COMPACT IMPACT: Policy
And Planning Implications
Pacific Island Health Officers
Association, 52nd Meeting
June 11-15. 2012
Agana, Guam
Neal A. Palafox MD MPH
Dept. of Family Medicine and Community Health
John A. Burns School of Medicine
University of Hawaii
Finding a new Paradigm
• Foster a constructive dialogue which moves
health sector towards more effective solutions
to various health related challenges
• Meeting participants take ideas to
constituency
• PIHOA – regionalism ,planning
Compact Impact
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Defining: Compact of Free Association (COFA)
Defining: Compact Impact
Evaluation of the Compact Impact
Current Response to Compact Impact
New paradigm : Problem Solving
– Federal, State, Country, Jurisdiction, Community
– Understanding Expectations and Plans
• Urgency and Planning
Colonial and Political Rule
Under Colonial Rule for 400 yrs
 Spain 1500 Germany 1860 Japan end WWI
US, end of WWII, under UN Trusteeship Agreement,
obtained Administrative Oversight of Northern
Marianas, Palau, Truk, Yap, Kusaie, Ponape, and
Marshall Islands
Became TTPI ( Trust Territory of the Pacific Islands) as
“Strategic Trust of US” under UN Security Council
Micronesian History
• 1960 UN issued report that criticized US for not
preparing Micronesia for self government
• Mid 60’s US increases financial assistance to
Trusteeship 10 fold
• Many Federal and education programs started, and
large contingent of Peace Corps
• Public high schools see first graduates and increase
in college bounds
Freely Associated States (FAS)
• 1977 offered political self –determination to
Northern Mariana, Palau, Marshalls, Chuuk, Yap,
Korsrae , Pohnpei
• Net effect: Northern Marianas became
Commonwealth (CNMI); Palau, Marshall Islands, FSM
became FREELY ASSOCIATED STATES (FAS)
• US TTPI last of all UN Trusteeship
Freely Associated States
• Formed Relationship with US Governed by
COMPACT of Free Association (COFA): Each
entity has own COMPACT with US
• COMPACT with FSM and RMI – 1986-2001;
extended to 2003; amended 2003 to 2023
• Republic of Palau – different cycle. Initial
COMPACT 1994, renegotiate with US 2010
• Terms: COMPACT 1 and COMPACT 2
(Amended COMPACT)
Definitions
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Micronesian
Compact
Compact 1 and 2 (amended Compacts)
Migrant vs Immigrant
Freely Associated State (FAS)
COFA not COFAs
Compact of Free Association-COFA
• FAS Goals
– Independence
– Development, Health , Education, Infrastructure,
Business, Welfare
– Economic Self Sufficiency
• US Goals
– Democratic Governments
– Strategic Denial / Military
– Economic Self Sufficiency
COMPACT
• Economic Provisions
– Federal Grants
– Sector grants
• Political Provisions
– Postal Service, FEMA
– FAA. Communications, Weather
– Migration (Work, habitual residence)
• Military
– Strategic Denial and Security
US GAO Reports on Compact 1,2
FSM and RMI
• Achieved
– Democratic Stable Governments
– Strategic Denial and Security of Region
• Not Achieved and Unlikely to be achieved
– Economic Self Sufficiency
– Trust Fund Inadequacy
USAPI Per Capita Total Expenditure on Health, 2007
(in Purchasing Power Parity (PPP) terms, International $)
WHO World Health Statistics 2010
Metrics
• US Government Accounting Office Reports
– COFA 2003, 2006
– Compact Impact Nov 2011
• Hawaii Uninsured Project 2004
• Hawaii Compact Impact Committee 2008
• PIHOA and Country reports
Compact Impact
• Diaspora
– Why:: health , education, opportunity
• Effect (+ /-) on Host State / Jurisdiction
– Health /Social / Impact
– Military Impact / Security Impact
– Financial Impact
– Political Impact
• Effect (+ /- ) on FAS
– Brain Drain, resource, military
Diaspora
• 2008 Census Bureau - 56,000 Migrants Since
Compacts 1986 (25% of population?)
• 12% of Guam’s Population ( 12,000 migrants)
• 1% of Hawaii , (15,000 Migrants)
• CNMI
• Arkansas, California, Texas, Washington
– 9000 Marshallese Ark
– 4000 Marshallese Costa Mesa, CA
Compact Impact- Hawaii State Agency
Costs
• Health – State Medicaid, Education, Housing /
Social Services, Legal System
• 2002 – $32,000,000
• 2007 - $101,163,113
• 2008- $100,963,808
• 2010 – $114,912,326
– 25 million state health medicaid (QUEST)
US Policy Changes that directly
affect Compact Impact
– FAS categorized by INS initially as “Qualified
Aliens” who are “Permanently Under Color of Law
(PRUCOL)”, means they are legal residents in the
US under administrative discretion
– 1996 Personal Responsibility and Work
Opportunity Reconciliation Act (PRWORA)
changed PRUCOL to “Non Qualified Aliens” status
rendering FAS migrants ineligible for fed public
assistance
Compact Impact Funding
• US Congress Appropriated $30 mil / yr for 20
years beginning in 2004
• Divided between Guam, CNMI and Hawaii
• Based in relative impact
• $10-11 million / jurisdiction / yr
• Used in different ways – pay hospital bills,
education costs, DOH?
Health- Lightning Rod
• Infectious- TB/ Hansen’s
– MDR- TB
– Fear
• NCD
– Dialysis, Cancer
– Diabetes, Obesity
Reaction
• Federal
– Legislation- reinstate Medicaid
– Insular Affairs Interagency Group and HHS
– Interagency Security
– Recommendations
• Dialysis, stop migration, increase screening
• Sector grants to fund Compact Impact
• Deportation
• Hawaii
Understanding the Problem- Data
• Enumeration: who??, how many , where ,
when
– Who tracks and keeps data
– Process of enumeration 2013 GAO (cost)
• CNMI, Hawaii, and Guam between 2004-2010
stated over $1 billion in compact impact costs
– Defining migrant
– Accounting for Compact Impact Dollars
– Accounting for migrant revenues
Understanding the Solutions
• FAS
– Preparation for Migration
– Screening
– Education and Health Infrastructure
• Regional Approach
• Hosting State / Jurisdiction
– Integration (3 pillars)
• Federal
– Medicaid, coordinated
Lessons Learned
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Failed Planning
Unintentional Consequences
Lack of Standards
Assets vs deficits model of evaluation
Issues of Accountability on both sides
360 dialogue– silo conversation
Levels of engagement
– owning the problem and solutions
• People suffer- elephant
Partners
• White House Initiative
– 3 PILLARS OBAMA
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APIHF
Federal
State
Regional
Community , Community, Community
Observations
• States and Territories believe Federal Problem
• Federal Believe it is Jurisdiction Problem
• Federal Agencies believe they have limited
oversight and guided by set Government
policy
• Jurisdictions believe migrants chose to
move—its their issue
• Migrants looking for fruition of new
opportunity and health in Promise land
Regionalism
• Globalization
• Who is not affected
– All partners (eg Am Samoa, CNMI)
– Priorities and nationalism
• Planning – Unintended Consequences
– Textbook case
• Levels of Integration, Military
Going Forward
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Proactive
Community
Assets / Deficits
COMPACT Impact Conference
Urgency and Planning
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Compact Structure
Federal Grants
Effect of Diaspora on FAS
Climate Change
Darwin
• It is not:
– Strongest
– Most intelligent
– ……..
The Beginning
• Regional Planning
• Bringing all stakeholders to the table