COMPACT IMPACT: Policy And Planning Implications

Pacific Island Health Officers Association, 52nd Meeting

June 11-15. 2012Agana, Guam

Neal A. Palafox MD MPHDept. of Family Medicine and Community Health

John A. Burns School of MedicineUniversity 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

• 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

• 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 1,2FSM 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

• 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)

Compact Impact- Hawaii State Agency Costs

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– BHH, Federal pressure

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

• 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

• 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• Affected area targetting new migrants coordiantion

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

• Proactive• Community• Assets / Deficits• COMPACT Impact Conference

Urgency and Planning

• 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