The Insular Cases Revisited: Guam, Federal Medicaid Funding, and Constitutional Subordination.

Citizenship is part of the foundation of being American. Yet the United States treats some of its own as second class citizens. Deep in the South Pacific, forgotten amidst the vast ocean and coconuts, is a small series of islands that represent the only U.S. jurisdiction below the Equator. American Samoa remains the last American territory that does not recognize its inhabitants as citizens. For more than a century, American Samoans have fought American wars, pledged allegiance to the American flag, and played a significant amount of American football, yet are categorized as U.S. nationals rather than citizens.Recently, some Samoans lost a suit against the Department of State to declare all those born in American Samoa as U.S citizens under the Fourteenth Amendment’s citizenship clause in the case of Tuaua v. United States. The case resurrected a series of early twentieth century Supreme Court decisions concerning American expansion and the territories known as the Insular Cases. These cases developed a framework for applying parts of the Constitution to territories without fully accepting them as American. As one justice described it, the territories are “foreign to the United States in a domestic sense.”However, the concept of citizenship is not necessarily welcomed by Samoans, even while they remain adamantly pro-American. Despite significant Western influence, they have managed to maintain their cultural institutions dating back thousands of years. They fear that citizenship, and the Constitutional responsibilities that come with it, may erode what is left of their culture. The Insular Cases, once devised to subvert a people, are now seen as the last salvation of a culture.This paper attempts to navigate the Insular Cases and subsequent case law to determine whether citizenship for American Samoans is a fundamental right. In Tuaua, the plaintiffs sought to overturn the Insular Cases, while the court viewed the Insular Cases as a ban on citizenship. However, this paper finds a path to provide citizenship for American Samoans within the Insular Cases’ doctrine that would protect their rights as well as their culture and institutions.

In the aftermath of the Spanish-American War and the subsequent Treaty of Paris (1898), the United States acquired the territories on Guam, the Philippines and Puerto Rico. In the process of creating new governments and regulating trade, Congressional policies led to legal challenges over the application of habeas corpus in Cuba, the universality of duties and tariffs between the United States and the territories, and, the extension of trial by jury to the territories. In what would become known as the Insular Cases , the Supreme Court legitimized a policy of imperialism as it allowed Congress the plenary power to treat the territories, and their inhabitants, as being “foreign in a domestic sense.” In this legal limbo, Congress possessed the plenary power to create policies for the territories while, at the same time, it denied the territories Constitutional rights and protections. It is my argument that the Insular Cases controversy represents a debate over what role the United States would play in foreign affairs at the beginning of the 20 th century. This debate centers on romantic narratives of the United State’s duty to itself and the rest of the world. According to Hayden White, romantic narratives employ a good versus evil or redemption versus sin plotline to understand the development of a conflict. In relation to the Insular Cases , this romantic style of narrative justifies the acquisition and governance of the territories while also providing a means to critique their acquisition and rule. When dissenting in the Insular Cases , Justice Harlan argues that the constitutional silence from which the plurality and then majority legitimize Congressional power to deny the inhabitants of the acquired territories creates a crisis in republican government as it undermines the constitution of the United States. To emphasize this crisis in republicanism, Justice Harlan employs rhetorical echoes that compares the Insular Cases to three of the most important debates during the American Revolution and the constitutional ratification debates: the problem of imperium in imperio, the problem of legislative supremacy, and the denial of fundamental right of trial by jury, especially trial by jury. Though unsuccessful, Justice Harlan’s critique in his Insular dissents provides scholars with a means to critique imperialism through a Constitutional framework, allowing for the development of an anti-imperialistic legal and political rhetoric.

The Insular Cases are a set of early twentieth‐century US Supreme Court cases establishing the legal relationship between the United States and its territorial acquisitions. The Insular Cases have received limited scholarly attention in geography, despite their integral role in continuing to deny full constitutional protections to over 3.5 million American citizens and nationals. Informed by conceptualisations of territory as both process and political technology, political geography offers a critical lens through which to interpret the spatial implications of the Insular Cases. This article conducts a discourse analysis of the Insular Cases, tracing the US Supreme Court's creation of incorporated and unincorporated territorial statuses as they are positioned within contemporaneous racist logic and international norms. I argue that, by inventing differentiated categories of territory, the Insular Cases sought to spatially accommodate white supremacist imaginaries. This paper advances political geography by centring the judicial production of American territorial categories, and adds a geographic perspective to existing literature that interrogates the white supremacist, imperialist source of territorial status today.

