Federal Funding Provision to Provide Healthcare Coverage for U.S. Marshallese ResidentsCity of Dubuque
ITEM TITLE:
SUMMARY:
SUGGESTED DISPOSITION:
Copyrighted
May 18, 2020
Action Items # 2.
Federal Funding Provision to Provide Healthcare Coverage
for United States Marshallese Residents
Letters submitted to Senator Grassley, Senator Ernst, and
Congresswoman Finkenauer supporting federal funding
provision to provide healthcare coverage for United States
Marshallese residents.
Suggested Disposition: Receive and File
ATTACHMENTS:
Description
Letter to Senator Grassley
Letter to Senator Ernst
Letter to Congresswoman Finkenauer
Human Rights Commission Support for COFA Act
Marshallese Legislation Draft -Summary
Type
Supporting Documentation
Supporting Documentation
Supporting Documentation
Supporting Documentation
Supporting Documentation
Masterpiece on the Mississippi
May 12, 2020
The Honorable Charles Grassley
United States Senator
State of Iowa
Washington, DC 20515
Dear Senator Grassley,
Dubuque
All•Ameriea City
NVk YJN.I P,1,1 Fh;LI
'l 1►
2007*2012.2013
2017*2019
Office of the Mayor
City Hall
50 West 13' Street
Dubuque, IA 52001-4805
www.cityofdubuque.org
As Mayor and on behalf of my city Council colleagues and the citizens of Dubuque, I am writing to
request your advocacy and support for the bipartisan Covering Our FAS Allies Act (COFA Act, H.R.
4821 and S.2218). We appreciate that there was an effort to include a provision for access to
healthcare coverage for Marshallese and other Pacific Islanders in the CARES Act and we were
extremely disappointed that the effort was unsuccessful.
Since the late 1980's, the Compact of Free Association (COFA) has 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, the United states was granted access to strategic military bases in the Pacific and,
in exchange, the United States government would provide broad migration privileges for COFA citizens,
including the Marshallese. Currently there are nearly 70,000 COFA citizens residing in the US and an
estimated 800-900 in Dubuque.
In 1996, with the passage of welfare reform legislation in Congress, COFA citizens were statutorily
barred from access to Medicaid in what was considered an egregious oversight. Previously included in
Medicaid eligibility rolls, this nearly twenty -five-year lack of access to medical coverage for COFA
citizens has had a devastating impact and is especially evident now during the global pandemic of
COVID-19.
Nationally, the Marshallese population is experiencing rapid population growth primarily in the Midwest
and the South. The U.S. Census indicates that the following states have populations more than 1,000:
Hawaii, California, Texas, Washington, Oregon, Utah, Oklahoma, Florida, Arkansas, Missouri, and
Arizona. These numbers will continue to increase as the islands become uninhabitable between 2030
and 2050 because of climate change.
https://www.latimes.com/environment/story/2019-10-11 /marshall-islands-national-climate-crisis
Between 2000 and 2010, Dubuque experienced a 279% population growth in the Pacific Islander
population according to the U.S. Census. While the results of the 2020 Census are not complete, over
a period of three days during the COVID-19 crisis in April, City of Dubuque staff members working with
community leaders were able to identify 600 Marshallese residents in need of food assistance within
the City of Dubuque limits, suggesting our numbers continue to climb.
In addition, 19.6% of Pacific Islanders in the U.S. live in poverty, compared to 15% of the overall
population. Ineligibility for Medicaid, even when income requirements are met, creates an almost
insurmountable barrier to prosperity for Marshallese. Locally here in Dubuque, Crescent Community
Health Center saw 263 patients in 2019 who identified themselves as being Pacific Islanders. Of these
patients, 93 are diagnosed with diabetes representing 35% of the patient population. For comparison,
about 8% of the general patient population at Crescent has a diagnosis of diabetes. In addition, 72 of
these patients, or 27%, are diagnosed with hypertension. This compares to 16% of the general patient
population. Fifty-two patients have both diagnoses. As a result, many members of the population at
high risk for significant negative outcomes if they contract COVID-19. Within the past three weeks, at
least three Marshallese community members have died from COVID-19 in Dubuque and several are in
intensive care.
