Overview of the State

Guam, "where America's day begins," is the largest and southernmost island in the Marianas Archipelago. The island is approximately 3,806 miles west of Hawaii, 1,500 miles from Japan and 1, 5000 miles east of the Philippines. The island is 30 miles long and 4 to 9 miles wide, giving it an area of 212 square miles, making it the 32nd most significant island in the United States.

The climate is tropical marine, with slight seasonal; temperature variation. There are frequent squalls during the rainy season and, occasionally, potentially very destructive typhoons from June to December.

Guam is an organized, unincorporated territory of the U.S. with policy relations under the jurisdiction of the Office of Insular Affairs, U.S. Department of Interior. The island's Governor and Lieutenant Governor are elected on the same ticket by popular vote and serve a term of four years. A unicameral Legislature operates the legislative branch with 15 seats. The members are elected by popular vote to serve two-year terms. The judicial branch was revamped to create the Unified Judiciary of Guam, consistent with the Organic Act, comprised of the District Court of Guam (federal), the Supreme Court of Guam, and the Superior Court of Guam.

Population

The population of Guam is multi-ethnic, with 153,836. The population comprises the indigenous people of Guam, Chamorro at 34.6%; Filipinos at 30.7%; 7.1% Chuukese; 7.2% White; and 6.9% Other Pacific Islanders, 6.7% Other Asian and 11.6% other groups. English is the most commonly spoken language, with at least six other major languages and numerous dialects. Guam's population included at least 15,000 active-duty personnel and their dependents in 2010, and according to the 2020 Census, Guam's military population is approximately 21,000. Other military personnel are being deployed elsewhere and come to Guam for "short stays" in transit.

The  Table below is Guam’s Population n by Age according to the 2020 Guam Census :

Education

The island of Guam is committed to providing an effective and efficient education system that prepares every student for continuing education and rewarding employment. The territory offers public and private instruction to all residents from preschool through college, with various private and public kindergarten through grade 12, a community college, and a public university.

The onset of the Covid 19 pandemic in March 2020 caused the Guam Department of Education (GDOE) to restructure the 2019-2020 school year. GDOE suspended in-person teaching and implemented remote learning. Computers and internet devices were distributed to students who needed these items. The online educational platforms remained accessible through the end of the school year. GDOE consolidated breakfast and lunch distribution through a "pack and go" drive-thru system. All school activities, proms, and graduations were canceled to stop the spread of the virus. However, several high schools conducted "drive-by" graduation ceremonies. After virtual learning for the past two years, students in all grade levels are returning to in-person learning in 2022.

However, according to the GDOE, enrollment numbers have decreased in the past decade. In the school year 2011, there were approximately 32,000 students; in 2021, there were about 4,042 fewer students from 2011 to 2021. This creates an average decrease of about 513 students per year. Factors like declining fertility rates, migration/emigration rate of school-aged families, and student transfer to private and charter schools can note decreased enrollment.

Enrollment at elementary schools has declined by 15%, middle schools by 16%, and high schools saw a decrease of 11.5%. GDOE is predicting a decline of 3.5% in enrollment to current enrollment at each GDOE school for the school year 2030.

Employment

Employment and average weekly hours paid have continued their recovery from the pandemic lows. Employment numbers began a moderate rebound in December 2020, with the recovery of COVID Pandemic continuing. Total employment as of September 2021 remains 5,240 jobs below the pre-pandemic employment of 67,580 in December 2019 despite an increase of 1,670 jobs in the construction industry. The private sector reduction remains nearly eleven percent below pre-pandemic employment. Preliminary Private Sector employment figures increased from 1,360 in the quarter ending September 2021 and were up by 3,310 jobs over the year. Average weekly hours paid rose from 31.1% to 35.1%, and average weekly earnings increased from $540.82 to $571.17 or 5.6%percent.   Has stated below on the Table below on Guam Employment Situation from June 2022 versus June 2019:Source: Dept of Labor

 

By June 2022, private sector employment was 7.5% below pre-pandemic. By industry, only three industries (agriculture, construction, and manufacturing) have returned or exceeded their pre-pandemic employment levels. Five sectors (transportation and public utilities, wholesale and retail trade, finance and real estate) have yet to return to their pre-pandemic employment levels.

