1. COFA Migrants in Hawaii: Real Life Challenges Sheldon Riklon, MD Assistant Professor, JABSOM Chair, MHAC PIHOA Meeting – Honolulu August 7, 2015

2. Outline 1.Discuss health challenges for COFA migrants 2.Discuss Compact Impacts 3.Discuss On-going COFA Community Organization, Collaboration & Outreach Activities

3. Very Brief History  Under colonial rule for 400 yrs (spain, Germany)  Japanese rule since 1914  US rule in 1944-5 after in some of the fiercest battles of World War II  US set up a military base in Marshall Islands and began US Nuclear Weapons Testing Program (1946-58)  Became TTPI ( Trust Territory of the Pacific Islands) as “Strategic Trust of US” under UN Security Council 1947

4. Compact of Free Association  1977 offered political self –determination to Northern Marianas, Marshalls, Palau, Chuuk, Kosrae, Pohnpei, Yap  Net effect: 1.Commonwealth of the Northern Marianas (CNMI) 1978 2.Freely Associated States/COFA 1979-1986:  Republic of the Marshall Islands (RMI)  Republic of Palau (ROP)  Federated States of Micronesia (FSM)

5. Compact of Free Association  US Perpetual strategic denial  US strategic denial over water, land, airspace  US may operate armed forces in Compact nations, may negotiate for land to operate bases, may exclude the militaries of other nations from the region  Affords COFA citizens broad migration rights  right to reside and work in US  no visa or labor certification  no limitations of stay

6. Compact of Free Association  Initially classified as “qualified aliens”  Permanent Residence Under Color of Law (PRUCOL)  considered legal residents in the US under administrative discretion  Changed to “non qualified aliens”  1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA)  COFA migrants ineligible for fed public assistance  Hawaii continued to provide Medicaid-like benefits to COFA residents using only State funds

7. Basic Health Hawaii - 2010  State’s plan to save $15 million (other sources: up to $27 million/yr) in healthcare costs  Approach:  12 Outpatient visits/10 Inpatient visits  5 generic medication prescriptions/month (cut to 4 prescriptions/month in 2010 version)  No dental, except for emergencies  No chemotherapy; no dialysis  Became effective July 1, 2010

8. COFA Migrants/LEJ Response On August 23, 2010, filed case in Federal court alleging claims for violations of the Equal Protection Clause and the ADA On September 13, 2010, filed a Motion for Preliminary Injunction On December 13, 2010, Motion for Preliminary Injunction went into effect by Fed Judge Seabright State of Hawaii appealed the decision of Judge Seabright in the 9 th Circuit Court 2012

9. 9 th U.S. Circuit Court of Appeals Decision (April 2014)  Hawaii has no constitutional obligation to fill a gap left in 1996 when Congress cut health care funding for migrants under the Compact of Free Association  A three-member panel of the 9th U.S. Circuit Court of Appeals — with one judge dissenting — ruled in favor of the state, vacating a District Court injunction that had prevented the state from reducing health coverage

10. US Supreme Court  Plaintiffs appealed to the U.S. Supreme Court  On November 3, 2014, the Supreme Court declined to hear the case ending the plaintiffs’ appeal of the Ninth Circuit decision.  The Ninth Circuit subsequently vacated the injunction, which had the practical effect of requiring the State to immediately comply with the BHH rules.

11. Affordable Care Act  In 2010, Congress passed the Affordable Care Act  Under ACA, COFA residents and other lawfully present noncitizens are eligible to purchase health insurance through the State’s health insurance exchange, called the Hawaii Health Connector (the Connector).

12. Community Organization  Meeting with DHS Director & HHC  Weekly Conference calls with DHS, HHC, Providers, Community  Several COFA KOKUA with Hawaii Health Connector  Collaboration with HMSA & Kaiser  Letter to Governor Ige

13. Community Organization  Legislative Approaches  HB1239  SB1327  HR854 -- Compact-Impact Aid Act of 2015 (Rep Takai)  “COFA Task Force” – Sen Chun-Oakland/Rep Morikawa  Compact Impact issues in Hawaii  Focus on health, housing, jobs, and homelessness

14. Community Organizations  Nations of Micronesia (NOM)  Micronesian Health Advisory Coalition (MHAC)  Interpreter Committee  All Mike Committee  COFA Community Action Network ( COFA CAN)  Micronesian Community Network (MCN)  Micronesian United (MU)  We Are Oceania (WAO)  RMI & FSM Consulate Offices - Honolulu