Senator, I urge you to correct the injustice that was created by an oversight in 1996 and restore access
to healthcare through Medicaid to our Marshallese neighbors in Dubuque.
Through this global crisis, the City of Dubuque has reaffirmed its identified goal to "create an equitable
community of choice" by demonstrating and building greater resiliency, sustainability, equity and
compassion into the lives of our residents and in the Dubuque community writ large. We value and
depend upon your partnership to achieve this goal of health care access for the Marshallese in
Dubuque and throughout Iowa and the country.
Sinc
0
Ma'or
,1
. Buol
Masterpiece on the Mississippi
May 12, 2020
The Honorable Joni Ernst
United States Senator
State of Iowa
Washington, DC 20515
Dear Senator Ernst,
Dubuque
All•A�e�iea City
NVk YJN.I P,1,1 Fh;LI
'l 1►
2007*2012.2013
2017*2019
Office of the Mayor
City Hall
50 West 13' Street
Dubuque, IA 52001-4805
www.cityofdubuque.org
As Mayor and on behalf of my city Council colleagues and the citizens of Dubuque, I am writing to
request your advocacy and support for the bipartisan Covering Our FAS Allies Act (COFA Act, H.R.
4821 and S.2218). We appreciate that there was an effort to include a provision for access to
healthcare coverage for Marshallese and other Pacific Islanders in the CARES Act and we were
extremely disappointed that the effort was unsuccessful.
Since the late 1980's, the Compact of Free Association (COFA) has 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, the United states was granted access to strategic military bases in the Pacific and,
in exchange, the United States government would provide broad migration privileges for COFA citizens,
including the Marshallese. Currently there are nearly 70,000 COFA citizens residing in the US and an
estimated 800-900 in Dubuque.
In 1996, with the passage of welfare reform legislation in Congress, COFA citizens were statutorily
barred from access to Medicaid in what was considered an egregious oversight. Previously included in
Medicaid eligibility rolls, this nearly twenty -five-year lack of access to medical coverage for COFA
citizens has had a devastating impact and is especially evident now during the global pandemic of
COVID-19.
Nationally, the Marshallese population is experiencing rapid population growth primarily in the Midwest
and the South. The U.S. Census indicates that the following states have populations more than 1,000:
Hawaii, California, Texas, Washington, Oregon, Utah, Oklahoma, Florida, Arkansas, Missouri, and
Arizona. These numbers will continue to increase as the islands become uninhabitable between 2030
and 2050 because of climate change.
https://www.latimes.com/environment/story/2019-10-11 /marshall-islands-national-climate-crisis
Between 2000 and 2010, Dubuque experienced a 279% population growth in the Pacific Islander
population according to the U.S. Census. While the results of the 2020 Census are not complete, over
a period of three days during the COVID-19 crisis in April, City of Dubuque staff members working with
community leaders were able to identify 600 Marshallese residents in need of food assistance within
the City of Dubuque limits, suggesting our numbers continue to climb.
In addition, 19.6% of Pacific Islanders in the U.S. live in poverty, compared to 15% of the overall
population. Ineligibility for Medicaid, even when income requirements are met, creates an almost
insurmountable barrier to prosperity for Marshallese. Locally here in Dubuque, Crescent Community
Health Center saw 263 patients in 2019 who identified themselves as being Pacific Islanders. Of these
patients, 93 are diagnosed with diabetes representing 35% of the patient population. For comparison,
about 8% of the general patient population at Crescent has a diagnosis of diabetes. In addition, 72 of
these patients, or 27%, are diagnosed with hypertension. This compares to 16% of the general patient
population. Fifty-two patients have both diagnoses. As a result, many members of the population at
high risk for significant negative outcomes if they contract COVID-19. Within the past three weeks, at
least three Marshallese community members have died from COVID-19 in Dubuque and several are in
intensive care.
