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

COFA Migrants in Hawaii: Real Life Challenges

Sheldon Riklon, MDAssistant Professor, JABSOM

Chair, MHAC

PIHOA Meeting – HonoluluAugust 7, 2015

Outline

1. Discuss health challenges for COFA migrants

2. Discuss Compact Impacts

3. Discuss On-going COFA Community Organization, Collaboration & Outreach Activities

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

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)

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

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

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

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 9th Circuit Court 2012

9th 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

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.

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).

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

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

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

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)

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 pressure16

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

“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

“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

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)

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

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.”

Homelessness in Hawaii

Caucasian31%

Hawaiian30%

Marshallese6%

Micronesian10%

Other PI6%

Filipino5%

Other Asian4% Black

5%

Native American2%

Homeless Service Utilization State

Source: Homeless Service Utlization Report (2014)

Homelessness in Hawaii

White37%

Native Hawaiian22%

Other Multiple Race17%

Pacific Islander (including Micronesian)

10%

Asian5%

Black4%

Unknown3%

Amer Indian2%

Unsheltered Homeless Statewide

Source: Statewide Homeless Point-In-Time Counts (2014)

COFA Migrants in Hawaii

Reasons for Migration to Hawai‘i :

1. Health

2. Education

3. Employment/job opportunity

Pobutsky, et al. 2009

COMPACT IMPACT

Compact Impact on COFA nationsPoor health and education persistsEconomic development challengedLarge out migrationActual numbers unclear

Out migration to US 20,000 Micronesians to HI, Guam, CNMI4000 Marshallese Costa Mesa CA10,000 – 14,000 Marshallese in Arkansas

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

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

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

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?

Where in the US are the Marshallese ?

Acknowledgments

Megan Inada

Dr. Gregory Maskarinec

Dr. Neal Palafox

Dina Shek