Unemployment

The unemployment in Guam for December 2022 was 4.0%, a decrease of 0.4% from the September 2022 figure of 4.4%, which was a reduction of 3.2% from December 2021. Guam's population covered by the unemployment survey, 16 years and older, in December 2022 was 123,110. The covered civilian population is comprised of those in the labor force and those not in the labor force.  

The December 2022 unemployment rate reflects a decrease in the number of persons unemployed due to an increase in employment and a reduction in the number of persons out of the labor force. The number of persons not in the labor force decreased from 51,950 in December 23021 to 49,740 in December 2022.   As stated in the Chart above on Guam Unemployment Rate from December 2019 to December 2022.

 

 

Cost of Living

The cost of living is the sum required to pay basic prices such as rent, housing, food, utilities, taxes, heating/cooling, and healthcare services in a specific location and time period.

The minimum wage in Guam went from $8.75 an hour to $9.25, following Guam Public Law 35-38. However, the rising cost of goods is canceling the wage increase for many workers. In today's economy, the value of a dollar has shrunk to 48 cents on Guam, compared with its purchasing power in 1996.

Based on the Guam Occupation and Employment Wage estimates, the average hourly wage was $9.07 or $18,870 annually in May 2020. This reflects the 10th percentile of the island’s earning power. At the 90th percentile, the average hourly wage was $313.88, with an average annual salary of $66,303.

The single-person monthly estimated costs are around $2,164. However, a family of four can easily reach around $4,306. According to the Guam Chamber of Commerce, the monthly rent for furnished accommodations in the island capital for an area of 900 sq. feet was around $2,551, whereas the monthly rent for furnished accommodations in other areas was $1,815.

The U.S. average utility cost for two people is around $128. Surprisingly, utilities for two people in Guam are around $275, making it $147 more expensive in Guam. Overall, the cost of groceries is very high, especially for consumables, housekeeping supplies, dairy products, fresh fruit and veggies, other food goods, snacks, and beverages. You can expect to pay 31% more in Guam compared to the U.S.

The primary reason for the high cost of living is the "Jones Act." A century-old law mandates that all cargo shipping between U.S. Ports occur only on U.S. flagged vessels, not foreign vessels. The Jones Act is widely credited with artificially inflating the cost of shipping goods to Guam, other U.S. territories, and Hawaii.

The cost of living has seen a notable increase, one that the U.S. Department of Agriculture's Food and Nutrition Services Supplemental Nutrition Assistance Program has taken into account with adjustments to benefits-eligible Guam residents receive. Formerly known as food stamps, SNAP is a government welfare program that provides nutritional assistance to families and individuals suffering from food insecurity.

Based on the inflation rate, program recipients saw a 12.5% increase in benefits on Oct. 1. In the prior year, SNAP maximum benefits for Guam ranged from $369 to $2,216. Adjusted annually, current allotments for a family of four living in Guam increased to $1,385, and the minimum benefit per person rose to $33.00.

Furthermore, income eligibility requirements have also been adjusted, meaning more families may qualify for SNAP based on net and gross monthly income. The resource limit for households increased by $250 to $2,750 for the 48 states and the District of Columbia, Alaska, Hawaii, Guam, and the U.S. Virgin Islands. The resource limit for households where at least one person is age 60 or is disabled increased by $500 to $4,250.00.

Inflation

Guam's inflation rate was kept manageable in 2020 and 2021 but increased to 6.2% during the first nine months of 2022, meaning that prices of the 160+ items that Guam consumers purchase were 6% higher during July-September 2022 compared to the same time in 2021.The Table on the left is Titled: Guam Inflation Rate for 2017 to 2022,

 

Source: Guam Dept. of Labor

The motor fuel “gas” price rose 15.8% in 2022 but comparatively less than its 29.7% increase in 2021. This is hardly consoling when gas prices for the entire year never went below the average price of $4.58 in 2022, and worse, it stood above $6 per gallon of regular gasoline during June, peaking at $6.49.