Senator, I urge you to correct the injustice that was created by an oversight in 1996 and restore access
to healthcare through Medicaid to our Marshallese neighbors in Dubuque.
Through this global crisis, the City of Dubuque has reaffirmed its identified goal to "create an equitable
community of choice" by demonstrating and building greater resiliency, sustainability, equity and
compassion into the lives of our residents and in the Dubuque community writ large. We value and
depend upon your partnership to achieve this goal of health care access for the Marshallese in
Dubuque and throughout Iowa and the country.
Sinc
0
Ma'or
,1
. Buol
Masterpiece on the Mississippi
May 12, 2020
Honorable Abby Finkenauer
124 Cannon House Office Building
U.S.Capitol
Washington DC 20515
Dear Congresswoman Finkenauer,
Dubuque
All•Ameriea City
NVk YJN.I P,1,1 Fh;LI
'l 1►
2007*2012.2013
2017*2019
Office of the Mayor
City Hall
50 West 13' Street
Dubuque, IA 52001-4805
www.cityofdubuque.org
As Mayor and on behalf of my city Council colleagues and the citizens of Dubuque, I am writing to
request your advocacy and support for the bipartisan Covering Our FAS Allies Act (COFA Act, H.R.
4821 and S.2218). We appreciate that there was an effort to include a provision for access to
healthcare coverage for Marshallese and other Pacific Islanders in the CARES Act and we were
extremely disappointed that the effort was unsuccessful.
Since the late 1980's, the Compact of Free Association (COFA) has 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, the United states was granted access to strategic military bases in the Pacific and,
in exchange, the United States government would provide broad migration privileges for COFA citizens,
including the Marshallese. Currently there are nearly 70,000 COFA citizens residing in the US and an
estimated 800-900 in Dubuque.
In 1996, with the passage of welfare reform legislation in Congress, COFA citizens were statutorily
barred from access to Medicaid in what was considered an egregious oversight. Previously included in
Medicaid eligibility rolls, this nearly twenty -five-year lack of access to medical coverage for COFA
citizens has had a devastating impact and is especially evident now during the global pandemic of
COVID-19.
Nationally, the Marshallese population is experiencing rapid population growth primarily in the Midwest
and the South. The U.S. Census indicates that the following states have populations more than 1,000:
Hawaii, California, Texas, Washington, Oregon, Utah, Oklahoma, Florida, Arkansas, Missouri, and
Arizona. These numbers will continue to increase as the islands become uninhabitable between 2030
and 2050 because of climate change.
https://www.latimes.com/environment/story/2019-10-11 /marshall-islands-national-climate-crisis
Between 2000 and 2010, Dubuque experienced a 279% population growth in the Pacific Islander
population according to the U.S. Census. While the results of the 2020 Census are not complete, over
a period of three days during the COVID-19 crisis in April, City of Dubuque staff members working with
community leaders were able to identify 600 Marshallese residents in need of food assistance within
the City of Dubuque limits, suggesting our numbers continue to climb.
In addition, 19.6% of Pacific Islanders in the U.S. live in poverty, compared to 15% of the overall
population. Ineligibility for Medicaid, even when income requirements are met, creates an almost
insurmountable barrier to prosperity for Marshallese. Locally here in Dubuque, Crescent Community
Health Center saw 263 patients in 2019 who identified themselves as being Pacific Islanders. Of these
patients, 93 are diagnosed with diabetes representing 35% of the patient population. For comparison,
about 8% of the general patient population at Crescent has a diagnosis of diabetes. In addition, 72 of
these patients, or 27%, are diagnosed with hypertension. This compares to 16% of the general patient
population. Fifty-two patients have both diagnoses. As a result, many members of the population at
high risk for significant negative outcomes if they contract COVID-19. Within the past three weeks, at
least three Marshallese community members have died from COVID-19 in Dubuque and several are in
intensive care.
