Pacific migrants run up hefty healthcare tab
By Alice Keesing
Advertiser Health Writer
Dr. David Derauf of the Kalihi Valley community health center has seen patients step off the plane from Micronesia so ill that they are barely catching their last breath.
They come to Hawai'i — stricken with cancer, diabetes, tuberculosis or Hansen's disease — drawn by the promise of better medical care, a better education for their children and a better life.
"Without any question they are the sickest group of people we take care of," said Derauf, medical director for the Kokua Kalihi Valley center.
Doctors such as Derauf are driven by a mission to help those in need; at the same time they acknowledge the economic burden on the state.
What Derauf sees on a regular basis is part of the staggering social and economic cost borne by Hawai'i because of a federal agreement that gives people from three small Pacific nations the right to migrate freely to the United States.
More than 6,000 people from the so-called freely associated states now live in Hawai'i. They are small in number — less than 1 percent of the population — but officials say they are having a large effect.
The cost of supporting the migrants — largely in healthcare and education — was $86 million between 1996 and 2000. Private hospitals are owed millions more, and the bill is expected to keep growing.
"What they're finding is that, especially in health, many of them are coming to Hawai'i with severe health problems because they're not addressed where they come from, and I think some of the children also come with learning disabilities, so I would say they disproportionally impact services in our system," said Rep. Dennis Arakaki, House Health Committee chairman.
Arakaki, D-28th (Kalihi Valley, Kam Hts.) and others are so concerned about the situation they are working on a resolution this session, urging Hawai'i's congressional delegation to continue efforts to acquire reimbursement for the state.
The concern has been brewing for years but has come to a head as the federal government this year renegotiates the Compact of Free Association with the Federated States of Micronesia and the Republic of the Marshall Islands. Another compact with the Republic of Palau does not expire for several more years.
Defense boosted in Pacific
The compact with Micronesia and the Marshalls was signed in 1986. It gave the United States a strategic foothold in a vast area of the Pacific with access to the air and water of the island nations. Micronesia alone spreads over 2,000 miles.
In return for the national security benefits, residents of the nations are able to live and work in the United States. Many have arrived on Hawai'i's doorstep.
When the compact was signed, federal lawmakers said they would be "sympathetic" to the financial cost to Hawai'i, but that hasn't been the case, said Madeleine Austin, senior deputy attorney general, who is tracking the issue for the governor's office.
"The whole country is benefiting from this defense-wise, but Hawai'i is bearing a disproportionate burden of this open migration," Austin said.
Kasio Mida, the consul general in Hawai'i for the Federated States of Micronesia, admits it is worrisome to hear his people discussed as a "burden."
"Many of our peoples are gainfully employed," he said. "They pay taxes, they go to the stores; so it's not as if they are just here to receive, and I think they are giving back some to the community. ... Whether we are putting back everything that we have received, that is the question. Maybe not, but I feel we are making some worthwhile contributions also to the economy."
Many health concerns
Most are drawn to Hawai'i by the promise of work and a better education for their children, Mida said. They end up working in low-skill, low-wage jobs and more than half live in poverty. While they have carte blanche to enter the country, the 1996 federal welfare reform act cut them off from access to federal welfare and medical programs, forcing many to rely on state aid.
Without the money or insurance to cover their often serious health problems, the community health centers and emergency rooms are often left paying the bill.
In 1999, Hawai'i's hospitals and community health centers were owed more than $17 million for treating people from the compact nations, said Rich Meiers, Healthcare Association of Hawai'i president.
That unpaid debt is partly responsible for hospital's having to cut back their services, Meiers said.
Compact migrants have diseases such as diabetes, heart disease and cancer. They also suffer from high rates of tuberculosis and Hansen's disease (leprosy). And they have sparked outbreaks of vaccine-preventable diseases such as whooping cough and Hepatitis A.
As interim chief of communicable diseases for the Health Department, Dr. Paul Effler has two aims: to get the migrants the care they need and are entitled to; and protect Hawai'i's people from infection.
"It doesn't take much of a leap in judgment to say if the individual's arriving with TB there's a chance it will spread to the local population ... but I would stop short of saying that we know for sure that that has occurred," Effler said.
Schools absorbing high costs
Adding to the Health Department's challenge is that they are not legally able to screen migrants for diseases such as TB when they enter the state.
Hawai'i's public schools also are paying the price as migrant children enter classrooms without the English needed to get along. Between 1988 and 1999, the state spent $54 million on education for compact children, $9 million of it in 1999.
"We have had to absorb this loss as best we could, at a terrible cost to our own children," wrote Gov. Ben Cayetano in a letter included in a recent report from the U.S. General Accounting Office. "It is one reason Hawai'i is last among the 50 states in per pupil expenditures for its public school children in kindergarten through 12th grade. Our schools need that $54 million back."
Finding a solution
In one bright sign, Congress last year appropriated $4 million to help cover costs. That money will likely go to the Department of Education's English as a Second Language program, said Austin, who said she hopes it sets a precedent for more to come.
U.S. Sen. Dan Inouye, D-Hawai'i, will work to get more money this year, said spokeswoman Sandi Skousen. But "he is, however, mindful of the present budget climate that we are in."
While Hawai'i lawmakers wanted to see the issue addressed in compact negotiations, Al Short, who is heading up the talks for the U.S. State Department, said that's something that has to happen through Congress.
What the new compact will do, he said, is direct Micronesia and the Marshalls to spend their money to build up their health and education systems to address the problems at their source.
But even Short admits that is a long-term solution that will not bring immediate relief to Hawai'i.
Reach Alice Keesing at akeesing@honoluluadvertiser.com or 525-8014.
