Island Areas Pursue Policies That Advance Health Outcomes

June 08, 2026 | Beth Giambrone, Takiyah Thomas

The U.S. territories and freely associated states (collectively known as the island areas) do not fall under the category of a state or federal district. Instead, the territories — American Samoa, Guam, the Commonwealth of the Northern Mariana Islands (CNMI), Puerto Rico, and the U.S. Virgin Islands (USVI) — have American sovereignty but no voting representation in Congress. Meanwhile, the freely associated states — the Federated States of Micronesia, Republic of the Marshall Islands (RMI), and Republic of Palau — are sovereign nations that have Compacts of Free Association with the U.S. federal government.

And while these areas do share many public health concerns with their state counterparts, they often face unique challenges, too. Over the past year, island areas have introduced and enacted legislation aimed at:

• Strengthening public health infrastructure.
• Modernizing health care oversight.
• Expanding prevention strategies.
• Addressing health risks shaped by geography, culture, and workforce capacity.

These measures reflect a broader trend toward reinforcing the policy and regulatory structures that shape health outcomes — particularly in jurisdictions navigating geographic isolation, workforce shortages, limited specialty care availability, and unique regional health risks.

Health Care Workforce and Infrastructure

Island areas continue to pursue policies that strengthen health care infrastructure, stabilize the health workforce, and improve the systems that support care delivery. These efforts range from creating more independent community health governance structures to expanding licensure pathways, modernizing data sharing, and adjusting reimbursement structures to better support providers serving Medicaid patients.

One of the ways island areas are looking to strengthen infrastructure is by allowing for more local control of health care, enabling communities to better respond to their needs. Guam enacted PL 38-97, separating the Guam Community Health Centers program from the Department of Public Health and Social Services and establishing it as an independent governmental agency. The law creates a separate Board of Directors that adheres to Health Resources and Services Administration guidelines and includes patient representation. By moving the program into an independent structure, the measure supports local control while maintaining alignment with federal community health center requirements.

Health care workforce shortages remain a significant concern across many island jurisdictions, where geographic distance, limited specialist availability, and workforce migration can create barriers to care access. Guam recently enacted PL 38-107, establishing a physician licensure pathway for graduates of medical schools outside of the United States or Canada as well as a provisional license pathway for foreign-trained physicians, with eligibility for permanent licensure if specified requirements are met. Puerto Rico is considering PS 15, which would modify eligibility criteria for their incentives framework designed to retain and attract highly skilled physicians.

Island areas are also pursuing data modernization and financing reforms to support connected and sustainable health systems. Guam enacted PL 38-27, modifying its Medicaid reimbursement structure for health care providers. The new structure includes a 20% base reimbursement rate, along with additional rebates tied to health care professionals employed by and physical locations of providers serving Medicaid patients. USVI is considering 36-0228, which would establish the Virgin Islands Health Data Utility as a separate non-profit corporation of the government, tasked to establish and manage a Health Information Exchange.

Improving Health Care Across the Continuum

In addition to broader infrastructure reforms, island areas have considered measures aimed at improving health care across the continuum (i.e., emergency response, non-emergency transport, cancer prevention and treatment, long-term care, and services for older adults). A number of bills focused on supporting long-term care infrastructure as well as the welfare of older residents:

• In 2025 Guam enacted PL 38-25, authorizing and establishing licensing regulations for intergenerational care centers, which provide resources and activities for children and older adults in one location.
• CNMI recently introduced SB 24-62, which would establish a framework for the development, licensing, operation, and oversight of long-term care facilities.
• Last year, USVI enacted two bills related to long-term care: 36-0086 expands the eligibility criteria for government employees to receive monthly caregiver leave, and 36-0099 requires the Department of Human Services to develop a multidisciplinary team to improve prevention of and responses to elder abuse complaints.

Island areas have addressed different points along the emergency and non-emergency care continuum through legislation. Guam enacted PL 38-45, providing civil immunity protections to individuals who give emergency aid to people in life-threatening situations and expanding immunity protections to medical personnel who provide emergency aid while off duty. CNMI is considering SB 24-30, which would allow for the certification of non-emergency medical transport ambulances.

