1. COFA citizens in
Oklahoma
Moving Health Forward
Many COFA migrants suffer from chronic diseases and health conditions that can be linked to the medical
effects of U.S. nuclear testing in the region. The current fiscal crisis, however, has forced many states to
reduce funding for these efforts in the absence of federal dollars.
By:
TERRY L. MOTE
Micronesian Community Health Coordinator
Garfield County Health Department

2. COFAcitizensinOklahoma
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Report Backgrounds:
Following information were
captured from my notes that I
took and also the handouts during
the VOICES2015 Conference that I
went to in Washington, D.C.
The conference was about
“Moving Health Forward”, to help
supporting the COFA health
access issue. Participants were
from difference states
representing their coalitions and
communities. It was encouraging
on our hill visit to our respective
legislators. It was a time for many
of us to voice our concerns and
needs on Medicaid issues for the
COFA migrants in the U.S.
No matter what the outcome will
be for the bill, but I think we’ve
started by joining together as
COFA migrants to move health
forward.
COFA citizens
in Oklahoma
Moving Health Forward
Who are COFA migrants?
Since 1986, the Compacts of Free Association (COFA) have
defined the relationship between the United States and the
independent governments of the Freely Associated States
(FAS) including: the Republic of the Marshall Islands, the
Federated States of Micronesia and the Republic of Palau.
Under the Compact, in exchange for permitting the U.S.
exclusive use and military strategicpositioning in the
Pacific, the U.S. provides grants to fund education, health
care, and infrastructure in the FAS. Maintaining good
relationships with the FAS is imperative to our national
security as other countries seek to grow their influence in
the Pacific region.
Under the COFA, these individuals have a unique
relationship with the United States that allows them to
freely travel without a visa and with no time restraints.
The Compacts also permit citizens of the FAS broad
migration privileges to the U.S. and its territories. Known
collectively as “COFA migrants” when they enter the U.S.,
the Compacts allow citizens of the FAS to apply for
admission to the U.S. as “non-immigrants” and without visa
requirements. Currently there are at least 56,000 migrants
from the COFA nations legally residing, working and
studying in the U.S. These COFA migrants pay taxes and
play a role in driving our economy, but arenot eligible for
many of the programs that their tax dollars support.

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Are COFA migrants immigrants?
While they are not immigrants, COFA Migrants share many of the same difficulties faced by
immigrants trying to access affordable health insurance and care. Their unique status has caused
unexpected health carecosts on the states and territories where they reside. COFA migrants
reside in all states, with the largest concentration in Hawaii, the territory of Guam, California,
Arkansas, Oklahoma and Washington.
COFA migrants were formerly eligible for federal health programs:
In 1996, the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA),
commonly referred to as welfare reform, changed the categories of persons eligible for certain
federal safety-net programs including Medicaid and the Children’s HealthInsurance Program
(CHIP). As a result, COFA migrants were stripped of their ability to qualify for these programs. In
the aftermath of PRWORA, some states continued to provide health care services to COFA
migrants using their own funds, recognizing the contributions and health needs of COFA migrant
populations in their states. Many COFA migrants suffer from chronic diseases and health
conditions that can be linked to the medical effects of U.S. nuclear testing in the region. The
current fiscal crisis, however, has forced many states to reduce funding for these efforts in the
absence of federal dollars.
Coverage options are limited:
Because COFA Migrants arestatutorily barred from Medicaid, regardless of their income or
length of time in the U.S., they are left with few coverage options. COFA migrants are subject to
the Affordable Care Act’s (ACA) individual mandate, which requires nearly all citizens and
lawfully present persons to have minimum essential coverage or pay a penalty. While COFA
migrants are eligible to purchase health insurance plans in the newly createdMarketplaces with
the support of subsidies, many still struggle to afford these plans. The lack of affordable
coverage options is becoming increasingly problematic as more COFA migrants move out of the
Compact designated impact jurisdictions of Guam, the Commonwealth of the Northern Mariana
Islands (CNMI), American Samoa, and Hawaii. Nine additional states have COFA migrant
populations exceeding 1,000: California, Washington, Oregon, Utah, Oklahoma, Florida,
Arkansas, Missouri, and Arizona.
Even with this financial help in the Marketplaces, however, coverage is unaffordable for most.
Many COFA migrants work in low-paying jobs, such as poultry processing or the hospitality
industry.

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Why is the relationship to Hawaii litigation?
Because COFA migrants are statutorily excluded from Medicaid, states must use their own
dollars to pay for their care if they are uninsured. This has placed large economic burdens on
states like Hawaii. On Nov. 3, 2014, the Supreme Court issued an order denying certiorari of
plaintiff’s appeal in Korab v. McManaman, a case challenging Hawaii’s decision to remove COFA
migrants from full-scope Medicaid. The result is that the decision by the Ninth Circuit Court of
Appeals in favor of Hawaiistands. Hawaii does not have to use its own dollars to provide care for
COFA migrants within its borders. Since the decision, Hawaii has shifted COFA migrants to
private coverage in the Marketplace
Impacted Jurisdictions:

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CONGRESSIONAL EFFORTS TO REINSTATE COVERAGE
Since 2001, 21 bills have been introduced to reinstate COFA eligibility for Medicaid. In the 114th
Congress, Senator Hirono (D-HI) and Representative Gabbard (D-HI) introduced S. 1301 and H.R.
2249, the Restoring Medicaid for Compact of Free Association Migrants Act of 2015.
How much would it cost?
There is no Congressional Budget Office (CBO) score for the COFA Medicaid restoration bills
pending in the 114th Congress. In 2013, the CBO scored an amendment by Sen. Hirono to the
Senate immigration reform bill (S. 744), estimated that restoring eligibility for COFA migrants
would increase Medicaid spending by $200 million over a 10 year period (FY2014-2023). That
amendment was adopted and included in S. 744, as passed by the Senate.
What can be done for COFA migrants in Oklahoma?
More than 30 years agoafter the first Marshallese arrived in Oklahoma, this state does not have
an exact data of COFA populations. In an effort to enforce civic rights, we need a collection and a
reporting system that can feed our state government about our population. The failure of many
state agencies to consistently implement state standards, especially on budget policies for COFA
citizens, is a result of inequitable access to resources and data for the population.
The COFA communities face disproportionately high rates of health illnesses. However, many are
still uninsured and lack of culturally and linguistically appropriate services createsignificant
barriers to become a healthier and more productive community.
The policy makers, health careproviders, insurance companies, organizations that advocate for
healthier communities including the following:
 Make certain that the linguistic and cultural appropriate health careservices
 Encourage access to affordable health care for all COFA citizens regardless of
immigration status
 Available Funding for research on the issues that arecritical to COFA, such as
diabetes, cancer, obesity, asthma and other illness.
 Dilate the participation of COFA in health care through workforce diversity
initiatives and inclusion of COFA on local and state boards and committees that
address health issues relevant to COFA citizens.

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 Increasing Federal Funding for states to adequately offset the impact of COFA
citizens.
 COFA citizens need a Champion! As of today, we have no voice or
representation with our City or Stateto address our concerns.