Innocenta Sound-Kikku has spent this year in the thick of Hawaii’s COVID-19 pandemic. As a staffer at a Kalihi community health center who is also Chuukese, she has watched her community get hit harder by the coronavirus than any other in Hawaii and scrambled to provide food, medicine and water to families stuck in quarantine.

But on Sunday, she got good news. Congress is restoring Medicaid access for her community — citizens from the Marshall Islands, Palau and the Federated States of Micronesia living in the U.S. — nearly 25 years after taking it away.

The change is part of a $900 billion COVID-19 relief bill now sitting on President Donald Trump’s desk. It’s a policy Sound-Kikku had been advocating for over more than a decade. She wasn’t sure if it would ever happen.

“It brought so much emotion,” she said of the news. “I thought about my dad and those that have gone before. It’s just amazing to arrive here during a pandemic of all times. It’s such a blessing, especially for our community. I hope we don’t have to wait too long for it to be implemented.”

Senator Mazie Hirono speaks on election night at the Dole Cannery Ballroom.
U.S. Sen. Mazie Hirono said she has long been urging Democratic leaders in the Senate to prioritize Medicaid restoration for the COFA community. Cory Lum/Civil Beat

The change comes more than two decades after the federal government revoked Medicaid access for the Pacific Islander migrant community, in spite of a long history of U.S. nuclear testing in the Marshall Islands that’s associated with higher cancer rates. The U.S. also has ongoing defense treaties with Palau, the Marshall Islands and the Federated States of Micronesia known as the Compacts of Free Association that give the U.S. military critical control over the northwestern Pacific Ocean.

U.S. Sen. Mazie Hirono told Civil Beat Monday she “routinely hounded Chuck Schumer,” the Senate Minority Leader, to include this in the COVID-19 relief bill after years of unsuccessful attempts.

Innocenta Sound-Kikku works at Kokua Kalihi Valley Comprehensive Health Services. Courtesy of Innocenta Sound-Kikku

The bottom line, she said, is “any of the COFA citizens who are in the U.S. can qualify and apply for Medicaid.” She said her research showed the removal of the community from Medicaid by Congress in 1996 was accidental. One estimate suggests the change could help as many as 94,000 people nationally, including 25,000 in Hawaii.

The measure is something that Hawaii officials have been advocating nationally for years out of concern for the state’s coffers. It’s not clear yet, however, what effect the change will have on the state budget, or when it will go into effect.

Knowing that the change was inadvertent is painful for David Derauf, a physician who leads Kokua Kalihi Valley Comprehensive Health Services, a community health center that serves many Pacific Islanders in Kalihi, which has been hit hardest by the pandemic.

If that is the case someone should be doing a study of the human cost of a clerical error,” he said. “We know that people have needlessly suffered and died because of this.”

What is clear is that access to Medicaid will help ease anxieties about health insurance for low-income Micronesians both in Hawaii and throughout the nation.

“This is 25 years overdue,” Derauf said.

The Cost Of No Medicaid

After Congress and then-President Bill Clinton revoked Medicaid access for COFA migrants in 1996, Hawaii continued to provide it out of state funds for more than a decade. But the policy became increasingly expensive and unpopular and in 2009, former Gov. Linda Lingle shifted the community onto much more limited insurance.

Sheldon Riklon, a Marshallese physician who was then living in Hawaii, remembers the 2009 change forced families to reschedule surgeries and cancel dialysis.

“We heard stories of people actually going home to die because they couldn’t get access to the health care they needed,” he said.

Josie Howard, Christina Killion and Innocenta Sound advocate for Medicaid coverage for COFA migrants in Congress. Courtesy of Josie Howard

State-funded Medicaid, known as Med-QUEST, was restored following a lawsuit, but after the state won on appeal, Gov. David Ige’s administration stopped providing Med-QUEST to adult COFA migrants between the ages of 18 and 64 in 2015. More than 7,600 people were moved onto the federal marketplace for health insurance and expected to buy private health insurance.

The change resulted in fewer Micronesian patients going to Hawaii hospitals, one University of Hawaii study found. Those who did go to emergency rooms were more likely to be uninsured.

The Micronesian community’s mortality increased too, sharply diverging from that of Hawaii residents of white and Japanese ancestry, another study found. On average, 24 additional Micronesian people died in Hawaii each year between 2015 and 2018, with the community’s mortality rate rising each year, according to the study’s author, UH economist and assistant professor Teresa Molina.

The pandemic made everything worse. Pacific Islanders, excluding Native Hawaiians, have by far the worst rates of COVID-19, making up more than a quarter of cases despite composing just 4% of the state’s population.

Ige told Civil Beat that in addition to wanting to save money, back in 2015 he thought that moving the migrant community onto private health insurance might actually give them better health care. But the state continued to provide Med-QUEST for elderly, blind and disabled COFA migrants and other recent immigrants who don’t qualify for federally funded Medicaid.

That cost more than $50 million last fiscal year, according to Judy Mohr Peterson, who runs the Med-QUEST program. Hawaii also helps subsidize federal marketplace premiums for low-income non-U.S. citizens that aren’t eligible for Medicaid. Peterson didn’t have more details about exactly how much the state spends or what it could expect to save but said that she intends to figure that out.

Other Barriers To Health Care

Neal Palafox, a Hawaii physician who works with Marshallese communities, said he’s delighted by the Medicaid change but cautions that it won’t solve the community’s health care woes.

Health insurance is only one part of access to medical care, he said. People also need transportation, language interpretation and culturally appropriate care. Social determinants of health — such as stable housing, access to water, jobs and food — still need to be addressed, he said.

Neal Palafox is a physician and professor at the University of Hawaii. Courtesy of UH

The bill doesn’t completely reverse the 1996 law — citizens of Palau, the Marshall Islands and Federated States of Micronesia still lack access to other federal safety net programs like food stamps that could help them economically, particularly in the midst of the pandemic downturn.

Palafox said he hopes the restoration of federal funding for Medicaid does not make Hawaii officials complacent about the urgent health care needs among Pacific Islanders. He noted that Native Hawaiians, Native Americans and African-Americans have long had access to Medicaid yet still experience significant health care disparities.

The lack of Medicaid access also undermined trust in the government, something Hawaii health officials today are rapidly trying to rectify as they seek to track the spread of the coronavirus and encourage people to accept the COVID-19 vaccine.

“The state was doing all these things that seemed to be against us, against a community that’s in need medically. The distrust just kind of grew from there,” said Riklon, who advocated for Med-QUEST at the Hawaii Legislature in 2009. Political discourse often framed the Micronesian community as a burden to Hawaii, even though a recent state study found they contributed $336.2 million to the state’s gross domestic product in 2017 alone.

“If you hear these leaders coming to you and say you’re costing us too much, it’s not a nice thing for you to hear. That tone, that language, it’s difficult to hear,” Riklon said.

Riklon, Sound-Kikku and other members of the Micronesian community spent years urging state and federal officials to restore Medicaid access. They helped create a multi-state network of advocates, knocked on doors in Congress and coordinated with national health and immigrant advocacy groups.

Putting themselves forward was “very un-Micronesian,” Riklon said. At times it was challenging and discouraging but looking back, it was very much worth it. He thinks that the pandemic outcomes for his community have been worse because of lack of consistent health care access over the years.

“It will be easier for me to control somebody’s diabetes if they have access to medications because they are covered by the Medicaid program,” he said. “This is basically life-saving.”

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