That may mean cutbacks in coverage in a few years, said Lillian Koller, director of the state agency. "We're very grateful to get this assistance, but we are pointing out the fact that our expenses are much higher," Koller said.

The state's grant plan identifies services provided to migrants such as education and social services. The entire grant, however, is allotted to the Department of Human Services.

Two medical programs for migrants are estimated to cost $23 million in the coming fiscal year. The $10.6 million federal grant, plus $7.3 million that the state has set aside for the programs still falls $5 million short, Koller said.

The federal grant was authorized by the new compacts of free association, which Congress signed last fall. The 20-year agreements allow migration from the Federated States of Micronesia, Republic of Palau and Republic of the Marshall Islands to U.S. territories, in exchange for U.S. military access to the region. The grants are designed to reimburse local governments for the cost of providing services to the migrants. Hawai'i's grant plan cites a 2003 census report showing the number of migrants to the state rose 35 percent in the past six years, to 7,297.

It is not the first time Hawai'i has received federal money to offset migrant expenses. The state Department of Education, for example, received two $2 million annual grants appropriated in 2002.

But it is the first aid under the agreements that guarantees minimum allotments for Hawai'i, Guam, American Samoa and the Commonwealth of the Northern Mariana Islands.

Hawai'i's grant plan directs that the money be spent on two medical assistance programs run by the Department of Human Services:

• Hawaii QUEST, a managed-care program that provides medical and mental health services through selected health plans and doctors;
• Medicaid Fee for Service Program, which pays medical providers directly for serving migrants 65 and older, blind or disabled. Under the federal grant program, services will be covered to qualified migrants who became ineligible because of a 1996 law delaying access for five years after entering the United States.

Micronesians' most prevalent medical costs are for hypertension, diabetes, pregnancy and respiratory ailments.

But Koller noted that in recent years migrants have needed more and costlier care upon arrival. "More are coming over; they're sicker when they come; and they have chronic diseases that are difficult to manage," she said.

Higher standard

One problem with the way grants were allocated to U.S. territories affected by migration is that the allocations were based on a census of the Micronesian population in each location, Koller said.

"The more important thing that doesn't show up in a census is that we spend more per person than they do elsewhere," she said. "We're more generous with the benefits compared to the others. We need a formula that looks at per-capita spent."

Koller said Hawai'i would continue to lobby Congress for more aid, and predicted that the 2006-2007 state budget would show a reduction in health services to the migrants. Government-financed healthcare for U.S. citizens limits membership and type of care offered, she said; for example, dental coverage is restricted to the most essential emergency services.

However, no change in service to migrants is expected through the 2005 fiscal year, Koller said.

For 2004, QUEST monthly premium costs are estimated at $180 per member, and monthly fee-for-service costs at $522.76 per member.

Everyone pays

The impact of high costs is being felt at many clinics that treat the uninsured. May Akamine, executive director of the Kalihi Palama Health Center, said Micronesians often turn to emergency-room care. The clinic patient population of about 17,000 includes some 1,600 Micronesians, she said, and the clinic is hiring a fund-raising expert to seek alternative sources of money.

"Our whole philosophy is we want to serve our community the best way we can," Akamine said. "We really do not to turn anyone away. If all our providers are full up, we'll refer them elsewhere."

Despite government financing, the healthcare system often absorbs costs, and sometimes has to curtail services to make up for it, said Rich Meiers, president of the Hawai'i Healthcare Association, which represents the state's hospitals. Kapi'olani and Queen's medical centers are among the hardest hit, Meiers said.

"People are being treated in emergency rooms, for which our hospitals are not getting reimbursed," he said. "Because we have not been seeing the reimbursements through the years, it's very frustrating to our CEOs.

"The federal government invited them in here — and we weren't getting paid for that."

The impact of continuing shortages eventually will fall to the general healthcare consumer.

"We're all going to be affected," said Beth Giesting, executive director of the Hawai'i Primary Care Association, a nonprofit group that focuses on health services for needy populations. "It has an effect on insurance rates. We're all eventually going to pay for this one way or another."