The Commonwealth of the Northern Mariana Islands (CNMI) is a U.S. Commonwealth formed in 1978, formerly of the United Nation’s Trust Territory of the Pacific region of Micronesia within Oceania. The CNMI is comprised of 14 islands with a total land area of 176.5 square miles spread out over 264,000 square miles of the Pacific Ocean, approximately 3,700 miles west of Hawaii, 1,300 miles from Japan, and 125 miles north of Guam. The CNMI’s population lives primarily on three islands; Saipan, the largest and most populated island, is 12.5 miles long and 5.5 miles wide. The other two populated islands are Tinian and Rota, which lie between Saipan and Guam. The nine far northern islands are very sparsely inhabited with few year-round inhabitants and no infrastructure services. The islands have a tropical climate, with the dry season between December and June, and the rainy season between July and November. Due to the CNMI’s position in the Pacific Ocean, the islands are vulnerable to typhoons. There are also active volcanoes on the islands of Pagan and Agrihan. Saipan, Rota and Tinian are the only islands with paved roads, and inter-island transport occurs by plane or boat.

 

 

In October 2011, Public Law 16-51 dissolved the Department of Public Health and created the Commonwealth Healthcare Corporation (CHCC). CHCC is a quasi-governmental corporation, and while it is a part of the CNMI Government, it is semiautonomous. The CHCC is now the operator of the Commonwealth's healthcare system and the primary provider of healthcare and related public health services in the CNMI. This law transferred all the functions and duties of the CNMI Department of Public Health including management of federal health related grants to the Commonwealth Healthcare Corporation, so that the CHCC is the successor agency to the now defunct Department of Public Health.  The only hospital in the CNMI is also administered by CHCC. The Chief Executive Officer of CHCC is the authorized representative for the CNMI MCH Title V Program. There are three divisions under the corporation: 1) Public Health -- provides preventive and community health programs in which many are federally funded; 2) Hospital; and 3) Community Guidance Center. The Director of Public Health Services also provides oversight to all the public health programs, including the MCH Title V Program.

 

Demographics

According to the 2010 U.S. Census, the population of the Commonwealth of the Northern Mariana Islands (CNMI) is 53,883.  This reflects a 22.2 percent decline (15,338) between 2000 and 2010.  This trend contrasts the previous decade, when the CNMI’s population increased by 59.7 percent to 69,221 residents.  Today the majority of the population resides on the island of Saipan 48,220, followed by Tinian with 3,136 (6 percent), then Rota with 2,527 (5 percent).  By age group, the largest proportion of the decline is among women between ages 20 and 34 (26 percent).  This may be due to the closing of garment factories on Saipan since 2000 that employed a majority of temporary workers from abroad. 

 

Single ethnic groups that accounted for the majority population in the CNMI were identified as Filipino (35 percent), followed by Chamorro (24 percent) and Chinese-except Taiwanese (7 percent).  Carolinians make up about 5 percent of the total population.  Asians were the largest group representing nearly half of the total population.  Native Hawaiian and Other Pacific Islanders made up about 35 percent and Caucasians less than 2 percent.  About 13 percent of CNMI’s population were of two or more ethnic origins or races.

 

Table 1 MCH Population

Population	1990	2000	2010
Infants (less than 1)	824	1,297	1,138
Children (1-12)	8,372	12,701	11,124
Adolescents (13-17)	2,709	3,735	4,372
Women (15-44)	13,669	25,836	12,522

Source:  U.S. Census Bureau

   

                                          

Table 2 CNMI Population by Ethnicity

Ethnicity	1990	2000	2010
Chamorro	12,555	14,749	12,902
Carolinian	2,348	2,652	2,461
Filipino	14,160	18,141	19,017
Chinese	2,881	15,311	3,659
Caucasian	875	1,240	1,343
Other Pacific Islanders	3,663	4,600	3,437
Other Asians	4,291	5,158	4,232
Others	2,572	7,370	6,832

Source:  U.S. Census Bureau

 

CNMI has a large percentage of the population that are uninsured.  The 2010 U.S. Census reports the uninsured population in the CNMI at 34 percent, more than double the 15 percent uninsured rate in the United States.  A challenge with the uninsured population is the status of the immigrant contract workers who are ineligible for Medicare and Medicaid.  In the CNMI, based on 2010 US Census data, residents with Medicaid constitute 32 percent of the population, double the Medicaid rate of the U.S. at 16 percent.

