COMPACT of Free Association
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1 COMPACT of Free Association Pacific Global Public Health Conference October Honolulu, Hawaii Neal A. Palafox MD MPH Dept. of Family Medicine and Community Health John A. Burns School of Medicine University of Hawaii
2 ObjecFves: Structure for Compact Panels: 3 panels: groundwork, perspecfves and problem solving What is the Compact of Free AssociaFon What is the Compact Impact What is Basic Health Hawaii and its legal /polifcal implicafons Community PerspecFve on the Impact
3 Micronesian: history Geo- cultural term Total area equal to enfre United States,: land mass area size of Rhode Island Micronesia = Marshall Islands, Pohnpei, Yap, Palau, Chuuk, Kosrae, Northern Marianas, Guam, Nauru, KiribaF
4 Map
5 MIcronesian ImplicaFons of term Peoples from geographic Micronesia People from the Federated States of Micronesia (FSM) Yap, Kosrae, Chuuk, Pohnpei People from US Micronesia Guam, CNMI, FSM, Rep Palau, Rep Marshall Islands
6 Colonial and PoliFcal Rule Under Colonial Rule for 400 yrs Spain 1500 à Germany 1860 à Japan end WWI US, end of WWII, under UN Trusteeship Agreement, obtained AdministraFve Oversight of Northern Marianas, Palau, Truk, Yap, Kusaie, Pohnpei, and Marshall Islands General Assembly vs Security Council Became TTPI ( Trust Territory of the Pacific Islands) as Strategic Trust of US under UN Security Council
7 US - TTPI US set up Military base in Marshall Islands (Kwajalein Missile Range) and began US Nuclear Weapon TesFng Program Trusteeship Agreement main objecfve : economic development and self reliance of TTPI
8 Atoll Lagoon
9 US Associated Micronesian History 1960 UN issued report that crifcized US for not preparing Micronesia for self government Mid 60 s US increases financial assistance to Trusteeship 10 fold Many Federal and educafon programs started, and large confngent of Peace Corps Public high schools see first graduates and increase in college bounds
10 Freely Associated States (FAS) 1977 offered polifcal self determinafon to Northern Mariana, Palau, Marshalls, Chuuk, Yap, Korsrae, Pohnpei Congress of Micronesia Net effect: Northern Marianas became Commonwealth (CNMI); Palau, Marshall Islands, FSM became FREELY ASSOCIATED STATES (FAS) US TTPI last of all UN Trusteeship
11 Freely Associated States Formed RelaFonship with US Governed by COMPACT of Free AssociaFon (COFA): Each enfty has own COMPACT with US Military RelaFonship Strategic Denial Economic Provisions Federal Grants, OperaFons $ PoliFcal relafonship MigraFon (work indefinitely) Immigrants, refugees, illegal immigrants, migrant farm workers Other (differences) 177 Nuclear DuraFon: Term Longer term - Imperpetuity
12 COMPACT of Free AssociaFon COMPACT w/ FSM and RMI ; extended to 2003; amended 2003 to 2023 Republic of Palau different cycle. IniFal COMPACT 1994, renegofate with US 2010 Terms: COMPACT 1 and COMPACT 2 (Amended COMPACT)
13 US GAO Economic Self Sufficiency Not Likely Context for Health / EducaFon COMPACT ObjecFves Three ObjecFve from US DemocraFc Governments Strategic Denial (Military Security) Self Sufficiency FSM and RMI in their efforts to advance economic development and self- sufficiency US General AccounFng Office (GAO) 2003 (goal has not been achieved)
14 Compact US GAO Economic Self Sufficiency Not Likely Context for Health / EducaFon Economic Provisions Trust Fund Purpose ImplicaFons of not sufficient Now models
15 Compact ObjecFves Ensure certain nafonal security rights for all parfes US Strategic Denial ( over water and land) Military Base ; amended through 2066 US Army at Kwajelein Atoll- USAKA- Missile Range TesFng Site Nuclear Issues: TesFng DuraFon
16 Passports: Country Passport (vs Guam, CNMI, Am Samoa) Compact of Free AssociaFon (COFA) FAS sovereign except for Military makers( Strategic Denial of access to FAS airspace and waters) Affords FAS cifzens broad migrafon rights ( right to reside and work), no visa or labor cerfficafon, no limitafons of stay
