Once again, Hawaii’s congressional delegation is attempting to remedy an injustice from nearly 20 years ago, when Congress eliminated federal Medicaid support for migrants from Micronesia, the Marshall Islands and Palau — the Compact of Free Association (COFA) countries.
The delegation, speaking as one, introduced legislation on May 12 to amend the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 to restore the Medicaid coverage. While the effort may seem Sisyphean, the delegation must persist until it succeeds.
The 1996 act was part of a major overhaul of the welfare system, which left many low-income COFAmigrants — in the U.S. legally, working and paying taxes — without access to health care coverage available to qualified immigrants. For sound policy reasons, states like Hawaii did not want to deny legal residents access to basic medical care. So they got the bill.
Until recently, the cost to Hawaii was about $58.3 million a year to cover COFA individuals, according to the state Department of Human Services. Over the years, the state has tried to reduce its costs by reducing coverage, efforts that met with protests and legal challenges. The 9th U.S. Circuit Court of Appeals ruled last year that the state was under no obligation to fill the gaping hole left by the federal government; but given that the migrants weren’t just going to leave, the state prudently chose to provide an alternative solution.
On March 1, DHS transferred 7,617 adult able-bodied COFA individuals to the Hawaii Health Connector, the local conduit to federally subsidized Affordable Care Act health insurance plans. The state continues to provide the most vulnerable COFA migrants, including the aged, blind, disabled, children and pregnant women, with full state-funded Medicaid coverage.
Because of these changes, the state managed to reduce its costs to provide medical assistance to COFA individuals from $58.3 million to a projected $29.1 million. This may be a better deal for the state, but it’s no bargain.
Unlike Medicaid, COFA migrants must pay certain costs with the Connector, itself a troubled program whose survival is threatened because of non-compliance with federal rules. For some, even the ACA plans may prove too burdensome — the insured must cover such costs as co-payments, deductibles and premiums. DHS’ Premium Assistance Program helps, by paying the premiums for eligible COFA migrants and legally permanent residents who have incomes less than 100 percent of the federal poverty level.
But additional out-of-pocket costs could discourage those already living hand-to-mouth from going to the doctor, leading to much more expensive medical care to correct undiagnosed or untreated ailments.
This is especially disconcerting when so many are living in squalor on the streets, as can be seen in Kakaako’s tent cities, where a vast majority of those homeless appear to be from Micronesia and the Marshall Islands. It’s been estimated that of the 12,000 COFA migrants in Hawaii, more than 1,000 of them are homeless. And there is no end in sight: Residents of COFA nations will continue to establish residency in the U.S. — as is their legal right. As city and state officials continue to dither, the tent cities grow and harden. Without more federal help, the state’s costs undoubtedly will increase.
The federal government bears primary responsibility. Through the COFA pact, the federal government opened the door to migration from the impoverished COFA countries by negotiating exclusive military rights over more than 2 million square miles of ocean; the U.S. conducted nuclear weapons tests in the Marshall Islands through the late 1950s. In exchange, COFA migrants would be treated like other legal residents, free to live and work in the U.S., with the equal obligation to pay state and federal taxes.
In 2013, U.S. Sen. Mazie Hirono and then-U.S. Rep. Colleen Hanabusa attempted to restore the federal Medicaid benefits through legislation, to no avail. This time, our delegation will need to work even harder, and gather allies in Congress to help.