Congresswoman, I urge you to correct the injustice that was created by an oversight in 1996 and
restore access to healthcare through Medicaid to our Marshallese neighbors in Dubuque.
Through this global crisis, the City of Dubuque has reaffirmed its identified goal to "create an equitable
community of choice" by demonstrating and building greater resiliency, sustainability, equity and
compassion into the lives of our residents and in the Dubuque community writ large. We value and
depend upon your partnership to achieve this goal of health care access for the Marshallese in
Dubuque and throughout Iowa and the country.
Sinc
i6.,-
4 . Buol
Ma or
Masterpiece on the Mississippi
Dubuque
A*•America Cilj
2007.2012.2013
2017*2019
TO: Michael C. Van Milligen, City Manager
FROM: Kelly Larson, Human Rights Director
DATE: May 12, 2020
SUBJECT: Human Rights Commission Support for Health Care for Compact of Free
Association Migrants, Including the Marshallese
The purpose of this memo is to forward to the City Council the Human Rights
Commission's support for State and Federal solutions to provide health care coverage
for community members from the Marshall Islands, as well as other community
members who are covered by the Compact of Free Association (COFA).
At its regularly scheduled meeting on May 11, 2020, the Human Rights Commission
discussed the impact COVID-19 is having locally on our Marshallese community
members, including concerns regarding the lack of Medicaid coverage for this
population. Art Roche, a community member and retired employee of Mercy One who
is actively involved in leading the Dubuque Pacific Islander Health Project Advisory
Committee, provided background on the health conditions facing our local population,
their legal status, and the efforts that have been underway to address a gap in their
healthcare coverage. Assistant City Manager Teri Goodmann provided information
related to the City Council's support of state and federal action to address this gap as
part of its legislative priorities.
At the conclusion of the conversation, the Commission voted in favor of forwarding a
memo to the City Council expressing its support for a letter from the Mayor to State and
Federal officials encouraging actions to grant healthcare coverage to the COFA
population via Medicaid or through other means. This memo serves as their statement
of support for taking action to advance healthcare coverage for this population,
particularly during this time of COVID-19.
Cc: Teri Goodmann, Assistant City Manager
Health Insurance Coverage for COFA Migrants
HISTORICAL BACKGROUND
The Marshall Islands, stretching over 70 square miles in the Pacific Ocean, consists of 29 coral atoll nations and
five single islands located along 2,000 miles northeast of Australia. With a population of only 60,000, the
Marshall Islands is one of the world's youngest nations, gaining its independence in 1986 as a self-governing
democratic nation under the Republic of the Marshal Islands in free association with the United States. Prior,
the U.S. administered the Islands for nearly four decades in accordance with the UN Trust Territory of the
Pacific Islands treaty.
The Islands became a strategic nuclear testing site for the U.S military during the Cold -War era, following the
end of World War II. From 1947 until 1962, the U.S. had detonated 67 nuclear bombs in Bikini and Enewetak
atolls. In one of the tests on March 1, 1954, a 15-megaton thermonuclear device detonated at Bikini atoll,
releasing 1,000 times the power of the atomic bomb dropped on Hiroshima, Japan. The nuclear tests had
devastating impact on the Islands, from physical destruction, exposure to radiation and various terminal
diseases directly linked to the testing within a few short years.
Under the Compact of Free Association Act (COFA) of 1985,
the U.S. granted certain citizenship privileges to residents
of the Republic of Marshall Islands, the Federated States
of Micronesia and Republic of Palau, including the right to
live and work in the United States, without retaining a
visa or green card.
Under the Compact of Free Association Act (COFA) of 1985 (amended 2003), the U.S. agreed to grant certain
citizenship privileges to residents of the Republic of Marshall Islands, the Federated States of Micronesia and
Republic of Palau including the right to live and work in the United States, without retaining a visa or green
card. Other social welfare programs and benefits including healthcare coverage were extended to the
residents of the Islands. However, in 1996 the U.S. Personal Responsibility and Work Opportunity Act ended
the Medicaid benefits for COFA residents.