When the United States took control of Cuba, Puerto Rico, the Philippines, and Guam following the Spanish-American War, it was unclear to what degree these islands were actually part of the U.S. and, in particular, whether the Constitution applied fully, or even in part, to their citizens. By looking closely at what became known as the Insular Cases, Bartholomew Sparrow reveals how America resolved to govern these territories. Sparrow follows the Insular Cases from the controversial Downes v. Bidwell in 1901, which concerned tariffs on oranges shipped to New York from Puerto Rico and which introduced the distinction between incorporated and unincorporated territories, to Balzac v. Puerto Rico in 1922, in which the Court decided that Puerto Ricans, although officially U.S. citizens, could be denied trial by jury because Puerto Rico was unincorporated. There were 35 Insular Cases in all, cases stretching across two decades, cases in which the Court ruled on matters as diverse as tariffs, double jeopardy, and the very meaning of U.S. citizenship as it applied to the inhabitants of the offshore territories. Providing a new look at the history and politics of U.S. expansion at the turn of the twentieth century, Sparrow's book also examines the effect the Court's decisions had on the creation of an American empire. It highlights crucial features surrounding the cases - the influence of racism on the justices, the need for naval stations to protect new international trade, and dramatic changes in tariff policy. It also tells how the Court sanctioned the emergence of two kinds of American empire: formal territories whose inhabitants could be U.S. citizens but still be denied full political rights, and an informal empire based on trade, cooperative foreign governments, and U.S. military bases rather than on territorial acquisitions. The Insular Cases and the Emergence of American Empire reveals how the United States handled its first major episode of globalization and how the Supreme Court, in these cases, crucially redirected the course of American history.

Insurance coverage of abortion varies widely across the United States and is an extensively debated issue. Medicaid coverage of abortion is particularly relevant because the majority of abortion patients are poor or low-income and are thus often covered by Medicaid. Since the Hyde Amendment was first passed in 1976, federal Medicaid funds have been banned from covering the costs of elective abortion. Although states are allowed to use their own funds to cover abortions for their Medicaid recipients, only 17 states currently do so. Of these 17 states, only five cover abortion costs voluntarily; the others do so pursuant to court order. The medical literature includes few ethical analyses of the Hyde Amendment's ban on Medicaid funding of elective abortions. To fill this gap, we perform an ethical analysis of federal policy to fund elective abortions using a consequentialist approach focused on consequences for pregnant women and their children.

Conservatives and liberals alike are increasingly calling for condemnation of the Insular Cases—a series of U.S. Supreme Court cases from the early 1900s, in which the Court developed the doctrine of territorial incorporation to license the United States’ indefinite holding of overseas colonial possessions. In March 2021, members of the U.S. House of Representatives introduced House Resolution 279, which declares that the Insular Cases should be rejected as having no place in U.S. constitutional law. Moreover, in 2022, Justice Gorsuch called for the Supreme Court to squarely overrule the cases. For many, rejecting the Insular Cases is a long-overdue reckoning for U.S. colonialism. Nonetheless, some representatives and scholars from the U.S. territories have raised concerns about potential implications for existing local laws in the territories. Many of these local laws protect Indigenous territorial peoples from further colonial harms. If the proposed bill or Supreme Court’s overruling of the cases functioned to extend the U.S. Constitution in full to the territories, these laws may be found invalid under current constitutional jurisprudence. This Article employs a contextual framework for Indigenous peoples to explore the nuanced restorative-justice implications of rejecting the Insular Cases. It emphasizes the varying perspectives of Indigenous peoples of the present-day U.S. territories, who would be most impacted by the measure. Finally, flowing from this restorative justice framework, this Article demands that any resolution to the Insular Cases forward the human rights principle of self-determination for Indigenous peoples—not mere equality.

