Nancy*, a 26-year-old from Pohnpei, the Federated States of Micronesia, moved to Hawai’i about five years ago. She was diagnosed with a life-threatening ailment and doctors back in her home island advised advanced treatment. Fortunately, the Compact of Free Association (COFA) between the Federated States of Micronesia (FSM) and the United States made it possible for Nancy to travel to the latter without any hindrance.
The United States has three separate Compacts of Free Association signed with the FSM, the Republic of the Marshall Islands (RMI), and the Republic of Palau, respectively. The COFA arrangement terminated the United States’ trusteeship over the erstwhile Trust Territory of the Pacific Islands (TTPI) and established the independent nations of the FSM, the RMI, and the Republic of Palau. Under the respective Compacts, the citizens of the associated countries, and those of the U.S., may lawfully live and work in each other’s countries, with no restriction on the duration of their stay.
Thousands from the associated countries take advantage of the COFA to travel to the United States to work, study, or receive medical treatment. In 2018, according to the U.S. Census Bureau, an estimated 94,000 people resided in the U.S. and its territories, with Hawai’i accounting for about 37 percent of this population. Guam, Washington, and Arkansas are the other U.S. states and territories with a significant number of COFA migrants.
Under the COFA, the United States allots federal funding to the three associated states to offset the costs of providing services and benefits to their respective citizens. It would be a mistake, however, to think of this funding as largesse. Starting in the late 1940s, many atolls in the erstwhile TTPI were used by the U.S. military to test nuclear weapons, resulting in diseases, displacement, and land loss for the peoples and communities therein. The funding is compensation for the deleterious consequences of those tests.
The funds are also a way to ensure that the United States maintains its presence in the Pacific Ocean region; a strategically important part of the world that accounts for one-third of global trade. In doing so, the U.S. retains access to crucial sea lines of communication extending well into the East China and South China Seas. Thus, the COFA serves the interests of both the United States and the associated states.
For the citizens of the associated countries, the COFA is especially important because it extends federal Medicaid coverage to them. In doing so, it enables them to access the high-quality health care that is available in the United States. Yet, their ability to access Medicaid has often been marked by uncertainty owing to the pulls and pressures inherent to the U.S. policy landscape.
In an ongoing research project in the city of Honolulu, Hawai’i, spearheaded by the East-West Center’s Pacific Island Development and Research Programs, the COFA Workers Association of Honolulu, and the members of the NieiRek (Women of Vision) community, Honolulu, we found that the shifts in Medicaid-related policies of the United States compromised the COFA migrants’ ability to access health insurance and thereby, decent healthcare.
COFA Migrants and Health Insurance: A Brief History
The first blow to COFA migrants’ access to federal Medicaid came in 1996, in the form of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA). This law stripped COFA migrants of most federal Medicaid benefits. As a 2017 report by the Woodrow Wilson Institute of Public and International Affairs, Princeton University (WW Report), showed, between 1996 and 2000, the state of Hawai’i continued to submit insurance claims under federal Medicaid and receive funding for the same. After 2000, the COFA migrants were shifted to Hawai’i state’s Medicaid-like system, the Med-QUEST. However, this coverage was without any matching federal funds.
In 2009 when the Child Health Insurance Program Reauthorization Act (CHIPRA) was promulgated, Hawai’i moved the insurance coverage of children and pregnant women to this program. The others were moved to a new program called Basic Health Hawai’i (BHH), to save costs. Under this program, the number of doctor visits per annum was restricted, along with access to certain treatments like dialysis. Community organizations like the Micronesia Health Advisory Coalition (MHAC) fought against this in courts but, in 2014, the U.S. Court of Appeals held that Hawai’i was not constitutionally obligated to provide health insurance to COFA migrants.
Throughout this period, the COFA migrants continued to receive health insurance coverage under Hawai’i state’s Med-QUEST. But this changed in 2015 when the state moved all the COFA migrants except the pregnant, the elderly, and the disabled, to the Affordable Care Act (ACA). Under the provisions of the ACA, customers were expected to purchase low-cost health insurance products through an insurance exchange. The insurance exchange in Hawai’i was eventually closed down in 2015, to be replaced by a federally managed one. Those who had enrolled in the state exchange had to re-enroll into the federal one. The closure of the state-level exchange compelled customers to call the federal exchange for clarifications, which in turn required conversing in English – a major challenge for many COFA migrants.
Ending federal Medicaid was detrimental to the health of the COFA migrants. Studies have shown that the withdrawal of federal Medicaid led to a significant decline in the utilization of medical services, increased the number of uninsured emergency room (ER) visits, and might have pushed up the mortality rate among the COFA migrants. The tenuous access to medical insurance would have exacerbated the risk for an already vulnerable demographic segment like the COFA migrants during crises like the COVID-19 pandemic.
Micronesian community members, leaders, and allies, including the MHAC, rallied to advocate for the restoration of federal Medicaid. Over the years, numerous delegations petitioned the Hawai’i state representatives and the state’s congressional delegation. According to Paulina Perman, one of the community leaders (and a co-author of this article), knowing their rights and making repeated representations during public hearings and at every available venue drew the attention of the powers-that-be to the precarity engendered among COFA migrants by the withdrawal of federal Medicaid.
