"In 1986, the Marshall Islands and the Federated States of Micronesia entered into a treaty with the United States known as the Compact of Free Association (COFA). It is embedded in laws in all three nations.
In 1994, Palau entered into a Compnact of Free Association with the U.S., which also became law in both nations.
The COFAs for all three of these island groups stem from a long and unique relationship between these north Pacific islands and the United States. Between World War I and World War II, Japan controlled these islands that cover an expanse of ocean area about the size of the continental United States. Japan built military bases throughout the area that were used to stage its assaults on different countries in the region, including the attack on Pearl Harbor in 1941.
The U.S. military wrested the islands from Japan in the latter part of WWII in heavy fighting — battles that cost thousands of American lives from the Marshall Islands to Palau and Chuuk to Saipan. The U.S. government administered the islands from the end of the war until the COFAs came into being.
The Micronesia area was formally administered by the U.S. under a United Nations Strategic Trust Territory arrangement — the only strategic trusteeship among the 11 established by the UN after WWII. The U.S. conducted 67 nuclear weapons tests in the Marshall Islands and established an important military base at Kwajalein Atoll, also in the Marshall Islands, after the end of WWII.
For the United States, a key provision of the COFAs allows the U.S. to prevent access to the region by any other nation and also gives it authority to overrule any foreign affairs action of the island nations that conflicts with U.S. defense authority (although this has not been used). The COFA with the Marshall Islands also provides the U.S. military with use of the Reagan Test Site at Kwajalein through 2066, with an option to extend its use to 2086. In exchange, the three island nations are provided with significant levels of funding for health, education, infrastructure development and other areas of government service. In line with the long-standing and special relationship between the U.S. and these former Pacific territories, citizens of all three of the COFA nations have visa-free entry privileges to live, work and study in the United States. The COFAs allow citizens of the three nations to join the U.S. armed forces, and hundreds have enlisted since the 1980s, with many doing multiple tours in Iraq and Afghanistan in recent years. U.S.-affiliated islands have the highest per capita enlistment rate into the U.S. armed forces. The three island nations are also members of the United Nations. They generally vote in support of the United States and Israel.
Since the 1990s, a large portion of the island populations have moved to the U.S. — Guam, Hawaii, the west coast states, and Arkansas have the largest islander populations, but there are also significant pockets of citizens from COFA countries throughout the mainland U.S. It is estimated that as much as one-third of the populations of the Marshall Islands and Federated States of Micronesia now reside in the U.S. (about 22,000 of a total of 75,000 Marshall Islanders, and about 50,000 of approximately 150,000 Micronesians). COFA citizens have moved to the U.S. seeking educational opportunities for their children in elementary and high schools, as well as university educations. They also move to U.S. territories and states seeking jobs and health services not available in their islands.
Many thousands of islanders are now employed in U.S. factories, nursing homes, and service industry businesses (such as fast food restaurants). Today, nearly 30 years after the COFAs came into effect, many of the people who are identified as “COFA citizens” in the U.S. are, in fact, American citizens, having been born and raised in the U.S.
Because COFA citizens’ legal status is not well understood in the U.S., they often fall through the cracks. A recent example of this is the Federal Real ID Act of 2005, which did not make mention of the COFA agreement. As a consequence, states have interpreted the Act to mean that COFA citizens cannot obtain regular driver’s licenses and so are issued only temporary one-year licenses. Oregon is the only state in the nation that has rectified the Federal legislative oversight, passing legislation in 2013 that makes COFA citizens eligible for standard licenses beginning January 1, 2014.
Under the COFAs, citizens of the COFA nations were covered by Medicaid until 1996, when Federal legislation removed the eligibility. Over the past several years, various U.S. Senators and Representatives have supported legislation to reinstate COFA citizens’ eligibility. The most recent effort is a rider on the Obama Administration’s Immigration Reform legislation that passed the U.S. Senate in 2013 and (as of late 2013) was awaiting a response from the House.
States with large numbers of COFA citizens have absorbed significant costs to provide medical and health care services to this population. In part, this is the result of lack of health insurance coverage for many (and possibly most) COFA citizens. Because most COFA citizens are unable to afford medical care and insurance, their situation results in many islanders not seeking primary health care services that can help prevent more serious illness that leads to expensive medical treatment. Instead, heavy use of emergency room and tertiary services lead to high-cost services.
Medicaid coverage for COFA islanders is appropriate because: a) the close relationship between COFA nations and the U.S., including islanders serving in the U.S. military, b) many Marshall Islanders were exposed to radioactive fallout from U.S. nuclear tests at Bikini and Enewetak and there are no cancer treatment services available in the Marshall Islands, and c) coverage by Medicaid would likely reduce health care costs to states by making it easier for COFA citizens to seek early screening and treatment services, reducing the higher costs of emergency medical services."
This informational sheet was prepared by Giff Johnson, November 17, 2013.