Racial and ethnic disparities in chronic disease are a major public health priority. To determine if the amount of federal grant funding to federally-qualified health centers (FQHCs) was associated with baseline overall prevalence of uncontrolled hypertension and uncontrolled diabetes, as well as prevalence by racial and ethnic subgroup. Cross-sectional multivariate regression analysis of Uniform Data System 2014-2019, which includes clinic-level data from each FQHC regarding demographics, chronic disease control by race and ethnicity, and grant funding. Our main exposure were the average values of the prevalence of uncontrolled hypertension and uncontrolled diabetes among the overall population and by racial and ethnic group from 2014-2016. Average federal grant funding per patient from 2017-2019, as measured by annual health center funding from the Bureau of Primary Health Care (BPHC) and overall federal grant funding. We analyzed 1,205 FQHCs from 2014-2019; the average BPHC grant per patient across all FQHCs in 2019 was $168 while the average total federal grant was $184 per patient. Increasing shares of total patients with uncontrolled hypertension or uncontrolled diabetes were not associated with increased total federal grant funding in either unadjusted or adjusted analysis. Increased shares of patients who are American Indian or Alaskan Native (AI-AN) with uncontrolled hypertension and diabetes were associated with increasing total federal grant funding in both unadjusted and adjusted analysis (adjusted beta hypertension $168.3, p <0.001; adjusted beta diabetes 59.44, p = 0.02). However, cardiovascular clinical need among other racial and ethnic groups was not significantly associated with grant funding. FQHCs with higher overall rates of uncontrolled hypertension or diabetes do not receive more federal funds, and there is no significant association between federal funding levels and rates of uncontrolled blood pressure or diabetes within most racial and ethnic groups, with the exception of AI-AN populations. To narrow inequities in cardiovascular disease, HRSA should consider more explicitly targeting federal grants to clinics with higher levels of clinical need.

The United States (US) must strategically invest in diversifying its biomedical workforce to retain global leadership in biomedical research and to reduce racial and ethnic disparities in the US. The under-representation of minority groups in the biomedical sciences is influenced by the National Institutes of Health (NIH) grant funding process which relies heavily on peer review subject to bias. Despite recent initiatives to combat structural racism within the NIH, the NIH has done little to rectify racial disparities in funding allocation that have been known for over a decade. In this report, I evaluate current NIH proposals to reduce bias in peer review and present stronger policy options for reducing inequity in grant funding. I recommend that the NIH treat the race/ethnicity funding disparity as it did the early career investigator disparity and immediately relax paylines and simultaneously prioritize research topics that align with interests of under-represented investigators, while working to develop a modified lottery for grant funding as a long-term solution to the biases that can influence grant peer review. Policies to address disparities in grant funding will diversify the biomedical workforce and have a profound and long-term positive impact on providing equitable access to science careers, regardless of race.

We investigated systematic barriers, identified by previous research, that prevent women from obtaining Medicaid coverage for an abortion even when it should legally be available: when the pregnancy resulted from rape or incest or threatens the mother's life. We also aimed to document strategies to improve access to federal Medicaid funding in qualifying cases. We conducted in-depth interviews from 2007 to 2009 with representatives of 49 facilities that provided abortions in 11 states. Interviews focused on participants' experiences and strategies in seeking federal Medicaid funding for abortions. We coded data both inductively and deductively and analyzed them thematically. Common strategies described by the few participants who secured Medicaid funding for abortions in cases of rape, incest, and life endangerment were facility-level interventions, such as developing relationships with Medicaid staff, building savvy billing departments, and encouraging clients to advocate for themselves, as well as broader legal and collaborative strategies. Multipronged state-level interventions that combine advocacy, legal, and on-the-ground resources show the most promise of increasing access to federal Medicaid funding for abortion care.

