The welfare reform bill that President Bill Clinton signed into law in 1996 is often heralded as an overwhelming success, but it’s about time Congress finally acted to correct one of its glaring and costly mistakes.
Clinton vowed repeatedly at the time to revisit those immigrant provisions, saying it was unfair that legal immigrants could serve in the military but be banned from receiving federal benefits. Over the years, bills incrementally restored some benefits; but the exclusion of Medicaid — which provides health care to low-income individuals — still stands, affecting Hawaii and its 15,000 Micronesian immigrants profoundly.
As Civil Beat explains in a new special report — “The Micronesians: An Untold Story of American Immigration” — under the Compact of Free Association — a federal treaty between the United States and three Micronesian nations — citizens from the Marshall Islands, the Federated States of Micronesia and Palau are allowed to live and work in the United States without a visa. In exchange, our country enjoys full strategic and defensive control of the expansive region.
Asterio R. Takesy, ambassador of the Federated States of Micronesia, greets residents signing up for the Hawaii Health Connector in Kalihi earlier this year.
Cory Lum/Civil Beat
The treaty is rooted in the more than 60 nuclear tests that the U.S. military conducted in the Marshall Islands after World War II. Those tests established a long military presence in the region and launched the forced out-migration of many Marshallese whose homeland was no longer habitable.
Today, COFA citizens come to the U.S. for myriad reasons; but access to quality health care is high among them. Cancer and diabetes are overrepresented among Micronesians, in no small part because of the environmental and cultural impacts of the nuclear testing.
When the Clinton-era welfare reforms repealed Medicaid coverage for COFA immigrants, the state of Hawaii stepped in with Med-QUEST, a state-funded medical benefit that is essentially the same as Medicaid. But the high cost soon forced the state to reevaluate COFA coverage.
In 2009, then-Gov. Linda Lingle said that the 7,500 COFA immigrants covered under Med-QUEST were costing the state $100 million a year, 10 times what the federal government was reimbursing Hawaii for COFA-related costs.
Lingle’s decision to switch the immigrants to Basic Health Hawaii, a much more limited plan, ignited a firestorm of legal battles, race discussions, and straight-up confusion, as many Micronesians and Hawaii citizens wondered how to respond to such an emotional and urgent issue.
COFA citizens, after all, have every right to come to the United States. Many of them even serve in our military at higher per-capita rates than American citizens. But the cost burden to Hawaii is not getting any easier.
Last year, the state spent $163 million on health care, social services and education for COFA immigrants.
But while Hawaii is becoming more acutely aware of this predicament, it’s as if the federal government has forgotten all about it.
Or rather, as U.S. Sen. Brian Schatz told Civil Beat reporter Chad Blair, it’s as if Washington isn’t even aware of the problem.
“Nobody knows anything about this in the Congress, other than our delegation and a few others,” Schatz said.
And therein lies the real shame, because for anyone with even a rudimentary understanding of this issue, the onus to resolve it clearly falls on the federal government.
“This should be an apolitical issue that concerns every member of Congress,” Rep. Mark Takai told Blair.
Takai recently introduced legislation to increase the amount of money the federal government repays Hawaii, Guam and the Commonwealth of the Mariana Islands to help absorb COFA migration costs.
Takai says the issue is clear. The compact itself states that Congress will act “sympathetically and expeditiously” to cover all adverse consequences that result from the “freely associated states” status granted the COFA nations.
That means, Takai says, “The feds are supposed to pick it up.”
Restoring COFA eligibility for Medicaid is an obvious place to start.
The federal government currently spends more than $300 billion a year on Medicaid, which covers nearly 66 million people. While the Republican-controlled Congress has been unsympathetic to the notion of any expansion of Medicaid, including COFA immigrants would barely register in the budget. Many of the estimated 75,000 COFA immigrants throughout the United States are employed and wouldn’t even need or qualify for Medicaid.
But since 2001, 19 bills have been introduced and failed in Congress to reinstate COFA eligibility for Medicaid, including attempts by Rep. Colleen Hanabusa, Rep. Neil Abercrombie and Sen. Daniel Akaka. Sen. Mazie Hirono is the latest to try, having introduced The Restore Medicaid to Compact of Free Association Migrants Act in May.
Expanding Medicaid coverage to COFA immigrants is certainly not a silver bullet for the myriad problems our newest neighbors face, both in the United States and at home.
But it is the lowest hanging fruit — fruit that politicians in Washington need to recognize is ripe for the picking.
Stay Up To Date On The Coronavirus And Other Hawaii Issues