NATIONAL EFFORTS TO REINSTATE MEDICAID BENEFITS
COFA migrants were eligible for Medicaid health insurance when the initial COFA agreement was signed.
However. After the Personal Responsibility and Work Opportunity Reconciliation Act passed in 1996, COFA
migrants were rendered ineligible as they were excluded from "qualified immigrants" category. The 2010
Affordable Health Care Act (ACA) requires COFA migrants to buy health insurance, eligible for advanced
premium tax credit subsidies and subject to financial penalties for not enrolling in a health plan. COFA
migrants are not eligible for Medicaid or Medicaid Expansion through ACA even if they meet the income and
asset requirements.
Since 2001, twenty-two bills to reinstate
COFA eligibility for Medicaid have been
introduced at the federal level, without
success.
1
Since 2001, twenty-two bills to reinstate COFA eligibility for Medicaid have been introduced at the federal
level. Most recently, the Health Equity and Accountability Act (HEAA) of 2018 was introduced by Rep. Barbara
Lee and Rep. Judy Chu and sponsored by 71 Democratic Representatives, 9 Democratic Senators 1
Independent Senator. None of the Republican Representatives or Senators sponsored the bill. HEAA is aimed
at achieving health equity for COFA migrants, with an emphasis on restoring Medicaid as well as removing
immigration status as a barrier. HEAA asks that Congress should address health disparities and provide quality
healthcare to all.
On October 23, 2019 a bipartisan bill, the Covering Our FAS Allies Act (COFA Act), was introduce in the House
of Representative, aimed to reinstate Medicaid eligibility for COFA migrants. Nonetheless, little to no progress
has been made on a federal policy to reinstate Medicaid to COFA.
OVERVIEW OF STATE AND LOCAL HEALT COVERAGE PLANS
COFA migrants are predominantly located in Arkansas, California, Hawaii, Iowa, Nebraska, Oregon and
Washington. In the absence of a federal policy action since 1996, it has been up to states to take action and fill
the gap in extending Medicaid to COFA migrants. Lessons from some of COFA migrant host states share light
on the issue.
Iowa
According to a 2018 estimate, 1000-1200 COFA migrants reside in Iowa. A 2015 Iowa Department of Human
Rights Office of Asian and Pacific Islander Affairs found limited English-speaking and lack of time and resource
were the principle barriers to career advancement. In 2018, 44% of Marshallese living in Dubuque were
reported unemployed. The Marshallese population in Dubuque City is roughly between 800.
In 2015, Local health professionals, city officials, religious leaders and educators established the Dubuque
Marshall Island Health Project, which provided regular nurse home visits and provide wellness education. A
local survey 2017 survey indicated that 75 percent of Marshallese living in Dubuque did not have health
insurance coverage while 60 percent hadn't seen a doctor in a year. Nearly one in four had diabetes and
roughly 10 percent had heart disease.
A local survey 2017 survey indicated that 75
percent of Marshallese living in Dubuque did
not have health insurance coverage while 60
percent hadn't seen a doctor in a year.
A local survey of 82 Marshallese adult residents in Dubuque revealed that 61 percent have diabetes, 28
percent have heart disease, 5 percent have cancer, and 5 percent have hypertension. 73 percent of those
interviewed lack health insurance. 58 percent have not seen a doctor within the last year, 65 percent of those
because they lack health insurance, and 23 percent because of cost.
Arkansas
Home to the largest COFA migrant communities from 12,000 to 15,000 COFA migrants, over 50 percent
of all COFA migrant in Arkansas are uninsured. COFA migrants are ineligible for the state Medicaid -
funded private insurance coverage at or near the poverty level. Although the state has not funded Medicaid
2
for COFA migrants, it has extended coverage to COFA migrants through the state's Children Health Insurance
Program (CHIP). Adult Marshallese still do not have Medicaid coverage in Arkansas.