15. Community Information Sessions  Organize by COFA community leaders/organization/friends  Story gathering, informational, guidance, updates, connection  4 events  Waipahu Intermediate School (3/19/15)  Towers of Kuhio Park (3/20/15)  Palolo Housing (4/2/15)  St. Elizabeth Episcopal Church (4/11/15)

16. Worried and Afraid Can’t pay, health is getting worse “I stopped seeing the doctor because I’m afraid of the bill, I am afraid I won't be able to afford to pay for diabetes medication. My health is getting worse.” – A 57-year-old woman with diabetes and high blood pressure 16

17. Worried and Afraid “Now I'm worried I can't afford co-pay, which I don't understand in the first place. I work part time and my wife works full time but all our money goes to rent and our kids. If I get sick I'm afraid I can't see the doctor for fear I can't afford it. – A 52 year old man who was previously covered by QUEST 17

18. “I am very confused about (my) plan, I signed up but didn't really understand. Got letter… but I don’t know what it means. I’m worried I can’t pay” - 62 year old man who recently fell and hurt his leg Confused

19. “Provider couldn't find my insurance, I still don't have medications, told me it will cost $400 for meds. Long's called but when I arrived they sent me away again. [This is] very difficult, complicated, and confusing. ” - Woman who described her health as poor with thyroid issues, diabetes, hypertension and is suppose to have knee surgery Confused

20. Health Challenges  Lack of trained/certified translators  Lack of understanding of the health care system  Lack of understanding of insurance programs  Lack of understanding of Providers about COFA patients  Confusion with the rapid on-going changes with COFA eligibility for insurance programs  Quest  BHH  HHC  ??? (desolution of HHC)  ? Wrong plan ? Co-pays ? No meds ? No visit  Premium increase (49% HMSA)

21. Housing Challenges  Lack of trained/certified translators  Misunderstanding/miscommunication  Lack of understanding of the housing system  Conflicts with culture  Issues with discrimination/racial connotation/negative stereotype of COFA tenants with providers

22. Legal Challenges  Lack of trained/certified translators  Miscommunication  Misunderstanding  Code of Ethics  Lack of understanding of the legal system  Issues with discrimination/racial connotation/negative stereotype of COFA clients “send a message to the Micronesian community” that such behavior “is not acceptable in the laws of the United States and the State of Hawaii.”

23. Homelessness in Hawaii

25. COFA Migrants in Hawaii Reasons for Migration to Hawai‘i : 1.Health 2.Education 3.Employment/job opportunity Pobutsky, et al. 2009

26. COMPACT IMPACT Compact Impact on COFA nations Poor health and education persists Economic development challenged Large out migration Actual numbers unclear Out migration to US 20,000 Micronesians to HI, Guam, CNMI 4000 Marshallese Costa Mesa CA 10,000 – 14,000 Marshallese in Arkansas

27. Ozark Islanders in NW Arkansas  Springdale Arkansas Population: 75,229 (2013)  By the 2012-2013 school year, white students were 40.6%, Marshallese 11.38% (= 2000 children), and Hispanics 43.7%  Tyson has 27 different factories in this area; It has 95%+ of the US market share on Cornish hens.  Factory processes 42 million/yr, 806,000/week, 100,000 per ten-hour shift. Tysons employs 3000 Marshallese,  George’s & Cargills another 1000+.  Butterball Turkeys employs primarily Yapese and Chuukese  Marshallese CHW @ UAMS, CHC, DOH; liaisons @ DOE

28. Impact of COFA Migrants  Poor health status of COFA migrants parallel poor health indicators in COFA nations  COFA migrants usually have significant disease burdens  Health, Housing, Education. Social Services, legal Services  Demographic Preparedness

29. Compact Impact Aid  Hawai‘i - estimated $90 million annually in uncompensated care from FAS Migrants  Federal COMPACT IMPACT Aid = 30 million annual divided Hawai‘i, CNMI, Guam  Hawai‘i’s share is 11.2 million  based on Census figures  Hawai‘i spent estimated 30 million annually on health care  Money not reimbursed by Fed due to 1996 PRWORA

30. Cost  What is the health cost?  $14-25 million annually  2010 report sent to US Insular Affairs re Compact Impact cost– includes Quest costs  US GAO could not audit– not verifiable  Questions about who was included, how measured, numerator and dominator issues  Balance sheet and accounting?  pay taxes, how is this added to balance sheet  11 million / year HI – goes to Hospitals  Federal match?

31. Where in the US are the Marshallese ?

32. Acknowledgments  Megan Inada  Dr. Gregory Maskarinec  Dr. Neal Palafox  Dina Shek