Figure 1. Insurance Coverage in the CNMI- 2010 US Census

                 

 

                       Source: US Census Bureau

               

 

Economy

Since 1998, the CNMI’s economy has suffered one long continuous, downward spiral. A variety of factors contributed to the current circumstance, including the loss of tourism-related business, the effects of rising fuel costs across all of the CNMI, the closing of the garment manufacturing industry, and the implementation of federal Public Law 110-229, which removed local control over immigration. As a result of this confluence, the CNMI government’s revenues have fallen drastically causing the CNMI’s annual budget to drop 56 percent - more than $90 million dollars, over the last 12 years. As such, many jobs have been lost resulting in many people without the financial means, education, and experience needing to relocate to the U.S. mainland. According to the 2010 U.S. Census, 4,061 families in the CNMI had an income that was below poverty level with related children under 18 years old.  Approximately 52 percent of the total population lived below the federal poverty level.  Specifically, 11,693 individuals were living below 50 percent of poverty level, 32,885 individuals below 125 percent of poverty level and 40,368 individuals below 185 percent of poverty level.  Approximately 65 percent of the Filipino population, the largest ethnic group, were living below the poverty line. 

Figure 2. Income Level by Ethnic Group in the CNMI- 2010 US Census

         

              Source: US Census Bureau

 

 

 

 

Healthcare for the MCH Population

Commonwealth Healthcare Corporation (CHCC)

The sole hospital in the Commonwealth of the Northern Mariana Islands (CNMI) was initially established as the Department of Public Health and Environmental Services (DPH) in 1978 by Public Law 1-8.  In 2009, DPH was re-organized into the Commonwealth Healthcare Corporation, a public corporation, under the “Commonwealth Healthcare Corporation Act of 2008” by Public Law 16-51.  The CNMI established the Commonwealth Healthcare Corporation (CHCC), a public corporation in 2011.  The organization of both clinical and public health services in a public corporation is unique in the United States.  The CHCC is responsible for the Commonwealth Health Center hospital; ancillary services; the Rota and Tinian Island Health Centers; and Public Health functions and programs.

The Commonwealth Legislature cited a desire for the hospital to be an “independent public health care institution that is as financially self-sufficient and independent of the Commonwealth Government as is possible.”  Although the CHCC now exists as a quasi-independent institution, it remains a public corporation charged with the responsibility of providing essential health care to the people of the CNMI.  Yet, since its inception, the CHCC has struggled with the transition from a government agency to a public corporation.  In 2017 CHCC had approximately 726 personnel.  The CHCC provides 100 percent of inpatient services and 80 percent of ambulatory services in CNMI.

 

-          Services for Pregnant Women, Mothers, Infants

The Women's and Children's Clinics located at Commonwealth Healthcare Center (CHCC) provide comprehensive primary and preventive services for MCH target group. There are currently four OB/GYN working at the CHCC Women's Clinic and four mid-level providers. There are currently seven pediatricians and one mid-level pediatric provider at CHCC. The MCH Program supports services at both clinics such as case management of high risk patients, development of educational materials including posters and brochures, and staff to assist with developmental screenings and health coverage applications. The HIV/STD screening program, Family Planning Program, and Breast and Cervical Cancer screening program are also offered through the Women’s Clinic. Dental health services are made available to women and infants through the CHCC Dental Clinic.

 

-          Services for Children and Adolescents

Health care services for children and adolescents are provided at the Children's Clinic. Dental health services are also provided at CHCC Dental Clinic. Again, MCH Program provides enabling services such as transportation, translation, referrals, incentives, and educational materials. Through home visiting initiatives, the MCH Program helps families navigate through state programs. Majority of families seek assistance for WIC, NAP, and Medicaid. As previously stated, MCH Program plans to address barriers to health services for all MCH groups in the CNMI.  The utilization of a mobile clinic and expansion of clinical sites offering primary and public health services are planned strategies to improving services for children and adolescents.

