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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