Maternal, Child, and Family Health

Island areas are also advancing policies that support maternal and child health, protect vulnerable children, and strengthen family-centered services. Puerto Rico enacted PS 476 in 2025, consolidating existing breastfeeding protections and workplace policies into a comprehensive code. The measure…

• Supports the right for mothers to breastfeed in public and private spaces.
• Prohibits discrimination against breastfeeding mothers. 
• Requires designated lactation spaces in workplaces.
• Promotes education on the benefits of breastfeeding.

The U.S. Virgin Islands recently introduced 36-0278, which would establish immunization requirements for students from daycare through university, and mandates reporting to the Virgin Islands Immunization Registry System.

Island areas also considered measures focused on care to children in the foster and child welfare systems. Guam enacted PL 38-56 in 2025, affirming the rights of foster children and foster parents, including a foster child’s right to equal access to services (i.e., mental health services), and a foster parent’s right to departmental support and additional training if needed. CNMI is considering HB 24-16, which would require the Division of Youth Services to identify and assess suitable family members as caregivers within 24 hours of a child being taken into protective custody. It would also prohibit placing children in protective custody into confinement, such as a juvenile detention center or jail.

Food Safety and Environmental Health

Several island areas are using legislation to address food safety, consumer protection, and environmental health. CNMI enacted PL 24-22 in January 2026, outlining permitting requirements for cottage food operations or home-based businesses that prepare and sell freshly cooked meals directly to consumers, also known as microenterprise home kitchens, with sales under $50,000 per year. RMI is considering the Food Security Amendment Act, which would update current law to include additional registration, licensing, and inspection requirements for food establishments, as well as mandatory yearly food safety training for food handlers.

Two island jurisdictions also introduced legislation focused on environmental issues that can affect public health. USVI’s 36-0240 would prohibit the use of disposable food containers made of polystyrene foam as well as polystyrene packaging, beginning June 2027. CNMI’s HB 24-60 would authorize the Bureau of Environmental and Coastal Quality to establish a permitting process for imported solid waste if certain health, safety, and environmental conditions are met.

Substance Use Prevention, Tobacco Regulation, and Culturally Responsive Prevention

In parallel with health care modernization efforts, island jurisdictions are expanding policy frameworks that address health risks such as those posed by conventional tobacco products and substance use as well as culturally specific substances.

In the past year, CNMI has considered and enacted legislation regarding the use of betel nut (i.e., areca nut). Betel nut is wrapped in a leaf with a powdered limestone mixture and chewed, often with tobacco, has harmful health effects, and is classified as a carcinogen by WHO. Enacted in 2025, PL 24-02 requires a health warning label on all betel nut products imported, distributed, or sold in the commonwealth. It also requires retailers to track and provide information on product sales to the Department of Commerce. In addition, CNMI is considering HB 24-27, which would establish an excise tax on betel nut and lime.

Meanwhile, RMI enacted the Prohibited Drugs (Amendment) Act in 2025, which adds marijuana and marijuana concentrate to the list of prohibited drugs, requires witnesses of activities involving prohibited drugs to report to the national or local police, and provides immunity from civil or criminal penalties for doing so. RMI also enacted the Excise Tax Act, creating excise taxes on several products including tobacco products and soft drinks.

USVI recently enacted 36-0105, directing the Office of Cannabis Regulation to promulgate regulations for retail licenses for Delta-6, Delta-8, and Delta-10 products, and prohibiting the sale and distribution of those products until the office begins issuing licenses. Finally, CNMI is considering HB 24-71, which would create a revolving fund for the Substance Abuse, Addiction, and Rehabilitation Program, and allow it to collect fees to fund operations.

Conclusion

As island areas continue to consider and enact public health law to improve the health of their populations, ASTHO remains committed to supporting their work. It will continue to track and share legislative proposals that may yield positive health outcomes for their residents.