17 COMPACT PoliFcal NegoFaFon and Treaty Primary intent Economic Development and Self Reliance of FAS nafons Consequences / intended - unintended COMPACT IMPACT Federal support in place funding decreases over life of Compact Not intended to reduce disparifes
18 COMPACT IMPACT COMPACT Impact on FAS nafons Poor health and EducaFon Persists Economic Development Challenged Large out migrafon Actual Nos. Unclear Out migrafon to US 20,000 HI, Guam, CNMI 9000 Marshallese in Arkansas, 4000 Marhsallese Costa Mesa CA
19 Economic Shortages
20 Health Indicator- InfecFous diseases dengue fever cholera epidemic syphilis epidemic hepaffs B endemic TB endemic Hansen s endemic
21 Compact Impact Aid Hawaii - esfmated $90 million annually in uncompensated care from FAS Migrants Fed COMPACT IMPACT Aid = 30 million annual divided: Hawaii, CNMI, Guam Hawaii s share is 11.1 million ( based on Census) 2010 Hawaii Sate Gov $114 million all sectors
22 COMPACT IMPACT Next Basic Health Hawaii
23 COFA and Health Care- Medicaid ImplicaFons FAS categorized by INS inifally as Qualified Aliens who are Permanently Under Color of Law (PRUCOL), means they are legal residents in the US under administrafve discrefon 1996 Personal Responsibility and Work Opportunity ReconciliaFon Act (PRWORA) changed PRUCOL to Non Qualified Aliens status rendering FAS migrants ineligible for fed public assistance
24 COMPACT Structure Funding Trust Fund
25 FAS NaFon PopulaFon Chuuk- 54 K Kosrae- 8K Pohnpei- 34K RMI- 60K ROB- 18K Yap- 11K PopulaFon deplefng due to out migrafon
26 Health Outcomes Infant Mortality: (RMI- 4 x US) (ROB- 4 x US) (FSM- 6 x US) Longevity : (RMI 64 yrs) (FSM 65 yrs) (ROB 67 yrs) (US 77 yrs) MalnutriFon and Vitamin A Def Rampant Suicide rate
27 Health Indicators lifestyle 50% of people over 50 with DM Diabetes 75% of hospital days 50% of men and women overweight Ischemic Heart increasing CVA (strokes) increasing CA increasing Smoking/ ETOH high
28 Legacy of US Nuclear Weapon TesFng TesFng , Above Ground, total 68 bombs Bravo Shot first hydrogen bomb power 1000 Hiroshima bombs Total yield power of 7200 Hiroshima bombs
29 US Nuclear Legacy Irradiated inhabitants downwind from ground zero who were not evacuated Associated with 26 Cancers People uprooted from homelands Land and water radioacfve contaminafon 2004 NCI Report- 530 excess CANCERS; now 2010 NCI report
30 FAS Migrants in Hawaii 2000 US Census 8,725 Micronesians in Hawaii. Now esfmated 15-17,000 Key drivers: economic opportunity, employment, medical and subsistence ( Graham, 2008)
31 Public Health Impact of Migrants Poor health status of FAS migrants reflecfng health indicators in FAS nafons FAS migrants have numerous health problems including communicable and chronic diseases Low immunizafon rate among FAS children Poor living condifons, language and cultural barriers issues
32 Communicable Diseases among FAS migrants in Hawaii FAS migrant have high rates of hepaffs (FSM - 12 % to 15 %,RMI - 12 %,ROP - 12 % to 15 %) % of new TB cases were from FAS Hansen s Disease FAS highest ( 94% of new cases in 2008 from FAS) Total of $918,458 in 2007 akributable to communicable disease services
33 Non communicable Diseases among FAS migrants in Hawaii Data lacking on chronic diseases Suffer high morbidifes and mortality associated with obesity, diabetes, cardiovascular diseases, lifestyle associated cancers About 110 on renal dialysis and on chemotherapy according to recent report 2004 NCI study predict more nuclear related cancers aper 2004
34 Socioeconomic Indicators Average household size 6 Range from 1-2 people to 17 in the household Age range <1 yr to 78 yrs, average age 23 yrs old Housing issues ( overcrowding, affordability, homeless) EducaFon: 35% less than HS educafon, 34% with HS educafon, 15% some college or college degree Most in Service OccupaFons ( restaurants, security guards, airport/ airline cargo services, hotels/cleaning services, retail sales, delivery services Lack of Language Access Services Overrepresented in Homeless shelters Overrepresented in prison