 

-          Services for Children and Youth with Special Health Care Needs

One of the main challenges with the CNMI special needs population is the lack of specialty care on island. Families are referred off-island for care which adds financial burden. Through partnerships with Shriners Hospital in Honolulu and the Public School System certain specialty care are offered on island including Audiology, ENT, and selected surgeries. The Shriner’s Children’s Hospital of Honolulu conducts clinic outreach to the CNMI twice a year.

 

Early intervention services for infants and toddlers with special healthcare needs ages zero to three years are provided through a collaborative effort of the CNMI Public School System and the Commonwealth Healthcare Corporation. Funding for services for early intervention services is provided through Part C of the Individuals with Disabilities Act. The CNMI Public School Systems is designated by the CNMI Governor as the Lead Agency for carrying out the general administration, supervision, and monitoring of the early intervention program and activities in the CNMI. Services for children with special healthcare needs age three to five years are provided through the CNMI Public School System’s Early Childhood Program and for those ages five through 21 years through the Part B, Special Education Program. The following services are available for children with special healthcare needs in the CNMI: audiology services, occupational therapy, physical therapy, service coordination, sign language services, speech-language pathology services, vision services, psychological services, and counseling. During the 2016-2017 school year, there were 50 infants and toddlers enrolled in Early Intervention Services program, 48 enrolled in the Early Childhood Special Education program, and 796 enrolled in the Special Education program.

 

Rota Health Center

The Rota Health Center is the only medical facility on the island of Rota and services the entire population of about 2,500.  At present the Rota Health Center has two full time physicians who alternate every two weeks, two registered nurses, five licenses practical nurses and six nursing assistants.  The auxiliary staff includes two x-ray technicians, two lab technicians and twenty-three administrative support staff. The Rota Health Center has emergency, outpatient clinic, pharmacy, laboratory, and radiology units. Public Health services such as the MCHB Family Planning Program, Breast and Cervical Cancer Screening, and HIV/STD Screening are available at the Rota Health Center.

 

Tinian Health Center

The Tinian Health Center is the only medical facility on the island of Tinian and services the entire population of about 3,200.  At present, the clinic has a total staff of 31 personnel including two providers: one doctor and one nurse practitioner alternating every two weeks, four registered nurses, five licensed practical nurses, and one nursing assistant. The Tinian Health Center operates an emergency, outpatient clinic, pharmacy, laboratory, and radiology units. Public Health services such as MCHB Family Planning Program, Breast and Cervical Cancer Screening, and HIV/STD Screening are available at the Tinian Health Center.
 

Kagman Community Health Center (KCHC)

The establishment of the Kagman Community Health Center, a federally qualified health center (FQHC), in 2012 located in one of the remote villages in the southeast part of Saipan has improved access to healthcare services for the MCH population. The KCHC provides outpatient services such as: general primary care, basic diagnostic laboratory, screenings, family planning, well-child, gynecological care, obstetric care, preventive dental, case management, health education and outreach.

 

Challenges that Impact Access to Healthcare

There have been cuts in services including staff as a result of the transition of the Department of Public Health to the Commonwealth Healthcare Corporation. Federal public health grants have been the primary source of funding for services, activities, and infrastructure for programs in the DPHS. The budget cuts, combined with issues surrounding federal immigration policies for healthcare staff causes impedance to securing or retaining nearly any type of medical personnel. The CNMI is also a Health Professional Shortage Area (HPSA) for primary care, dental, and mental health and a medically underserved area. The CNMI licensure regulations require that physicians and mid-level providers hold United States medical credentials in order to practice medicine in the CNMI. This creates a challenge in recruiting and retaining clinicians because salaries are not comparable with similar positions in the US mainland.

 

Uninsured Population

CNMI has a large percentage of the population that is uninsured.  The 2010 U.S. Census, administered prior to the implementation of the Patient Protection and Affordable Care Act (PPACA), reports the CNMI uninsured population at 34 percent, more than double the 15 percent of uninsured in the US.  In 2013, CNMI Public Law 17-92 was passed, which released employers from the responsibility for providing health insurance coverage to non-U.S. qualified workers (legally-present foreign workers). The rate of the uninsured has not been reassessed since this law was passed but has likely increased after this policy change.