The U.S. Department of Agriculture Food and Nutrition Services increased the benefit amounts to SNAP (“aka Food Stamps”) participants by 12.5%, translating to $1,385 per month for a household size of 4. Data also show that the average weekly earnings for employees in the private sector outpaced the official inflation rate as revenues increased 6.4% between January and June 2022 and 13.4% between June 2021 and June 2022.

Poverty Rate

The availability of data from the 2020 Guam Census allowed for Guam's poverty rate to be calculated. Unlike the 50 U.S. states whose poverty rates are calculated by the U.S. Census Bureau annually, Guam does not have an estimate for its poverty rate, although one was calculated for 2020 at 29.7%, more than double the national average.

Below presents an estimate for the poverty rate for Guam for the year 2019, along with the 50 U.S. states using data from the U.S. Census Bureau. It shows that, in 2019, 25.6% of households in Guam had incomes below the federal threshold for a family of four. As shown, Guam's poverty rate is more than double the national average of 10.8% and is higher than Mississippi, which has the highest poverty rate among the 50 U.S. states.

Guam Poverty Rate vs. U.S. Poverty Rate 2019

Of the 25.6% of households living in poverty, 54% were individuals over 18 years of age; 4% were individuals over 65, and 4% were children under 18. When assessing families in poverty status, 41% were married-couple families, 44% were female-headed households, and 15% were male-headed households living in poverty. The Table below stated be and the US Census Bureau 2022.

Source: US Census Bureau

Homeless

Homelessness has been defined as the state of having no home or permanent place of residence. Few social problems are as visible as the light of homeless people. Once almost invisible and easily ignored, homeless people are familiar in cities, suburbs, and some rural areas. Some men roam the streets carrying what is left of their possessions in shopping bags in grocery carts. Women are curled up on benches, stairwells, or abandoned houses. Families, typically mothers, and children, are searching for food and seeking shelter. Homelessness takes many forms, but most people have one thing in common, poverty.

Homelessness has several causes, many of which are closely related. One major cause is a lack of affordable housing. Some people cannot afford rent or mortgage payments because they are unemployed. They may be unable to find work because of physical or mental illness. The loss of a job can cause some families to join the ranks of people experiencing homelessness for days, weeks, or months until another job is found. Other homeless people have jobs but do not make enough money to pay for housing, sometimes because the cost of living in their neighborhood has risen. People may also become homeless after living through natural disasters or personal hardship, such as domestic violence.

Nationally, about a third of the homeless population is less than age 24. Homeless children are more likely to have health problems, developmental delays, learning disabilities, emotional difficulties, and mental disorders than children with stable housing.

In January 2022, the BFHNS and Nista staff both participated at the Annual Point of Time (PIT) survey on January of 2022.  They identified 1,087 individuals that were homeless. Of the 1,087 individuals, 374 (34.4%) were children under 18. This was an increase of 2020 of 31.6%.

Guam Point-in-Time Data

	2017	2018	2019	2020	2022
Households without children	142	143	184	177	223
Households with at least one adult and one child	117	120	112	92	137
Households with only children	0	2	2	2	0
Persons in households with at least one adult and one child
Children under the age of 18	350	359	332	289	374
Persons aged 18-24	70	59	67	41	81
Persons over the age of 24	217	227	218	184	301
Persons in a household with only children	0	2	2	2	0
Unaccompanied Youth
Unaccompanied youth under the age of 18	0	2	2	2	0
Unaccompanied youth 18-24	1	5	12	13	15
Parenting Youth
Parenting youth aged 18-24	7	6	8	1	8
Children of parenting youth	14	3	11	1	11

Source: Guam PIT Count

Medicaid

The uninsured population in Guam is struggling with the high cost of living due to the high cost of living expenses  and insurance premiums. Most goods or commodities are imported. The cost of living in Guam is about 41% higher than in the United States, a family of four estimated monthly cost is easily around $4,306 without rent, and a single person's estimated monthly cost is $2,164 without rent.