Their sustained efforts, and the eventual involvement of Senators Mazie Hirono and Brian Schatz, led to the restoration of federal Medicaid in December 2020.
Precarity of the Un(der)-Insured COFA Migrant
Researchers at the EWC and their collaborators spoke to a community of COFA migrants from the Federated States of Micronesia living in Honolulu, Hawai’i. About 60 percent of the people that we spoke to had traveled to the United States to seek advanced medical treatment, either for themselves or for someone in the immediate family. Given that the ailments for which they sought treatment were of a serious nature, their stay in the U.S. would usually extend to several months or even years.
For any migrant preparing to leave their home, the journey to a new country, with a relatively unfamiliar culture, political economy, and social moorings, is a challenging experience. And it is no different for the people from the FSM. The high cost of the airfare from the FSM to Honolulu, the initial settling-in expenses, the need to find affordable housing and, in some cases, a job, all made the journeys of our interlocutors challenging.
However, as many of them pointed out, this process was made somewhat tolerable, by the time-tested tradition of reciprocity – a complex web of favors and obligations that is the hallmark of many communities within the associated countries. Reciprocity can take various forms; for example, someone might have helped their neighbor in the FSM repair their house and in return, some members of the latter’s family living in Arkansas in the U.S. might go and check in on a relative of the former who happens to live in their vicinity. Reciprocity is thus much more than a simple give-and-take. This notion allowed many of our interlocutors to stay with friends or extended family upon arriving in Honolulu.
People from the associated countries turn to the United States for medical treatment as they have access to state-funded medical insurance. However, there have been significant challenges in accessing it. First, there is a significant lack of information about the benefits that they are eligible to receive. Given that, over the years, the COFA migrants have been shunted from one state-sponsored health insurance program to another, there is a lack of clarity about the extent of coverage that they are entitled to, and how this entitlement might have changed when they were moved from program to program. Further, while transitioning from one program to another, the COFA migrants were required to re-enroll into the new one. Lack of timely information on the modalities of re-enrollment meant that many people were not fully aware of the new requirements and consequently suffered delays in accessing insurance benefits.
Second, under the ACA, COFA migrants had to file for Advanced Premium Tax Credit (APTC), a tax credit to lower monthly health insurance payment. Under the ACA, if an applicant did not file income tax, they would not receive the health insurance tax credit and, as a result, would pay the full premium. Most of the COFA migrants are below 100 percent of the federal poverty line (FPL) and do not have to pay taxes. It is not intuitive for them to file tax returns when they don’t have to pay taxes. Owing to this gap in understanding, many interlocutors reported being asked to pay medical insurance premiums out of their pockets.
Third, when COFA migrants were covered under the ACA, they qualified for Medicaid benefits only if they received emergency care. This prompted many to turn to the ER even for routine ailments. Given that such care attracts higher copayments, many COFA migrants ended up incurring significant out-of-pocket expenses in this process.
Things were expected to get better with the reinstatement of federal Medicaid in late 2020. However, lack of awareness continues to be a major handicap. Many interlocutors were unaware of the extent of coverage that they would receive under the reinstated federal Medicaid coverage; nor did they know the intricacies related to copayment, if any, or the extent to which their coverage varied depending on the nature of the care they sought (regular care vs emergency care, for example). This is despite the fact that many of them have been living in the United States for many years and have been regularly accessing health care here. For someone arriving from the FSM for the very first time, these nuances of health insurance can seem bewildering.
Without systematic guidance and accurate information, COFA migrants are likely to incur unnecessary out-of-pocket healthcare expenses. Under the ACA, a system of navigator and outreach assistance, known as kokua (“to help,” in Hawai’ian) was put in place for all customers, including COFA migrants. In practice, this service was only available for enrollment assistance. The availability of the kokua had a salutary effect on ACA enrollments. On the other hand, the absence of the kokua for outreach assistance undermined the ACA’s ability to reach out to many more eligible customers.
Moving forward, what is needed is a service similar to the kokua to ensure that Medicaid benefits reach as many of the eligible COFA migrants as possible, including those who are new to the U.S. healthcare system. If this service can be provided in both English and in the languages spoken by the COFA migrants, it might significantly expand the reach of the Medicaid program. What is more, this can also save valuable money for the migrants.
It is worth mentioning that a significant proportion of the COFA migrants fall below the federal poverty line and therefore live with constrained financial means. They occupy low-paying jobs and have very limited savings. Most of them can therefore ill afford to incur unexpected out-of-pocket medical expenses. Better information about the terms and conditions of the insurance program under which they are covered, and the extent of coverage that they are eligible to receive, can improve the overall experience of accessing medical services for the COFA migrants, and help them save money.
*The names of interviewees in this article have been changed to protect their privacy.
We would like to thank the members of the COFA Workers’ Association of Honolulu and the women of the NieiRek community, Honolulu, for their time and insights. This article would not have been possible without them.