Micronesia is one of the three main groupings for the islands of the Pacific Ocean, along with Polynesia (which includes Hawaii) and Melanesia. It is a region of thousands of islands and many cultures, histories, languages and traditions.

But the land mass is very small and spread out within some 3 million square miles of water. Indeed, Micronesia has been described as having a total area equal to the entire United States, but a total land mass area equal to Rhode Island.

Micronesia encompasses the Republic of the Marshall Islands, the Federated States of Micronesia, the Republic of Palau, Kiribati and Nauru, the U.S. territories of Wake and Guam, and the Commonwealth of the Northern Mariana Islands, which includes Saipan.

Micronesia’s ties to the United States came primarily through World War II, in which America wrested control of much of the region that had been held by the Imperial Japanese. Following the war the United Nations placed Micronesian in a Trust Territory of the Pacific Islands status controlled by the U.S., which has a military base on Kwajalein Atoll in the Marshall Islands.

Three Micronesian nations — the RMI, the FSM and Palau — gained independence in the late 1970s, and the trust territory was dissolved. But beginning in 1986, a Compact of Free Association, called COFA, comprised a set of strategic treaties made between the U.S. and the RMI, the FSM and Palau.

COFA outlines the relationship that these countries have entered into as freely associated states with the U.S. In exchange for full international defense authority and responsibilities, the U.S. provides guaranteed financial assistance to the FAS countries. Citizens of COFA states can travel freely to live and work in the U.S. and are eligible to receive many — but not all — the same services and benefits as U.S. citizens.

In particular, they have access to many of the social service programs available domestically in the U.S., such as health care and public housing assistance, but it varies from state to state. In turn, the U.S. can operate armed forces in and is responsible for protecting COFA states. COFA migrants are not, however, eligible for Medicaid unless they are U.S. citizens.

The first compact with the Micronesian states was signed in 1982 and ratified in 1986. An updated compact, commonly known as Compact II, went into effect in 2003. A separate compact was signed with Palau and became effective in early 1995. Accordingly, sometimes COFA is referred to in the plural — the Compacts of Free Association.

The Renewed Compact (“Compact II”) took effect for the FSM and the RMI in 2004. These compacts were renewed for 20 years in 2003. They provide $3.5 billion in funding for both nations — about $130 million annually to the FSM and about $70 million to the RMI — and changed some of the rules on immigration, including the stipulation that COFA migrants coming to the U.S. have passports.

COFA Challenges in Hawaii

COFA has become controversial in Hawaii in recent years, largely because complying with COFA requires a significant amount of the state’s resources. COFA migrants comprise about 1 percent of the state’s population, or around 15,000 people, although the number is growing as more move to the islands for health reasons, education and economic opportunity.

Hawaii’s politicians have taken up the cause, but with little success in altering the status quo.

In May 2011, for example, Hawaii’s congressional delegation signed a letter urging the U.S. government to adopt policy options to address what they argued as COFA’s increasingly non-viable financial stipulations. Those options include medical “screening measures” that would reduce the number of migrants “who are likely to become a public charge.”

The letter upset some Pacific Island officials who say that the U.S. is trying to renege on its commitment to migrants from a region that was the location for nuclear tests in the 1940s and 1950s.

Congress provides $30 million annually to Hawaii, Guam and the CNMI to help defray expenses related to their COFA populations. About $11 million goes to Hawaii, though in 2014 the state spent $163 million on services, primarily for education and health.

Hawaii’s congressional delegation has sought to increase the annual aid — known as Compact-Impact Aid — to $185 million. It has also sought to make COFA migrants re-eligible for Medicaid, something the Congress allowed until 1996. Thus far, the legislation has went nowhere.

The parameters of COFA have long been debated locally. In July 2010, under Gov. Linda Lingle, the Department of Human Services reduced health care benefits available to COFA migrants, giving them a cheaper and more limited program than the one available to U.S. citizens. This plan, called Basic Health Hawaii, allowed those covered only 12 doctors’ visits per year and four prescription medications.

Several migrants filed a class action suit and, in December 2010, federal Judge Michael Seabright ruled that COFA migrants must receive full medical benefits. Those benefits were resumed in January 2011.

Then-Gov. Neil Abercrombie, however, said the court order would be too costly for the state to fund on its own and that Congress would need help from the White House. His administration appealed the Seabright decision.

In November 2014, the U.S. Supreme Court declined a request from Honolulu attorneys to take up a case involving whether immigrants from Micronesia should receive state-funded health care coverage, leaving intact a lower court’s decision that determined Hawaii is not required to provide those benefits.

After the ruling, DHS announced temporary emergency rules that maintain the status quo for receipt of state-funded medical assistance benefits by noncitizens. By Feb. 28, 2015, about 7,500 Micronesians and other Pacific islanders were subsequently automatically enrolled in a replacement plan with the state’s federal insurance exchange, the Hawaii Health Connector.

COFA migrants and their supporters living in Hawaii worked to help the Micronesians through the Connector plans offered through Hawaii’s two largest health insurance companies, Kaiser and HMSA. But Connector, a privately run venture, effectively went bankrupt in June 2015.

The state is now working to enroll the affected COFA residents, now estimated around 8,500, to enroll in the federal Affordable Care Act known as Obamacare. But for many COFA citizens living in Hawaii, Obamacare is there fourth health insurance plan in six years, and it has caused much confusion.

Republic of the Marshall Islands

The RMI is a nation of about 53,000 people living on 29 coral atolls and five low-lying islands in the central Pacific. The capital is Majuro, an island in Majuro Atoll.