 

Inter-Island Medical Referral Services

The Tinian Health Center and the Rota Health Center, which is under the CHCC organizational structure has limited providers and no specialized services.  Inter-island referrals are covered by the CHCC and the Mayor’s Office of Rota or Mayor’s Office of Tinian.  The CHCC pays for the airfare of patients referred from Tinian or Rota and the respective Mayor’s Office pays for the hotel and subsistence expenses for the patient and escort.

 

Off-island Referrals

Treatment services, including access to diagnostic services, not readily available in the CNMI are handled through the Medical Referral Program. Patients are referred to healthcare facilities in Guam, Philippines, Hawaii, or the US mainland. In 2004 the number of off-island medical referrals was 437 patients and since that time the number of referrals has increased steadily to 565 patients in 2007, 924 patient referrals in 2009, and 1,117 patients in 2010. There was a 155% increase in the number of patients referred for off-island care between 2004 and 2010. In an interview with the CNMI Medical Referral Office Director, Ronald Sablan, it was noted that the rise in medical referral patients is largely attributed to a lack of medical maintenance among patients. Patients are increasingly forgoing preventive care and seeking medical attention when health conditions or diseases are at their worst stages and requiring care not readily available on island[i]. An economic crisis that began in the year 2000 impacted both the CNMI population’s ability to be able to access healthcare, more importantly, preventive healthcare and government spending, including spending on healthcare. In the year 2000, the CNMI’s garment manufacturing industry began to slowly close its doors until it eventually completely phased out in 2006. In addition to this, tourism, the CNMI’s second largest industry experienced a major decline. Together, the tourism and garment manufacturing industries accounted directly and indirectly for about 80 percent of all employment in the CNMI in 1995 and made up a large part of the government revenues[ii]. The economic condition of the CNMI during the early 2000s is one in which many individuals were out of employment and the government had little to no means of extending support or relief to community members in response to the economic crisis. Studies have shown that unemployment rates are linked to preventive healthcare utilization, with increases in unemployment corresponding to decreases in individuals completing preventive health services such as pap smears, mammograms, and annual check ups[iii].

 

Data from the CNMI Medical Referral Program for 2018 indicates that there were a total of 1,815 patient referrals for medical care outside of the Northern Mariana Islands.

Figure 3. 2018 CNMI Medical Referrals by Referral Location

                 

 

Referral data indicates that 72 percent of referrals are sent to the neighboring island of Guam, with oncology being the major reason for referral. Overall, the major health categories for referrals include oncology, orthopedics, cardiology, Radiology, and MRI studies. In May of 2019, the CHCC expanded specialty care to include oncology, therefore it is anticipated that there will be an overall decrease in referrals and particularly for reason related to oncology.

 

Health Coverage for MCH Population

As a territory, enrollment in the ACA is not available. However, enrollment into the Medicaid program is enhanced for eligible persons. The CNMI Medicaid program is unique to the CNMI and other US territories and jurisdictions.  The program is “capped” by the US federal government and limited to a set dollar amount allotted to the CNMI.  This limited funding severely affects access, cost, and quality of health care for all residents of the CNMI.  The current state plan limits use of CHIP money to the event where the general program has exhausted its standard funding.   This is a federal restriction imposed on the CNMI based on information verified by local health officials. CHCC is the primary provider for all Medicare and Medicaid beneficiaries in the CNMI, thus restrictions on services are currently enforced on private clinics.

 

Medicaid

Medicaid was first implemented in 1979 and covers approximately 16,000 lives in the CNMI and uses Supplemental Security Income (SSI) as the resource threshold rather than the federal poverty level (FPL) as in most states. As a result, the maximum resource eligibility for the CNMI Medicaid program is slightly less than 100 percent of the FPL. Medicaid is furnished to SSI beneficiaries, and income-eligible individuals who are U.S. citizens, or “qualified aliens” defined under the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), or non-qualified aliens for treatment of emergency medical condition, or lawfully present pregnant women.

