The chief executive of American Samoa's LBJ Hospital, Mike Gerstenberger, says a health insurance plan for the territory faces some very difficult obstacles due to the territory's poor health report card, and limited customer base.
Speaking to a business group, Mr Gerstenberger says health insurance works on the basis of companies collecting more in premiums than is paid out in claims.
He says American Samoans are so unwell that the risk of claims is high and while average monthly premiums for the United States mainland are around 400 US dollars, the rate would be much higher in the territory.
"How many of your neighbours could spend 600 dollars a month for health insurance. We just don't have the economic base to make that work. They other piece that is critical is the pooling part of the risk pool. You need to have a large enough pool that you have people paying in premiums who are not dipping out on the claims side. And with only 55 or 60 thousand we probably don't have enough people."