Some families in our population are not all qualified under the Guam Medicaid Program because of the program's low-income guidelines. Though Guam's current minimum wage is $8.75, the monthly average income for a full-time employee is $1,517 per month; most people still do not qualify because Guam Medicaid's eligibility determination is based on monthly gross income. The income guidelines for a household of one and four are $1,103 and $2,280 respectively.

The Medicaid Program in Guam differs from the 50 states and the District of Columbia. The U.S. territory's federal matching rate is fixed in statute, unlike the statutory formula for U.S. states. For instance, Guam's Medicaid's Federal Medical Assistance Percentage (FMAP) rate is 55%, the same as the other territories. However, the FMAP for the 50 states and DC varies by states per capita income, which ranges from 50% to 83%. In addition, the Medicaid Program in the U.S. territories is subject to annual federal capped funding, unlike the states and DC, which are open-ended.

On December 21. 2020 Congress passed an Omnibus Covid Relief bill that corrected a nearly 25-year error that unjustly excluded Compact of Free Association (COFA) citizens residing in the U.S. from participating in Medicaid. The exclusion dates back to the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), commonly called welfare reform, which changed the categories of persons eligible for specific federal safety-net programs, including Medicaid. As a result, COFA citizens were stripped of their ability to qualify for these programs. In the aftermath of PRWORA, some states continued to provide healthcare services to COFA citizens using their funds, recognizing the contributions and health needs of COFA citizen populations.

Because Medicaid in the U.S. territories operates differently than in the 50 states and DC, the law required the governor to certify to the Centers for Medicare and Medicaid Services (CMS) that the territory wishes to cover COFA citizens under the Medicaid program. If the governor makes this certification, COFA citizens who meet all other Medicaid eligibility rules would be eligible.

Compact of Free Association

The Compact of Free Association (COFA) between the United States and the Federated States of Micronesia was signed in 1982 and ratified in 1986. This allowed unrestricted immigration into the United States, its territories, and possessions, allowing citizens of these nations to enter into, lawfully engage in occupations and establish residence as non-immigrant citizens. Guam has experienced increased migration since the mid-1980s from the Federated States of Micronesia (mainly Chuuk) as well as from other U.S. Associated Pacific Islands (USAPI) (e.g., Palau and the Marshall Islands).  The map to the left is the islands mentioned earlier dealing with the Compact of the Free Association (COFA).   Generally, individuals who migrate to Guam speak English as a second language and tend to be of low-socio-economic status. According to the Bureau of Statistics and Plans, in 2010, 22.9% of Federated States of Micronesia (FSM) migrants were below the poverty level. Migrants from the USAPI, mainly migrants from the FSM, have significantly impacted Guam's public health system in terms of high cost and disproportionately high rates of (and subsequent treatment of) infectious disease for several decades.

Based on single ethnic group designation in the 1980 U.S. Census of Guam, the number of COFA individuals was low and constituted less than 2% of the population. This grew to 4.1% of the population in 1990, 8.3% in 2000, and 12.1% in 2010, estimated to be 12.7% in 2020.

Compact Negotiations

According to Title II of the Compacts of Free Association, economic assistance is set to expire at the end of FY2023 for the Marshall Islands and Micronesia and at the end of FY2024 for Palau. Compact provisions related to defense, security, migration, and other areas will continue unchanged. Such assistance, called grant assistance, is funded and administered through the Department of the Interior (DOI). The FAS is also eligible for some U.S. federal programs and services. The United States, led by Special Envoy for Compact Negotiations Joseph Yun, and each FAS aim to complete bilateral negotiations to renew economic assistance by May 2023. U.S. negotiating teams have included officials from the Departments of State, the Interior, and Defense. Once negotiators reach bilateral agreements to extend Compact assistance, the President is to submit draft legislation to Congress, and both houses of Congress are to approve them through implementing legislation. In January and February 2023, the United States signed memoranda of understanding with all three Compact countries on the basic levels and types of Compact assistance for the next 20 years  on 2043.

