摘要：The Republic of the Marshall Islands is a sovereign nation previously under the administrative control of the United States. Since 1986, the Compacts of Free Association (COFA) between the Republic of the Marshall Islands and the United States allows Marshall Islands citizens to freely enter, lawfully reside, and work in the United States, and provides the United States exclusive military control of the region. When the COFA was signed, COFA migrants were eligible for Medicaid and other safety net programs. However, these migrants were excluded from benefits as a consequence of the Personal Responsibility and Work Opportunity Reconciliation Act. Currently, COFA migrants have limited access to health care benefits in the United States, which perpetuates health inequalities. The Republic of the Marshall Islands is an archipelago that covers the largest area of ocean in the region of Micronesia. The sovereign nation was previously under the administrative control of the United States from 1947 until 1986 as part of the United Nations Trust Territory of the Pacific Islands and was the principal site of the US nuclear testing program in the Pacific Islands. 1 The Compacts of Free Association (COFA) between the former trust territories of the Pacific Islands (the Republic of the Marshall Islands [1986], the Federated States of Micronesia [1986], and the Republic of Palau [1994]) and the United States allows citizens of these nations to freely enter, lawfully reside, and work in the United States. 2 Citizens of these nations are known as COFA migrants to distinguish them from immigrants subject to US Citizenship and Immigration Services. 2 The COFA with the Republic of the Marshall Islands provides the United States with exclusive military use and control of 2 million square miles of ocean and land. The United States maintains a military installation on Kwajalein Atoll in the Republic of the Marshall Islands, the Ronald Reagan Ballistic Missile Defense Test Site, and leases 11 of the 97 islands for military activity. 1,3 COFA migrants are legally considered “nonimmigrants without visas.” 4 (p9) The vast majority of COFA migrants living in the United States are noncitizens, and their status limits their access to many public benefits. 5–7 COFA migrants have been largely forgotten in the ongoing immigration policy debates, which focus primarily on immigrants from Latin America. Limited literature exists on how current health policies affect COFA migrants, both at the federal level and in states with large populations of Marshallese migrants. We present an overview of health policies limiting health care access for Marshallese persons living in the United States, discuss the historical and current relationship between the United States and the Marshallese people living in both the Republic of the Marshall Islands and the United States, and offer policy recommendations to improve health care access and reduce health inequalities for Marshallese persons living in the United States. Although many of the policy considerations apply to all COFA migrants, the Marshallese people have a unique historical relationship with the United States, and the United States has used the Marshall Islands to advance its health, welfare, and strategic military position. Therefore, we focus our discussion on Marshallese migrants. Most health policies affecting COFA migrants living in the United States are made at the federal level. Federalism’s diffusion of power allows states to implement federal policies with some variance. 8 Hawaii and Arkansas are home to the largest populations of Marshallese migrants in the United States. 9 We discuss how Arkansas’s and Hawaii’s policies in regards to Marshallese migrants differ.