 

The framework for Medicaid financing in the CNMI resembles that of the fifty states: the cost of the program (up to a point) is shared between the federal government and the Territory and the federal government pays a fixed percentage of the CNMI Medicaid costs. For the CNMI, that fixed percentage is 55 percent. However, unlike the 50 states, the federal government pays a fixed percentage of the CNMI Medicaid costs within a fixed amount of federal funding. If CNMI Medicaid expenditures exceed the territory’s federal Medicaid cap, which was $6.3 in FY 2017, the CNMI becomes responsible for 100 percent of Medicaid costs going forward. Moreover, the CNMI receives a relatively low fixed percentage, which is known as the Federal Assistance Percentage, or FMAP. The FMAP rate for the CNMI is and historically has been lower than most of the 50 states. The formula by which the FMAP is calculated for the 50 states is based on the average per capita income for each state’s relative to the national average. Thus, the poorer the state, the higher the federal share, or FMAP, is for the jurisdiction in a given year. However, due to the statutory restrictions on Medicaid financing for the Northern Mariana Islands, the FMAP provided the CNMI is not based on per capital income of residents, thus the territories’ FMAP does not reflect the financial need of the CNMI in the same ways that the 50 states’ financial needs if represented. Pre-PPACA, the CNMI and other territories were statutorily capped at 50 percent. In 2011, the rate increased to 55 percent FMAP and jumped again to 57.20 percent until December of 2015, and has dropped again to 55 percent FMAP. In contrast, some states receive over 80 percent FMAP.

 

According to the Medicaid and CHIP payment and Access Commission (MACPAC), in fiscal years 2011 thru 2017, the federal spending for Medicaid in the Northern Mariana Islands exceeded the annual funding ceiling. This spending reflects the use of the additional funds available under the PPACA. The CNMI Medicaid Office has exhausted the additional funds made available by the PPACA in April 2019. As a result of this, all healthcare for Medicaid population has been directed towards the CHCC away from private clinic providers. The CHCC Women’s and Children’s clinic has experienced an influx of patients due to this policy resulting in clinic appointment availability extending from one and half to two months out.

 

Private Insurance

There are several private insurance companies (StayWell, TakeCare, SelectCare, Moylan’s NetCare, Aetna) in the CNMI that provide health insurance to the local government, other employers, and the general public, but individual health insurance plans are not guaranteed to be available to all residents. Private health insurers in the CNMI are not restricted from denying coverage due to health status or other factors.

 

Policies and Regulations that impact MCH Populations

 

Public Law 12-75 "To require the Commonwealth Health Center to provide free counseling and screening of pregnant woman in order to prevent the prenatal transmission of Human Immunodeficiency Virus (HIV) and to provide for clear authority for medical care providers to provide medical care related to the testing and counseling of sexually transmitted diseases, who request such care without parental consent.”

 

Public Law 13-58.  CNMI Health Improvement Act of 2003.  For monies in the Tobacco Control Fund to implement programs and services as follows: (a) Department of Public Health for the CNMI Comprehensive State-Based Tobacco Control Program, the CNMI Chronic Disease-Diabetes Control Program, the CNMI Cancer Registry, the Breast and Cervical Cancer Program, and the Bureau of Environmental Health for the enforcement of local tobacco control regulations; (b) CNMI Office of the Attorney General for overseeing the Master Settlement Agreement and future litigation; (c) Rota Health Center and the Rota youth organization; and (d) Tinian Health Center and the Tinian youth organization.

 

Public Law 15-50. The Vital Statistics Act of 2006. To adopt the “Model State Vital Statistics Act and Regulation Revision” as recommended by the National Center for Health and Statistics and the Centers

of Disease Control to establish a uniform system for handling records that satisfy legal requirements as well as meet statistical and research needs at local, state, and national levels.

[i] Deposa, M. (2014). Off-island Medical Referral on the Rise in CNMI. Saipan Tribune. Retrieved on August 26, 2018 from http://www.pireport.org/articles/2014/01/09/island-medical-referral-cases-rise-cnmi

 

[ii] Office of the Governor, Commonwealth of the Northern Mariana Islands. (2008). Economic Impact of Federal Laws on the Commonwealth of the Northern Mariana Islands. Retrieved on August 26, 2018 from https://marianaslabor.net/news/economic_impact.pdf

 

[iii] State-Level Unemployment and the Utilization of Preventive Medical Services, Nathan Tefft and Andrew Kageleiry. Health Services Research. Article first published online: 16 JUL 2013 | DOI: 10.1111/1475-6773.12091