This article considers the problematic place of individual American Sāmoans who have been denied full membership within the American political community, first due to the colonialist arcane notion of being unfit for full membership in the American community on racial and cultural grounds embodied in the Supreme Court’s Insular Cases, and second, because these same cases have been repurposed, ostensibly to protect Indigenous culture. To that end, this article reviews the United States Tenth Circuit Court of Appeals’ recent decision in Fitisemanu et al.v. United States, where a split panel reversed the U.S. District Court recognition of birthright citizenship to those born within American Sāmoa. The Appeals Court’s decision determined that American Sāmoa was not within the scope of the 14th Amendment to the U.S. Constitution through a controversial repackaging of the so-called Insular Cases, which have been criticized as being emblematic of racialist and colonialist jurisprudence that justified the denial of rights to inhabitants of American colonial territories.

Economic grand rounds: inpatient and partial hospital care under medicare.

BackgroundIn the transition from a planned economy to a market-oriented economy, China’s state funding for health care declined and traditional coverage plans collapsed, leaving China’s poor exposed to potentially ruinous health care costs. In reforming health care for the 21st century, equity in health care financing has become a major policy goal. To assess progress towards this goal, this paper examines the equity characteristics of health care financing in a province of northwestern China, comparing the equity performance between urban and rural areas at two different points in time.MethodsAnalysis of whether health care financing contributions were progressive according to income were made using the Kakwani index for each of the four health care financing channels of general taxes, public and private health insurance, and out-of-pocket payments. Two rounds of surveys were conducted, the first in 2003 (13,619 individuals in 3946 households) and the second in 2008 (12,973 individuals in 3958 households). Household socio-economic, health care payment, and utilization information were recorded in household interviews.ResultsLow-income households have undertaken a larger share of the health care financing burden in recent years, reflected by negative Kakwani indices, which indicate a regressive system. We found that the indices for general taxation were −0.0024 (urban) and −0.0281 (rural) in 2002, and −0.0177 (urban) and −0.0097 (rural) in 2007. Public health insurance presented different financing distributions in urban and rural areas (urban: 0.0742 in 2002, 0.0661 in 2007; rural: –0.0615 in 2002,–0.1436 in 2007.). Out-of-pocket payments were progressive but not equitable. Public health insurance coverage has expanded but financing equity has decreased.ConclusionsHealth care financing policies in China need ongoing reform. Given the inequity of general consumption taxes, elimination of these would improve financing equity considerably. Optimizing benefit packages in public health insurance is as important as expanding coverage, both for health care financing and for utilization management as well. Although they are progressive, out-of-pocket payments are not equitable in China and have the effect of excluding the poor from health care as they cannot afford to pay for medical care and so withdraw from treatment.

Sickle cell disease (SCD) and cystic fibrosis (CF) are severe autosomal recessive disorders associated with intermittent disease exacerbations that require hospitalizations, progressive chronic organ injury, and substantial premature mortality. Research funding is a limited resource and may contribute to health care disparities, especially for rare diseases that disproportionally affect economically disadvantaged groups. To compare disease-specific funding between SCD and CF and the association between funding and research productivity. This cross-sectional study examined federal and foundation funding, publications indexed in PubMed, clinical trials registered in ClinicalTrials.gov, and new drug approvals from January 1, 2008, to December 31, 2018, in an estimated US population of approximately 90 000 individuals with SCD and approximately 30 000 individuals with CF. Federal and foundation funding, publications indexed in PubMed, clinical trial registrations, and new drug approvals. From 2008 through 2018, federal funding was greater per person with CF compared with SCD (mean [SD], $2807 [$175] vs $812 [$147]; P < .001). Foundation expenditures were greater for CF than for SCD (mean [SD], $7690 [$3974] vs $102 [$13.7]; P < .001). Significantly more research articles (mean [SD], 1594 [225] vs 926 [157]; P < .001) and US Food and Drug Administration drug approvals (4 vs 1) were found for CF compared with SCD, but the total number of clinical trials was similar (mean [SD], 27.3 [6.9] vs 23.8 [6.3]; P = .22). The findings show that disparities in funding between SCD and CF may be associated with decreased research productivity and novel drug development for SCD. Increased federal and foundation funding is needed for SCD and other diseases that disproportionately affect economically disadvantaged groups to address health care disparities.

“Are we even speaking the same language?”: contested definitions of rape, incest and life endangerment under the Hyde Amendment

A Mystery Caller Evaluation of Medicaid Staff Responses about State Coverage of Abortion Care