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When Josie Howard heard that Gov. David Ige planned to push thousands of low-income Pacific Islander migrants off state-funded public health insurance in 2015, she worried about what that would mean for her community.

Howard, a Chuukese community leader, pictured patients waiting until they were really sick before going to an emergency room. She had flashbacks to the under former Gov. Linda Lingle in 2009. She remembered hearing about cancer patients and people on dialysis who couldn’t get the treatment they needed. She was afraid people might die.

Her fears were confirmed by University of Hawaii researchers last week. A new study found that the every year between 2015 and 2018, curving upward compared with that of white and Japanese residents.

Approximately 94 additional Micronesians died between 2015 and 2018 after the Ige administration removed the migrant community from — the state version of Medicaid that provides health coverage for impoverished people — and transferred them onto more expensive private insurance.

“Oh, I’m not surprised,” Howard said of the higher mortality rate. “But what’s next? Is this going to really change anything?”

Still, she still has some hope. Perhaps decision-makers will read this study and realize these statistics represent real people, she said.

The study comes as Hawaii’s coronavirus pandemic surges to record levels, with daily case counts in the triple digits. On Friday, the state reported that are among non-Hawaiian Pacific Islanders, even though they make up just 4% of the population.

It’s a disparity that far eclipses any other in the state. And it brings renewed urgency to calls to reinstate health care coverage for Hawaii’s Micronesian community, which tends than other ethnic groups. As Hawaii workers who lost their jobs due to pandemic shutdowns flock to Med-QUEST, those who are citizens of Palau, the Marshall Islands or the Federated States of Micronesia don’t have that safety net.

But the same pandemic that is making more Pacific migrants sick is also wreaking economic havoc, making it unlikely that they’ll get health coverage anytime soon. The Ige administration wasn’t willing to pay for their insurance in 2015, when the state was projecting tens of millions in extra revenue. Even in good times, Micronesians have little to no political sway in Hawaii, and now the state is scrambling to plug a major budget shortfall.

In Congress, Hawaii’s delegation is pushing for Medicaid reinstatement but so far has been stymied in the Republican-controlled Senate.

Neal Palafox, a physician and professor at the University of Hawaii Cancer Center, said the new mortality study is good data to have but it’s also predictable.

“The political will is not going to change until the people in Hawaii push it,” he said. He’s not confident that will happen. “A lot of them don’t feel that that vulnerable population is important or it’s not their priority.”

‘The Consequences Were Devastating’

In 2015, the the state expected to save about $29.2 million by transferring 7,617 non-U.S. citizens off of Med-QUEST and onto private insurance.

Not every low-income Micronesian migrant in Hawaii was affected. Pregnant, blind and disabled adults still got access to public health insurance, as did children and the elderly.

The state helped fund Howard’s organization, , tapping her to provide community outreach and facilitate the transition. Some extremely poor people got private or public subsidies to help them afford their co-pays. But it wasn’t enough.

“The share of people dying among Micronesians increased much more after this policy than when you compare it to the increases in white mortality rates and Japanese mortality rates,” explained Teresa Molina, an economist and assistant professor at the University of Hawaii and lead author on the study.

A found that after the policy change, fewer Micronesians went to the hospital and uninsured emergency room visits rose.

“This was a middle ground and still the consequences were devastating,” said Tetine Sentell, a co-author of the mortality study and professor at the University of Hawaii Office of Public Health Studies. “I hope policymakers see that as the very real consequences of numbers in a spreadsheet.”

Citizens of the three Pacific nations can live and work in the U.S. indefinitely due to defense agreements dating back to the Reagan administration known as the Compacts of Free Association. About 16,000 of them live in Hawaii, according to American Community Survey data between 2013 and 2017.

Many come for similar reasons that Hawaii residents move to the mainland: to find better-paying jobs and better education. Others are medical refugees, seeking life-saving medical care such as dialysis and chemotherapy that isn’t available in their home countries. Marshallese residents in particular associated with U.S. nuclear testing in the region.

But accessing health care isn’t easy. Even before the pandemic, about 14% of Micronesians were uninsured, more than three times higher than the state average — even taking into account nearly 9,000 Micronesians in Hawaii who are U.S. citizens and remain eligible for Med-QUEST.

Since 2015, Howard has thrown herself into helping her fellow migrants get health coverage. She brings in a nurse every month to her Kalihi office to check migrants’ vital signs. She set up calls with neighbor island advocates to facilitate health insurance sign-ups. She partnered with an urgent care center so health care providers could help people enroll in coverage.

And every fall during the open enrollment period, she and her staff work long hours to help both Micronesians and other immigrants who aren’t eligible for Medicaid to sign up for insurance through the federal marketplace. First, they have to apply to Med-QUEST and get rejected. Then they have to apply for insurance through the federal website. It’s confusing and complicated and the website isn’t translated into any Pacific Islander languages.

Howard and her staff spend hours interpreting information into multiple languages and helping people who don’t have access to computers navigate the complex process.

“This is the effort we have to take in order to get our people covered,” she explained. It doesn’t always work. Sometimes, people walk in asking for help getting on insurance after the sign-up period is closed. She has to turn them away, even though she can see that they are very sick.

