of the public health priorities. Those barriers include health care workforce shortages, health insurance coverage, and other socio-demographic factors such as income and poverty.

The US 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 an option for stateside doctors 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 substantially fewer per capita mental health providers than urban areas. Moreover, providers with higher level of specialization in the area of mental health and with greater expertise are extremely scarce.

Medicaid in the United States is a federal and state program that helps with medical costs for some people with limited income and resources. The Health Insurance Association of America describes Medicaid as "a government insurance program for persons of all ages whose income and resources are insufficient to pay for health care."[1] Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States, providing free health insurance to 74 million low-income and disabled people (23% of Americans) as of 2017. [2]

Unlike state Medicaid programs, financing for territorial Medicaid programs is capped, meaning territories can only access federal funds up to an annual ceiling, sometimes referred to as Section 1108 allotment or cap.

The federal medical assistance percentage (FMAP) which is the share of a state’s Medicaid costs paid for by the federal government, ranges from 50% for the higher income states to 83% for the lower income states. The FMAP for the territories is 55%.  An example is – if Guam spends $10 million of its own money on Medicaid services, the federal government at 55% FMAP would put in $12.2 million.

Historically, the amount in Section 1108 allotment funding has been insufficient to fund Medicaid in the territories. In recent years, Congress has provided time-limited increases to supplemental funds available under their Section 1108 allotments. Most recently, the Bipartisan Budget Act of 2018, the Consolidated Appropriation Act of 2017, and the Patient Protection and Affordable Care Act provided funds as follows:

• The ACA provided funding for all territories in two blocks: the bulk of funding was provided and made available through September 30, 2019. A smaller amount was provided and available until December 30, 2019, following the exhaustion or expiration of funds in September 30, 2019.

All sources of supplemental funds will expire in 2019 and Congress is now considering whether the territories will need additional funding to supplement Section 1108 allotments in 2020 and beyond. If no additional funds are available, the territories must consider how to proceed. Options include funding Medicaid entirely with unmatched local funds if available, cutting services or eligibility, or a combination thereof.

Guam is also working to strengthen the collaboration with Title V and Title XIX Medicaid program in our state. State Medicaid and MCH Services share the common goal of improving the health status of the maternal and child health population. Guam has a long‐standing IAA with Title XIX Medicaid. This agreement has helped support the future transformation of an island wide system of care. The agreement provides a way to hold both parties accountable for their individual roles and responsibilities within the agreement. Through the agreement, we have been able to formalize and support an agreed‐upon method for maintaining communication, collecting and sharing data, and exchanging information. By establishing the Interagency Agreement (IAA), we are working collaboratively towards creating stronger state programs with mutual goals that ensure women and children in our state receive needed services. Clear and accessible IAAs can also ensure policy continuity over time as agencies experience staff changes due to attrition and new appointments. These IAAs will reflect the needs and resources of both parties and consider current health care delivery and payment programs. The latter expectation is particularly important in today’s rapidly evolving health care delivery environment. Promoting the culture of collaboration through a partnership can assist in expanding the reach and effectiveness Title V and Medicaid agencies have on their populations and overlapping goals. The efforts made through this partnership can bring awareness to each program’s value.

[1] America's Health Insurance Plans (HIAA), p. 232

[2] Terhune, Chad (October 18, 2018). "Private Medicaid Plans Receive Billions In Tax Dollars, With Little Oversight". Health Shots. .