Arkansas enrolled COFA migrants in the
CHIP program; however adult Marshallese
do not have Medicaid.
Hawaii
Hawaii has an estimated 13700 COFA migrants. There has been little progress on providing Medicaid benefits
to COFA migrants in Hawaii. COFA migrants were enrolled in the state's Medicaid program until 2009 if they
met the income and asset requirements. Amidst the great recession of 2009, Republican Governor Linda Lingle
unenrolled 7,500 COFA migrants from Med-Quest, the state's Medicaid program and placed them in the Basic
Health Hawaii program. Newly arrived COFA migrants were no eligible to obtain any health coverage.
Hawaii has enrolled COFA migrants in ACA
while two bills are pending in state
legislature to extend Medicaid benefits.
In 2010, lawsuit filed challenged the constitutionality of the Basic Health Hawaii program on the basis of
violation of the 14th Amendment. In 2014, a Ninth circuit court overruled that Hawaii is not required to
provided healthcare to COFA migrants through its state -run Medicaid programs. Following this ruling, Hawaii
enrolled COFA migrants in the Affordable Health Care Act (ACA). Two bills are currently pending in the state
legislature to extend Medicaid benefits to all COFA migrants.
Oregon
Oregon has an estimated 9,000 COFA migrants. After many years of COFA migrants advocating for legislation,
Oregon implemented the COFA Premium Assistance Program, a state supplement that pays all insurance
premiums and out-of-pocket expenses for qualified COFA migrants living in Oregon.
Oregon has the most progressive policies for
providing COFA migrants health insurance.
The program was passed under the HCR21 bipartisan supported bill in 2015 to recognize and thank their
contribution to the state's economy. The program costs a federal contribution of $9 for every $1 state
contribution, with a total cost of $1 to $1.8 million per year. In 2017, Oregon considered adding adult dental
coverage to the coverage. Oregon has the most progressive policies for providing COFA migrants health
insurance.
POLICY ACTION RECOMMENDATIONS
Currently, COFA migrants who are living, working, and paying taxes in the U.S. are not eligible for federal
healthcare programs. While the Affordable Care Act (ACA) as it is currently written provides for health care tax
credits and subsidies, some proposed ACA amendments would explicitly block that access for COFA residents.
3
Other proposed amendments expand catastrophic coverage to those over age 30, raising the concern that
vulnerable populations with limited health literacy will need assistance to fully understand these options and
their limitations. At the same time, there is a proposal to end 20 years of funding for the REACH program
(Racial and Ethnic Approaches to Community Health), which is the only federal community driven program
focused on ending health disparities.
Despite many attempts nationally, reinstating Medicaid benefits to COFA migrants has not been successful.
The solution rests on the shoulders of the states. States must fill in the gap in providing Medicaid and health
care insurance to COFA migrants, ensuring the health and safety of all their residents and achieving health
equity.
Sources
McElfish, Pearl A. et. al (2019). Compact of Free Association Migrants and Health Insurance Policies: Barriers
and Solutions to Improve Health Equity. Sage, 56.
Encyclopedia Dubuque. http://www.encyclopediadubuque.org/index.php?title=MARSHALLESE
Diamond, Dan. (2020). "They Did Not Realize We Are Human Beings". Politico.
https://www.politico.com/news/magazine/2020/01/26/marshall-islands-iowa-medicaid-103940
The Joshua Project. https://joshuaproject.net/people groups/13554/US#generalinfo
Roche, Art. (2018). Health Care Benefits for Compact of Free Association (COFA) Migrants in Iowa: Advocacy
Case Statement.
Gomez, Brooke. (2019). Pacific Islander Population 2019 Summary. Crescent Community Health Center.
City of Dubuque. (2020). Federal Legislative Priorities.
4