There are about four million citizens living in the U.S. territories, yet they’re seldom considered in the calculus of national policy decisions. That blind spot is especially prominent in health-policy decisions, as the territories are uniquely dependent on federal programs and don’t have the same kind of latitude or flexibility as states to respond to the needs of citizens—who tend to be both poorer and sicker than their mainland counterparts.

When health-policy issues in the territories have made national news, they’ve almost exclusively come from Puerto Rico, by far the largest territory, and one currently facing public-health and solvency crises. But there are four other permanently inhabited territories, each with distinct governments and health-care needs. One of those territories is the U.S. Virgin Islands, where the territorial government has been working to solve health-care budgetary issues by restructuring its health-care safety net programs and eligibility, and by challenging some federal rules that have reduced its flexibility.

I spoke to U.S. Virgin Islands Governor Kenneth Mapp during his latest visit to Washington, D.C., about that restructuring, those federal rules, and the ways in which ongoing battles over Obamacare, Trumpcare, and—perhaps—“Medicare for all” affect the territory’s citizens. The following interview has been edited for length and clarity.

Vann R. Newkirk II: This is definitely an interesting time to visit Washington.

Kenneth Mapp: It's been a very interesting time to visit Washington since January 21, I believe. But in a storm there's some quiet corners and you can actually get some work done. My meetings with the congressional leadership have been going well. Every six to nine weeks I come to Washington and meet with Congress about specific issues that related to the Virgin Islands and our agenda.

Newkirk: What's at the top of your list of issues?

Mapp: A lot of things are near the top of my list. In an insular area, coming out of a recession, there are just a lot of things to deal with. Economic growth, federal relations, and infrastructure development, to start. One of our big issues is fiscal stability, and getting away from borrowing working capital every fiscal year.

When I was here in the National Governors Association meeting in February, most of the governors, regardless of which side of politics they were on, remained concerned about what the federal approach would be to health-care reform. There are fixes for us that can take place under the current Affordable Care Act. I'm not sure that throwing it out and trying to start from scratch is the best way.

Newkirk: What kind of fixes?

Mapp: I had 22,000 folks on the expanded Medicaid program when I entered office and now we've qualified another 19,000. So about 40 percent of my 100,000 population will depend on it. While there need to be improvements to the law, that's a significant number of people in a single jurisdiction.

Newkirk: How did you manage that increase of the Medicaid population?

Mapp: We requested an increase in the federal poverty level, by moving the minimum qualifying income up. The poverty level was at $8,100, and we selected the federal poverty level of $11,770, and that opens up another 19,000 people.

Newkirk: What’s the structure of health care in your territory?

Mapp: In the Virgin Islands, we've long had universal health-care. For decades we grappled with this issue of making sure there's money for the hospitals, because we have a law that says the hospitals—the only hospitals in the Virgin Islands are public—cannot deny benefits or services because of a person's inability to pay. That's not just for emergency services, that's not just for a person who fell off a ladder and needs sutures—it's everything.

Just take a pregnant mother who ends up with a premature birth, and that premie baby needs intensive care. If it's unavailable on the Virgin Islands, the hospitals have to put that mother and baby on an air ambulance and fly them to the mainland to a facility where they can be cared for. When public hospitals make those decisions, the government of the Virgin Islands foots that bill. We've had instances where people have been transferred to mainland facilities, and when it was all finished the bill was over $600,000. That comes directly out of the treasury. So if you relate that back to an expanded Medicaid program, any ceding of expense to the federal government is a reduction of costs for the Virgin Islands.

Newkirk: Can you give me a picture of the health-care infrastructure in the Virgin Islands?

Mapp: The hospitals are old. They were built in the '80s. They're larger than they need to be. They were 250 beds apiece. Our census of demand at high-peak times now is not even 120 beds territorially. So we don't need 500 beds. But they're old and their infrastructure is crumbling in certain respects, so we had to move $20 million to them to take care of those issues. I can't afford to have a hospital close. But in our strategy in terms of looking forward and looking at opportunities, we've made the decision that we have to pursue new hospitals. Whether it means a takedown of the facilities that currently exist, or a radical amendment or change of those facilities that produces a new facility, we've no option but to do that.

Newkirk: Where does health-care rank among your priorities?

Mapp: Well, it's very high. You can't do anything if you're not well. The Virgin Islands, as in any community, cannot have persons unattended and unwell. If we just look at the American economy, valued I believe around $17-18 trillion, $4 trillion is dedicated to health-care costs. We can't afford to deprioritize health care to save money. That won't work. When the buildings need care, you have to find the funds to do it.

Newkirk: People don't usually think about the large population of people of color in the territories when they talk about health reform, minority health, and health disparities. How can those ideas be expanded to include the Virgin Islands?

Mapp: National government as a whole doesn't really see the issues in the territories and how national policies affect them.

My discussions are centered around how national policies affect the quality of life for the American citizens living in the territories. We're not some other group of people. And let's just be candid: People have chosen to leave the Virgin Islands and take up full residence in mainland citizens across the country, and likewise people from the mainland have packed up their families and are living in the territories. The question is, should a national government have different policies in how it treats American citizens based on where they reside?

Newkirk: What's your forecast for how our national conversation on health care will affect the Virgin Islands?

Mapp: The United States cannot continue the policy of putting the burden of all medical costs on the private sector. And it can't sustain this trajectory of yearly increasing costs. We're a little under 25 percent of GDP for health-care costs in the nation. What that would mean if it get to 30, 33, or 40 percent would be disaster. Premiums would be through the roof. What it would do to the Medicare and Social Security fund would be horrendous. And those things deeply affect the Virgin Islands, too. The Affordable Care Act was certainly a step in the right direction. It didn't fix everything, and it wasn't designed to fix everything.

But most developed nations have what folks like to call social medicine or universal care. And while there are cons about that, there are some pros for us. I don't know if the United States government needs to go completely to a system like England's or Canada, but its current form is unsustainable. For the Virgin Islands, we are really about figuring out how to create a real policy for care for those who can't afford to pay, how to create a market so there's insurance coverage for those who can afford to pay, and how to make that system work within the national conversation around care. Our little island and our little policies are like throwing a pebble in the ocean. They're not going to create policies for the territories individually, but we need to make sure that we work with the national government and make sure our voice is heard, to ensure that we're not crushed by change. If the national government moves more towards a universal system, then we benefit.