COFA- Compact Impact Policy And Planning Implications
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Transcript COFA- Compact Impact Policy And Planning Implications
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