35 Key Health Disparity Issues LANGUAGE ACCESS Limited English Proficiency (LEP)pervasive CENSUS need for accurate demographic data
36 LANGUAGE ACCESS SERVICE LEP barrier to Quality Health Care and services further increasing health disparity among FAS migrants Need State policy advocafng for Culturally and LinguisFcally Appropriate Services (CLAS) for FAS migrants with LEP Language Access Service (LAS) cross curng theme in all aspects of health care delivery CLAS provides the necessary health connect from access of care to quality of care ( i.e medical hx )
37 CENSUS Beker demographic data or Census specific to FAS migrants in HI Accurate Census to inform public health policies Accurate and meaningful Census can help eliminate health disparifes Census has funding implicafons under the Compact Impact
38 Health Crisis: State vs. FAS Basic Health Hawaii, State Plan to save State 20 million Reduce care, cut dialysis and chemotherapy to FAS Migrants Met with strong opposifon from FAS migrants, State Legislature, Hawaii Congressional, local doctors Presently under Federal TRO
39 What is BHH Public Government Health Ins: Medicaid and Medicare Federal Medicaid State: California Medi- Cal, Hawaii- Quest Territories and Commonwealth have Medicare and Medicaid capped FAS: Do not have Medicare and Medicaid 1997 Fed Gov removed COFA peoples from ability to get Medicaid
40 What doe BHH Provide 4 prescipfons per month 12 outpt MD visits per year 3 out pafent vprocedures 10 in pt hospiital days
41 Other Provisions Pregnant Women Children Emergency Medical Care Dialaysis LimitaFons
42 BHH Timeline: 1997 State of Hawaii Quest- Medicaid July 2009 Announcement that Sept Two tears of COFA peoples 7500 on Quest : remain on new plan BHH New migrants cannot get on unfl less than 7000 Sept 1, 2009 Federal Judge InjuncFon Feb through April 2010 State Hearing and AdministraFve Process Sept 1, 2010 State AdministraFon reinstate BHH New InjuncFon Filed
43 Compact Remedies FEDERAL STATE COMMUNITY
44 Federal Remedies Increase COMPACT IMPACT Funds LegislaFon to allow COFA Migrants onto Medicaid Increase Resources for Health and EducaFon in COFA NaFons Reverse 1996 Fed PRWORA make FAS migrants eligible for federal assistance
45 State Remedies 2004 Hawaii Un- insured Policy Brief: Impacts of the Compacts of Free AssociaFon on Hawaii s Health Care System. (Developed by the Hawaii InsFtute for Public Affairs) Basically more Fed support needed for FAS migrants COMPACT of Free AssociaFon Task Force Report Support services to FAS migrants thru prevenfve care and to support health services in their home
46 Community Remedies FormaFon of community acfon groups MCN, MU, NOM Micronesian Health Advisory CoaliFon new health advocacy Resource Center to reduce health disparifes thru health advocacy and Culturally Competent Language Access Services
47 Levels of Argument Moral and Fairness Historical Data (save money?) Legal (Process)
48 Moral Do what s morally right Equity Fairness Military Nuclear TesFng IniFal expectafon when COMPACT 1 signed Taxes Recruitment Take care of business as Territory
49 Push and Pull Health EducaFon Opportunity Workforce- - unskilled Military
50 Hawaii and Guam Public: Impression Blogs Web
51 Impact in Other part US Treatment by other States Guam Territories
52 NavigaFon Find Ways of gerng through system CHC Gerng Meds Increase paper work for dialysis
53 MigraFon Pakerns Chuuk, Yap, Belau To Guam and CNMI College Age to Hawaii ConFnental US for School Marshall Ilsanders To Hawaii Oahu Big Island Ocean View Maui Costa Mesa California Springdale Arkansas- 9000
54 COMPACT IMPACT- Policy Policy Affects What you Do US Federal Support State Support Territory and Commonwealth Support AcFons affect USAPI Economics Affects Policy Dialysis / Cheno, Referral Pakerns
55 COMPACT IMPACT - Planning Dialysis Cancer Therapy MigraFon Climate Change Military Collateral Damage
56 Typical Island Sunset
57 Thank you- Komol Tata
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