The islands were settled by Micronesians — the term means “small islands” — in the second millennium B.C. Western contact began in the early 16th century with Spanish exploration. The islands are named after an English explorer, Captain John Charles Marshall.

Later colonizers included the Germans and the Japanese. According to its official website, the RMI adopted its constitution in 1979 and became a member of the United Nations in 1991.

The RMI is the location of Bikini and Enewetak atolls, former United States nuclear test sites. Its largest atoll is Kwajalein, a major World War II battleground now used as a U.S. missile defense test range.

While RMI industries include copra production and processing of coconut oil, fishing, crafts and tourism, the presence of the American military is central to the nation’s economy, which uses the U.S. dollar as its currency.

English is also an official language along with two Marshallese dialects. The population is predominantly Protestant.

The nuclear testing was conducted between 1946 and 1958, and the RMI has a detailed history of the testing on its website. A total of 67 tests were conducted. They involved the relocation of entire island communities.

According to the RMI, “In 1963, the first thyroid tumors begin appearing among the Rongelap people exposed to the Bravo test in 1954. Also, a higher than normal incidence of growth retardation among young Rongelap Islanders is noted by U.S. doctors.”

In 1966 the U.S. Congress approved a payment of $950,000 to the exposed Rongelap people for injuries resulting from their exposure. A decade later Congress approved $20 million and military logistic support for a nuclear cleanup of Enewetak Atoll.

While the U.S. initially said radiation levels in the islands had returned to safe levels, that has been in dispute along with questions about the latency period before health problems develop. In 1981, Bikinians filed a class action lawsuit against the U.S. seeking $450 million in compensation.

The 1986 COFA included a provision “prohibiting Marshall Islanders from seeking future legal redress in U.S. courts and dismissing all current court cases in exchange for a $150 million compensation trust fund.”

In the 2003 amended COFA, the U.S. agreed to pay the RMI $57.7 million annually through 2013, and then $62.7 million through 2023. At that time a trust fund comprised of U.S. and RMI contributions will begin perpetual annual payouts.

Federated States of Micronesia

The FSM is comprised of four states: Yap, Chuuk, Pohnpei and Kosrae, which are part of the Caroline Islands. The capital is Palikir on Pohnpei.

Micronesians settled the islands beginning several thousands of years ago. Beginning in the 16th century, Portuguese and then Spanish explorers arrived, later followed by Germans and then Japanese. During World War II the Americans defeated the Japanese who had colonized the islands.

The currency is the U.S. dollar and English is the official language, though local languages are also used. The islands are home to about 110,000 people.

The FSM were part of the United Nations Trust Territory until becoming independent in 1986 when the COFA treaty was signed. The FSM had formed its own constitutional government in 1979.

The nation’s economy is helped by tourism, farming and fishing, but American government assistance is by far the greatest source of revenue.

Republic of Palau

The Republic of Palau has about 21,000 people living in 16 states. The capital is Ngerulmud and the largest city is Koror.

The currency is the U.S. dollar, and English and Palauan are the official languages. The economy relies on tourism, agriculture and fishing but also some U.S. largesse.

According to the Palau visitors bureau, studies indicate that Palauans are distant relatives of the Malays of Indonesia, Melanesians of New Guinea and Polynesians. Carbon dating of artifacts from the oldest known village sites place civilization in Palau as early as 1,000 B.C.

Spain and Germany were early colonizers of Palau, followed by the Japanese from 1914 until the Americans took the islands in 1944. Independence from Trust Territory status came in 1994.

In 1981, Palau became the first country to vote for a nuclear-free constitution, banning the use, storage and disposal of nuclear, toxic chemical, gas and biological weapons unless three-fourths of the population voted in favor. The U.S. demanded the option to operate nuclear-powered ships and store weapons in the area, however, as part of the 1994 COFA agreement with the nation.

Health Problems and Outmigration

Because of hundreds of years of colonization and a loss of traditional cultural and sustenance practices, many Micronesians today have serious health problems.

In the Marshalls, those problems are exacerbated by radioactive fallout from 12 years of nuclear testing. A 2010 Census report counted 7,400 Marshallese living in Hawaii, but more recent estimates are around 15,000. The majority are from the Marshalls as well as Chuuk state in the Federated States. But there are many, too, from Palau, Pohnpei, Kosrae and Yap.

According to a 2009 Hawaii report produced by the Micronesian Health Advisory Coalition, migrants from COFA nations have numerous health problems “including communicable and chronic diseases,” low immunization rates among and poor living conditions as well as language and cultural barrier issues.

The migrants “suffer high morbidities and mortalities associated with obesity, diabetes, cardiovascular diseases, and lifestyle associated cancers.” Many are on renal dialysis and receiving chemotherapy treatment.

Poor living conditions, lack of English proficiency and cultural understanding are impediments to accessing health care, the report says.

The authors called for a commitment of government resources to help Micronesians.

Hawaii and Guam, which have the largest populations of Micronesians, have spent hundreds of millions of dollars to take care of many of the recent immigrants, an expense largely uncompensated by the federal government.

It’s estimated that as many as 75,000 Micronesians no longer live in the COFA nations. While many are successfully assimilating in states including Arkansas, Missouri, Oregon and California, states like Hawaii have also seen about 20 percent of its COFA residents living in homeless camps and shelters.

With federal payments to the COFA nations largely set to expire in 2023, and with climate change already threatening shorelines and flooding fresh water lenses, it is expected that many more Micronesians will migrate to Guam, Hawaii and the mainland U.S.