Crime

The 2021 Guam Uniform Crime Report*, violent crimes in 2021 decreased by 5.4% compared to 2020. The violent crime reported and known to police in 2021 was estimated at 3.9% violent offenses per 1,000 individuals.

Violent crime comprises four offenses: murder and non-negligent manslaughter, forcible rape, robbery, and aggravated assault. The volume of individual violations within the violent crime category showed that in a year-to-year comparison from 2020 to 2021, murder increased by 28.6%, rape decreased by 7.8%, robbery decreased by 42.4%, and aggravated assault increased by 10.8%.

The nature and extent of Guam's drug problem have not significantly changed over the years, Crystal methamphetamine or "ice" continues to be the most commonly abused illegal drug on Guam, and it has been the prominent drug of choice in Guam over the past three decades. The drug is smuggled onto the island through the postal service and private express mail. The Philippines, which serves as both a production and transshipment area, continues to be one of the primary sources of crystal methamphetamine. Crystal methamphetamine is also produced and transported from neighboring Asian countries such as Hong Kong, Taiwan, China, and Korea.

Marijuana is another prevalent illegal drug in Guam. Reports from law enforcement indicate that marijuana cultivated on Guam is done more in "grow houses" within residential homes rather than marijuana being grown outdoors in the jungle; Marijuana is shipped to Guma via postal packages or transported via commercial air flights from the U.S. mainland and Honolulu. It has attained a social status similar to other jurisdictions dealing with legalized or medical marijuana law. Guam legalized medical marijuana in 2014 under the Joaquin "KC" Concepcion II Compassionate Cannabis Use Act of 2013 but has yet to get off the ground due to the lack of a testing laboratory and enforcement resources.

Further, in April 2019, the Guam Cannabis Industry Act of 2019 was passed under Public Law 35-5 or the Recreational Marijuana Law. The new law allows those 21 to possess up to an ounce of marijuana, and adults can grow no more than six plants for personal use. People, however, still won't be able to legally buy or sell marijuana until rules and regulations are developed by the Legislature. The law establishes a nine-member Cannabis Control Board to oversee the testing, manufacturing, licensing, packaging, and production of marijuana. The cannabis industry could move forward before any legal sales could begin.

The Guam Police Department Officials has seen an influx of CBD (cannabidiol) products from the mainland transported via USPS and freight forwarding companies such as FedEx and DHL. CBD products have just been introduced into the market and currently do not have an approved manufacturer's listing. As with the recent legislation, of have been significant seizures of several types of marijuana products such as oils, vape juices, edibles (gummies, baked goods), and "dabs" (BHO-butane, honey, oil), which shows that the marijuana industry has become so sophisticated with the diversity of products available on the market.

Recently in June 2023, two middle school students fell ill from using "dab" pens. GDOE declined to go into further detail about the pen used. A “dab” pen is a device used to inhale oil concentrates and other extracts from the cannabis plant, according to the Centers for Disease Control and Prevention. “Dab” may also refer to a wax-like concentrate derived from cannabis.

Military Relocation

The island of Guam is playing a growing role in a contested, troublesome environment. The military relocation of U.S. Marine forces and their families from Okinawa to Guam provided billions of dollars of military projects in the past years and buffered the local economy from what could have been a devastating blow from the Covid 19 pandemic.

The estimated cost of the relocation is $13 billion, with $3 billion funded by the Government of Japan. One of the most significant projects is constructing the Marine Corps Base Camp Blaz in Dededo. The Department of Defense has invested $2.5 billion in Camp Blaz.

The U.S. Marine Corps reactivated a new base on Guam in a ceremony honoring the long-shared history of the Marine Corps and Guam and establishing a forward presence in the Indo-Pacific that will endure into the future.