Cost Savings

The Affordable Care Act insurance marketplace wasn’t intended for low-income families. When former President Barack Obama pushed for the health care law, he also pushed to expand Medicaid. That’s the mechanism that the federal government has relied on since the 1960s as a safety net for people in poverty.

But not everyone is eligible for Medicaid. Unauthorized immigrants aren’t, and the 1996 Welfare Reform Act . Green card holders suddenly needed to be in the U.S. for a full five years before they’d be eligible for the program. And anyone considered a “nonimmigrant” wasn’t eligible either — including COFA migrants.

Their legal status bars access not only to Medicaid but also programs like federal disaster assistance, food stamps and . Today COFA migrants like Howard may live, work and pay taxes in the U.S. for decades but they are effectively treated under the law like short-term residents.

“We are saving money and sacrificing lives.” — Tim Halliday, University of Hawaii economist

Hawaii initially covered migrants after they were cut from Medicaid, but doing so became increasingly unpopular as costs grew and federal reimbursements fell far short.

Judy Mohr Peterson from the state Med-QUEST office said the mortality increase is sad but there are other factors that could have affected it apart from the policy change.

Peterson said the state hasn’t continued to tally its cost savings from the 2015 shift. But a rise in uninsured hospital visits could mean that the state is paying for care to some extent. Peterson said the state reimburses hospitals for uninsured emergency room visits but she didn’t have the data available about how much is spent.

In the absence of public health insurance, costs have shifted to migrants, some of whom have racked up hefty medical debt. When they can’t pay, it may fall to hospitals.

Tim Halliday, an economist at UH who is also a co-author of the mortality study, said lack of insurance could ultimately drive up health care costs if people wait to seek care until diseases worsen.

Loss of life also has a cost, too. Halliday noted that when the Environmental Protection Agency calculates the value of a life, they estimate an individual is worth $10 million. So if 50 people died, that’s $500 million.

But he thinks that focusing on money misses the point.

“The thing is, we really are trading off dollars for life years,” Halliday said. “It’s not like we are going to insure them and save money. We are saving money and sacrificing lives. That should be enough to get people interested.”

Lack of Political Will

That might be not enough, according to Palafox from the University of Hawaii.

Palafox is skeptical that the political will exists at either the federal or state level to restore coverage. He noted a 2019 report by the U.S. Civil Rights Commission that found that only one congressional proposal out of more than two dozen related to COFA passed in the past decade.

“It really tells you, the system — including the legislative system — doesn’t understand this problem of inequity and further they’re not willing to address it,” he said.

He noted that there was plenty of data showing the community had poor health outcomes before Ige made the call to remove Micronesian migrants’ access to public health insurance.

“That was data way back when and then you put lack of access via insurance that of course will make it worse,” he said. “There was political will to dismantle the thing, there’s not political will to put it back in.”

When reached by Civil Beat Wednesday, House Speaker Scott Saiki said he hadn’t read the study yet. Senate President Ronald Kouchi hadn’t either, but said he was shocked to hear the results.

“Clearly 43% is a significant number and so it’s something we need to look into,” he said, referring to the study’s finding that the mortality rate was 43% higher for Micronesians compared with white Hawaii residents. “I don’t want to diminish the meaning of mortality rate because even one is too many. Forty-three percent is clearly way outside of any kind of so-called margin of error.”

Ige said in a statement to Civil Beat Friday that it’s sad the mortality rate went up for Micronesian migrants and that he supports federal legislation to reinstate Medicaid coverage. He didn’t mention any action that could be taken at the state level to address the rising death toll.

Peterson from the Med-QUEST office said the agency previously requested more money for subsidies to help migrants afford private insurance, but the Legislature did not provide any.

In Congress, the House approved Medicaid reinstatement for COFA migrants, and Sen. Mazie Hirono is

Hirono hasn’t always been so supportive. In 2011, she joined the late Sens. Daniel Inouye and Daniel Akaka and then-Rep. Colleen Hanabusa to urge the federal government to establish screening tests to limit migrants who were coming to Hawaii for life-saving medical care. She said Thursday she doesn’t recall signing that letter and doesn’t agree with it.

But in the wake of the election of President Donald Trump, Hirono has become an outspoken advocate for immigrants, including Pacific migrants. She wrote letters to the Trump administration that helped reverse federal guidelines that were preventing COFA migrants from getting driver’s licenses.

On Thursday, she said the U.S. has failed to fulfill its trust obligations to Micronesian countries, adding that fulfilling these promises is even more important now given China’s overtures in the region.

“If we are to ensure a free and open Indo-Pacific, we must treat the Compact nations with the respect they deserve. First and foremost, this means keeping the promises we’ve made to these partners – especially on health care,” she said Thursday.

Still, Palafox from the University of Hawaii said restoring Medicaid access is only going to solve one aspect of the problem. Patients continue to face language barriers, cultural barriers and bias from health care providers.

“The nature of this is much deeper than the health insurance issue but truly aggravated by the lack of access to health care,” Palafox said.

But he thinks perhaps the coronavirus pandemic will help people realize that the health of this community matters, even if they aren’t a priority. People who don’t have access to health care or trust the system may not seek testing or care, and during an infectious disease pandemic, that matters.

“If you have one segment of the population that doesn’t have good health care, it affects everybody,” Palafox said.

This story was produced with support from the  and its .