Strengthening Guam’s health care system requires balance in implementation

By Michael W. Cruz

Public Law 38-107 is a needed and important step forward for Guam.

Expanding pathways for physicians to practice on island, especially in underserved public settings, addresses a real and urgent need. Guam should be commended for taking action to improve access to care for patients who have long faced delays and limited options.

For patients, this is not about policy; it is about whether you can see a doctor when you need one and whether you trust the care you receive.

But passing a law is only the first step. How it is implemented will determine whether it strengthens health care on Guam or creates new challenges.

Guam does not have multiple health care systems. We have one: a public hospital, a private hospital and a military facility, all caring for the same community under different rules.

This law allows internationally trained physicians to work in government facilities under supervision. That can help fill gaps in the short term.

But it also changes how the system works.

Government health care operates with certain legal and financial protections, including limits on liability. Private providers do not have those same protections. At the same time, this law keeps these new physicians within the public system, limiting their ability to move across the broader health care network.

Private providers, however, remain essential. They deliver much of Guam’s specialty care, help absorb patient overflow and often care for patients who need more advanced treatment.

When the rules are different depending on where you receive care, it affects patients. It shapes who is available to treat you, how long you wait and where you are sent.

There is also the question of how care is paid for. Physicians working under limited licenses generally cannot bill independently. Instead, services are billed through the hospital or a supervising physician. When the person doing the work, the person responsible for care and the person receiving payment are not aligned, strain builds within the system.

There is also a financial reality. Guam Memorial Hospital operates under a Medicare system based largely on reported hospital costs. However, most physician services, especially direct patient care, are not automatically included in those reimbursable costs unless specifically documented and allocated. In practice, adding physicians can increase expenses without a matching increase in reimbursement.

Put simply: when costs rise but payments do not, the gap has to be absorbed somewhere—whether in budgets, staffing, or access to care.

Supervision is another critical issue. These physicians are expected to work under supervision, yet Guam already faces shortages in many specialties.

That raises a basic question: who is supervising?

A general surgeon cannot realistically supervise a neurosurgeon. A family practice physician should not be expected to supervise an OB-GYN. If supervision exists only on paper, it does not protect patients or physicians. And if supervising physicians share responsibility, they must also have the authority, expertise, and legal protection to do so.

Patients on Guam are often seen in one facility and then transferred to another. When that happens, responsibility for care should remain clear and consistent. Patients should not feel like they are entering a different system with different rules.

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Trust must remain central. As new pathways are introduced, patients should understand who is caring for them and how that care is supervised. Transparency builds confidence.

Public Law 38-107 is a good and necessary step. But it is only a first step.

On Guam, the safety net is shared. Public, private, and military providers all care for patients, often regardless of their ability to pay. But they do not operate under the same conditions.

If we strengthen one part of the system while placing more pressure on another, the result is not stability—it is imbalance.

And in a system as small as Guam’s, that imbalance affects everyone.

On Guam, the safety net is shared—but the responsibility, risk, and opportunity must be shared as well.

Michael W. Cruz, MD, MBA, is a physician with experience leading both public and private hospitals on Guam, including as former Chief Medical Officer of Guam Memorial Hospital and chief executive officer of Guam’ Regional Medical City. He has served in senior public service roles on Guam.

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