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Target Areas for Expanding Coverage: Free Association


In 2002, three of Hawaii’s hospitals (Queen’s, Straub, and Kapiolani) provided $15 million in services that was never paid for by Pacific Islanders, according to the Hawaii Health Survey conducted by the Healthcare Association of Hawaii. With hundreds of health care providers across the state, it is estimated that this $15 million is just a small percentage of the total in uncompensated care provided to Pacific Islanders.

Citizens of certain Pacific Island nations come to Hawaii as a result of Compacts of Freely Associated States. The Compacts are international treaties that spell out the rights and obligations such as:

  • unrestricted entry to the U.S.
  • access to residence, education, health care and employment.

Hawaii continues to experience a significant influx of these citizens.

Compacts of Free Association Established in 1986Federated States of Micronesia. Consists of four major island groups: Pohnpei, Chuuk, Yap and Kosrae.Republic of the Marshall Islands. Consists of two chains of 1,152 islands and 30 atolls, including Majuro (the capital); Ebeye Island, in Kwajalein Atoll; and Bikini and Enewetok atolls.

Republic of Palau. Consists of six island groups totaling more than 200 islands.

The 1996 Personal Responsibility & Work Opportunity Reconciliation Act eliminated eligibility of all legal immigrants for any public assistance. Federal funds may not be used to provide Medicaid benefits for Pacific Island citizens in Hawaii. As a result, taxpayers and the State of Hawaii underwrite the entire cost of QUEST and Medicaid fee-for-service health care.

“Compact migrants tend to be poor, have limited work skills, and face language and cultural barriers in Hawaii. They also come with a host of communicable diseases, notably Hansen’s disease, tuberculosis, hepatitis, and STDs,” according to Hawaii’s Special Needs, a September 2001 report. The report was prepared by the Statewide Strategic Projects initiative of the nonprofit Hawai‘i Primary Care Association, which advocates for access to quality primary care.

“Although most Compact migrants come for economic opportunities, some also come specifically to get health care that is not available to them at home,” the report stated. “This includes people with chronic conditions, such as diabetes and cardiovascular disease, and radiation-related illnesses, such as thyroid and other cancers.”

Some experts anticipate that the number of Pacific Islanders in Hawaii will continue to rise, further adding to Hawaii’s health care issues. Factors contributing to this increase include:

  • a growing and aging population of Pacific Islanders
  • high rates of infectious and chronic disease
  • a continued lack of health resources in these Pacific Island nations.

The Hawai‘i Uninsured Project has assembled a committee of health care providers and health coverage experts, along with representatives of Hawaii’s congressional delegation and the federal government to explore this issue and develop possible solutions.