Guam’s Military newly built Marine Corps Base (MCB) Camp Blaz is the first newly constructed Marine Corps base in 70 years and is a testament to the U.S.-Japan alliance. Guam was chosen as the location for the new base during the 2012 Bilateral Agreement between the U.S. and Japanese governments under the Defense Policy Review Initiative, which set the framework for relocating Marines from Okinawa to Guam. The base is named in honor of Brigadier General Vicente Tomas "Ben" Garrido Blaz, the first Chamorro Marine to attain the general officer rank.

Tourism

Tourism was starting to come back after the post-COVID pandemic and Guam has seeing a slight increase of arrivals of tourist on Guam.  From Japanese, Taiwanese, Vietnamese, Korean, and Filipinos are increasing slowly at the end of December 2022.  So, tourism expenditures represented the largest share of the source of funds flowing into the Guam economy pre-pandemic. The tourism expenditures impact revenue and employment primarily in tourism-supported industries, including transportation services, retail trade, and indirect effects on the economy.

The reduction in tourism due to the COVD pandemic is caused by the avoidance of travel due to concerns for safety for both personal and business travel. It is further reduced due to government-imposed travel cancellations, restrictions, and quarantine requirements. A significant reduction in travel for safety concerns began before government travel restrictions were enacted. To the extent that these concerns linger, recovery in travel will continue to be impacted as government restrictions are lifted. The resumption of significant international travel will require further easing of government travel and quarantine requirements and increased safety and confidence. For international tourism to Guam to flourish, the virus's incidence must be controlled both in the country of origin and destination.

The Guam Visitors Bureau (GVB) has issued tourist arrival projections for 2023. The history of Japanese tourist arrivals shows a pattern of repeated recovery after downturns due to natural or other adverse events. The pace of such a recovery has been considerable in the short time since Korea and Japan's travel restrictions were eased. Effective October 11, 2022, Japan began to allow entry of independent visa-free tourists and abolished the daily arrival cap. Travelers entering Japan from Guam will be exempted from submitting a negative certificate if they have received three times or more vaccinations.

All travelers entering South Korea are no longer subject to quarantine, regardless of vaccination status (as of June 8, 2022). COVID-19 testing is no longer required before departure (as of September 3, 2022).  The visitor arrivals from Korea were fewer than two percent of pre-pandemic levels as of March 2022; only nine months later, in December 2022, their arrivals increased dramatically and exceeded fifty percent of pre-pandemic levels for the respective months. Visitors from Japan were fewer than three percent of pre-pandemic levels in June 2022 and expanded to nearly nine percent over the six months ending in December 2022.  Table below are the countries that have arrived on Guam from 2019 and 2023:

Market	2023	2019	% of ’19 recovered
Japan	130,719	664,784	20%
Korea	372,209	734,339	51%
Taiwan	9,031	28,346	32%
U.S./Hawaii	85,912	94,141	91%
Philippines	17,997	20,708	87%

Total F.Y. 2023 Arrivals Forecasted = 670,000 (41% of 2019 levels)

Health Care Delivery

Guam's healthcare system consists of public and private providers supported by various health insurance options. The Department of Public Health and Social Services is the public health agency for the Government of Guam responsible for creating public health policies to assist the people of Guam in achieving and maintaining their highest levels of independence and self-sufficiency in health and social welfare. Two hospitals serve the residents of Guam as well as neighboring countries. The Guam Memorial Hospital (GMH) is the only public hospital that operates under the oversight of a Board of Trustees under the Guam Memorial Hospital Authority (GMHA). The second hospital is the Guam Regional Medical City (GRMC), a 136-bed privately owned acute hospital with an emergency department and specialty clinics. The island is served by two Federally Qualified Health Centers, the Southern and Northern Regions Community Health Centers, which provide primary healthcare, acute outpatient care, and preventive services and are under Guam's Bureau of Primary Care Services.

