Health Equity for COFA Islanders

Updated August 1, 2017

In 1986, the United States entered a Compact of Free Association with the Republic of the Marshall Islands, the Republic of Palau, and the Federated States of Micronesia. However, despite lawfully living and working in the United States and paying all federal, state, and local taxes, COFA Islanders are excluded from Medicaid and other federal programs.

The Commission on Asian Pacific American Affairs acknowledges that COFA Islanders should have access to affordable healthcare and has made it a priority to improve health equity for Pacific Islanders living in Washington under the Compact of Free Association.


The Freely Associated States are sovereign nations previously under the administrative control of the United States. Since 1986, the Compact of Free Association (COFA) between the Republic of the Marshall Islands, the Republic of Palau, the Federated States of Micronesia (Chuuk, Kosrae, Yap, Pohnpei), and the United States allows COFA citizens to freely enter, lawfully reside, and work in the US in exchange for providing the US exclusive military control of the region.

When the Compacts were originally signed, COFA migrants were eligible for Medicaid and other federal programs. However, these migrants were excluded from benefits as a consequence of the Personal Responsibility and Work Opportunity Reconciliation Act in 1996.

Currently, COFA migrants have limited access to healthcare benefits in the US, which perpetuates health inequities.

  • Washington State has the second-largest population of Kosraeans and the third-largest population of Palauans and Marshallese people in the US.
  • In Washington, large populations of COFA migrants reside in Auburn, Everett, Federal Way, Lynnwood, Spokane, and Vancouver.
  • The US conducted 67 nuclear atmospheric bomb tests in the Marshall Islands between 1946 and 1958. The radiation levels in many of the atolls remain extremely high – up to 7600 millgrays (mGy) compared to 10 mGy in the US.
  • Marshallese people suffer high rates of cancer and other radiation-related diseases. A significant number of migrants continue to suffer from radiogenic diseases, birth defects, and chronic illnesses directly tied to US nuclear testing.
  • Marshallese people suffer from high infant mortality (28.43 deaths/1,000 live births in 2006 estimation) and relatively low life expectancy (70.31 years in 2006 estimation).
  • The Federated States of Micronesia has a higher per-capita enlistment rate in the U.S. military than any U.S. state and had more than five times the national per-capita average of casualties in Iraq and Afghanistan in 2008.


At the Commission’s November 2015 board meeting, the board voted to make health equity for COFA Islanders a legislative priority for the Commission. The Commission recognizes that the legal non-immigrants living in Washington under the Compact of Free Association are in need of timely and cost-effective healthcare.

  • CAPAA staff met with the COFA Alliance National Network to learn about their achievements in Oregon to provide affordable healthcare to COFA islanders.
  • During the 2016 legislative session, Representative Sharon Tomiko Santos introduced HB 2986, Concerning Health Care for Pacific Islanders Residing in Washington under a Compact of Free Association.
  • The State Board of Health and the Governor’s Interagency Council on Health Disparities conducted a Health Impact Review for HB 2986 at the request of Representative Santos.
  • Senator Murray co-sponsored federal legislation S. 1301, Restoring Medicaid for COFA Migrants.
  • In 2016, Oregon passed legislation that created a Compact of Free Association (COFA) Premium Assistance Program that provides free health insurance for low-income citizens of the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau who live in Oregon under the compact. The State of Oregon pays for the enrollee’s share of premiums for standard silver-level health insurance plans purchased through The plans cover doctor’s visits, emergency care, preventative care (such as mammograms and screenings for blood pressure and diabetes), prescriptions and much more. Enrollees do not pay any bills for accepted in-network services.
  • CAPAA hosted a community meeting for COFA Islanders in Auburn on October 1, 2016 and in Spokane on October 22, 2016. Members from the COFA Alliance National Network spoke about their legislative achievements in Oregon and community members shared their concerns and experiences.
  • During the 2017 legislative session, Representative Sharon Tomiko Santos and Senator Rebecca Saldaña introduced HB 1291 and SB 5683 to improve health equity and health care access for Pacific Islanders residing in Washington under a Compact of Free Association. SHB 1291 passed the House 51-47, but did not reach the Senate floor for a vote.

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