Island Areas 101

To improve population and community health, ASTHO supports the work of U.S. territories and freely associated states (FAS), which are sovereign nations that have entered into Compacts of Free Association with the United States. ASTHO's members include the chief health officials of the five U.S. territories and three freely associated states and are collectively referred to as the Island Areas or Island Jurisdictions.

Each island jurisdiction has its own unique context, history, needs, and relationship with the U.S. When working with the island areas, it is important to understand the differences between island jurisdictions and as compared to U.S. states.

Sovereignty is a significant difference between the U.S. territories and FAS. The FAS are independent nations connected to the U.S. through the Compacts of Free Association, under which the U.S. government agreed to provide economic and technical assistance, ensure U.S. military defense support, and allow unrestricted travel to and from the United States for these non-resident FAS citizens. In return, the FAS agreed to give the U.S. Government unlimited and exclusive use of their land and waterways for strategic purposes. So, the three FAS are members of the World Health Organization and vote in the World Health Assembly, but the five territories are not members and are represented by the U.S. delegate.

Other distinctions include citizenship and differences in federal program and funding eligibility such as Medicaid, Medicare, SSI, and Veterans Affairs. The chart below summarizes these differences in political status, citizenship, visa requirements, and Medicaid and Medicare eligibility between the island jurisdictions.

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A PDF version of the island jurisdiction profiles is available for download.

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Table 1: Territories and Freely Associated States

Jurisdiction Flag Political Status U.S. Citizens? Vote for U.S. President? Reside/Work/Travel in U.S.? Medicaid/Medicare Eligible? Serve in U.S. Military?
Puerto Rico Flag of Puerto Rico Territory Yes No Yes Yes, capped Yes
USVI Flag of the U.S. Virgin Islands Territory Yes No Yes Yes, capped Yes
Guam Flag of Guam Territory Yes No Yes Yes, capped Yes
American Samoa Flag of American Samoa Territory No (U.S. Nationals) No Yes Yes, capped Yes
CNMI Flag of the Commonwealth of the Northern Mariana Islands Territory Yes No Yes Yes, capped Yes
RMI Flag of the Republic of the Marshall Islands Sovereign (except military) No No Yes No (migrants in U.S.: yes, 2021) Yes
FSM Flag of the Federated States of Micronesia Sovereign (except military) No No Yes No (migrants in U.S.: yes, 2021) Yes
Palau Flag of the Republic of Palau Sovereign (except military) No No Yes No (migrants in U.S.: yes, 2021) Yes

Health in the Island Areas

Each island jurisdiction has its own unique context and needs, which are important to understand when partnering with them. To learn more about a jurisdiction's health system, history, and relationship with the U.S., click on the corresponding links below.

American Samoa

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Commonwealth of the Northern Mariana Islands

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Federated States of Micronesia

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Guam

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Puerto Rico

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Republic of Palau

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Republic of the Marshall Islands

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United States Virgin Islands

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