By Jack Niedenthal
Marshall Islands Social Security Administration (MISSA) Board Vice-Chairman

Article II, Section 15 of the Bill of Rights of this country states, “The Government of the Republic of the Marshall Islands recognizes the right of the people to health care, education, and legal services and the obligation to take every step reasonable and necessary to provide these services.”

The above Section of our Constitution is perhaps a bit vague as it stands, but it becomes more poignant when you read Chapter 2, Section 218, entitled “Government Subsidy,” of the Social Security Health Fund Act, which states the following:

1. Beginning with the fiscal year commencing October 1, 1991, and for each of the four subsequent fiscal years, it is estimated that the administration of this Chapter shall require a Nitijela appropriation of the following amounts to maintain the Fund on an actuarially sound basis:

1. Fiscal year commencing October 1, 1991: $6,000,000
2. Fiscal year commencing October 1, 1992: $6,250,000
3. Fiscal year commencing October 1, 1993: $6,500,000
4. Fiscal year commencing October 1, 1994: $6,750,000
5. Fiscal year commencing October 1, 1995: $7,000,000

2. During the fiscal year commencing October 1, 1994, and every five years thereafter, the Marshall Islands Social Security Administration Board shall determine the Government subsidy necessary to continue the Health Fund on an actuarially sound basis for the next five year period.

For those without calculators handy, that amounts to what was supposed to be an initial investment of $32,500,000 in our health care system, with at least as much invested over the past 6 years. According to the law, that’s almost $70,000,000 to date. This is fairly interesting since, as it was mentioned in the Journal a while ago, none of the above has ever happened. Instead, our health care system has been living off of haphazard budget reprogramming exercises–and even thievery–for over ten years.

During this recent Nitijela session, some members have been casting around trying to place blame for the most recent collapse of our off-island referral system. The reason is actually very simple: As was mentioned by the Minister of Health in the Journal a while back, over the years the body that created the above law, the Nitijela, which includes both political parties in equal proportions of guilt, has NEVER followed the legislation that was supposed to provide this nation with a sound on-island and off-island health care system. We are at the stage now where it is probably impossible for the RMI to return to credibility with hospitals and drug vendors overseas unless about $8 million is found quickly. This figure includes paying past bills (some of which are almost ten years old), paying the over $2 million owed to the retirement system from the Health Fund, and, more importantly, upgrading our on-island health care capabilities. If we don’t find the money, hospitals in Honolulu demanding full payment up front for services, as they have off and on for the past year, will quickly become a standard practice. That means that if you are wealthy and flush with cash, you’ll get treated. But where does that leave the other 60,000 citizens of the Marshall Islands? The million dollar appropriation headlined in the newspaper weeks ago is just a band-aid, a temporary fix for a very big problem.

Several weeks ago the MISSA Board passed a resolution to request that the Nitijela create and ratify a Bill that turns over all responsibility to run the referral program and the health system from MISSA to the Ministry of Health. This is for a very good reason: As the aforementioned law states, this system was never designed to be solely operated by the tax revenues collected by MISSA; it was designed to be subsidized–-quite heavily–-each year by the Nitijela. Since these substantial subsidies failed to occur in the early years as the law dictated, the subsequent administrations weren’t left with many alternatives. The previous administration chose to unlawfully steal money from the Social Security retirement fund to cover medical costs. After inheriting a program that had completely unraveled fiscally, the current MISSA Board, once we crunched the numbers, immediately realized that the system could not work as designed unless these subsidies were entirely incorporated into the fiscal year budget. While we stopped the robbery that was going on with the retirement fund, we discovered that getting the needed funding from the current administration was proving to be difficult because this area has always been neglected in the budget process.

With inadequate fiscal year funding in place, the new MISSA Board, because of the Health Fund Act law and our refusal to “borrow” from the retirement fund, became by default a group of honorary beggars for the nation’s health care system as we were forced over and over again to go banging our tin cup in front of the government to get them to cough up the necessary funds to cover referrals and health care related supplies and equipment for the country. One administration official jokingly refers to the MISSA Board members as “demons” because we are always up on the fourth floor asking for money. It has been very uncomfortable, frustrating and aggravating for everyone involved.

MISSA’s feelings of disappointment have often been compounded by the many misconceptions about why this off-island health care crisis keeps reoccurring. There is now a Bill on the Nitijela floor that kills the Supplemental Plan in Honolulu because there is a perception that this plan is a main cause of our referral funds drying up. This is not even close to being true as the Supplemental Plan is now very close to paying for itself: the numbers back this up as the revenues collected for this plan increased from $298,000 in FY 2000 to $460,000 in FY 2001 (about a 60% increase), and in this current FY year revenues collected will easily be over $500,000. The Nitijela is hardly giving the Supplemental Plan a chance to prove it can work if administered in a sound and auditable fashion. Most of our huge deficit is a result of a large number of referrals from the Basic Health Care Plan because the hospital is inadequately supplied with proper diagnostic and life sustaining equipment, and that is where the focus should be.