During the pandemic year, having two hospitals has been a godsend. With an additional hospital provider in Guam, the unique and unanticipated pandemic scenario has given the island other resources and expertise to help in the fight against a devastating virus.

 

While Covid 19 has devastated Guam hospitals' utilization, finances, and overall operations, the unique crisis has brought an unexpected potential benefit. Significant funding (through the federal government's pandemic relief allocations to Guam) will cover a sizeable portion of the construction cost of a new hospital. Based on the Army Corps of Engineers' projection, it will cost $743 million to build a new medical facility comparable to GMH.

 

The Guam Behavioral Health and Wellness Center (GBHWC) is a public entity providing comprehensive mental health services and substance abuse treatment to adults and children. Medicaid and Medicare are available to Guam residents. In addition, there is a locally-funded Medically Indigent Program for low-income and uninsured residents.

Like many rural areas, Guam has a shortage of primary care physicians, specialists, and psychiatrists. The Health Resources and Services Administration (HRSA) has qualified Guam as both a Medically Underserved Area (MUA) and a Health Professional Shortage Area (HPSA). The shortage of health professionals is primarily attributed to the difficulty in recruiting providers due to Guam's remote island setting, small scale, and territorial status (i.e., not linked to any larger state entity), the physician salary not comparable to the U.S. rate, and the high cost of malpractice insurance. Clearly, with an estimated population of 160,000 individuals, there remains a shortage of primary care physicians, which is felt, most especially among the Medicaid, Medically Indigent, and uninsured patients who struggle to find a provider and a permanent "medical home" since providers on island refuse to accept Medicaid patients due to delayed Medicaid payments. Thus, clients are forced to seek treatment in the hospital emergency room, which is more costly.

The Guam MCH Program focuses on the well-being of the MCH populations of women and infants, children and adolescents, and children with Special Health Care needs (CSHCN) and their families.  The program emphasizes developing core public health functions and responding to healthcare delivery system changes.

As a territory with significant shortages of pediatric medical services and limited existing services, Guam faces many challenges in developing systematic approaches to population-based direct care services. In the past few years, program activities addressed the improvement of access to services for low-income, underserved, or uninsured families, identification of the needs of culturally diverse groups, especially non-English speaking and other immigrant groups, and recognition of changes brought about by lack of access to adequate health insurance coverage, public or private, for a significant percentage of the population. In addition, activities for children and youth with special health care need to be focused on assuring pediatric specialty and sub-specialty services to children and families, integrating data systems, continuing collaborations with private and public partnerships, and integrating community-based services.

Other than the shortage of providers, there are gaps in tertiary care services (there are no tertiary care facilities in Guam as in the U.S.), off-island referrals, and inpatient care services. Additionally, there are instances when off-island hospitals/doctors refuse to accept Guam's Medicaid referrals due to untimely reimbursements. Thus, the difficulty of accessing health care (facilities and specialists) increases patients' physical and emotional stress, reducing the likelihood of seeking medical care, and so they forgo medical care until their condition worsens and they have to be hospitalized.

Given the above factors, the cost of providing health care in Guam is relatively high because of its unique geographic location, limited primary care physicians, specialists, and allied health professionals, and lack of tertiary care facilities.

Similarly, the cost of drugs is more expensive in Guam compared to the U.S. due to the limited number of pharmaceutical wholesalers and distributors that can ship drugs and medical devices to Guam effectively compared to hundreds of companies available in the U.S. mainland. These vendors may exploit this lack of competition by imposing a higher medication price. Other factors contributing to the high cost of pharmaceuticals are the shipping costs and the stocking of drugs with a limited shelf life.

The DPHSS held a Pan Flu Retreat for reviewing finalizing the different chapters of the Plan, this event gave the different clinics, hospitals, health care agencies and program. To sit together to discuss the issues and draft the future plans of the DPHSS Pan Flu Emergency Plan has a whole to provide input and strategies that can help our staff prepare for any future disaster.  It’s Plan, Practice together, Apply the interventions, and evaluate the process of the plan.