The Compact of Free Association (COFA) is an agreement created in 1986 between the U.S. and the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau. Individuals from these islands who come to the U.S. are often called either COFA migrants or COFA citizens. We will be using both terms interchangeably throughout this blog.

Through COFA, the U.S. provides a variety of services to those islands and allows COFA citizens to enter the U.S. and work as non-immigrants without a visa. For public benefits, COFA citizens are considered qualified non-citizens. An estimated 73,000 COFA citizens currently live in the U.S., including roughly 1,400 individuals in Colorado. 43% of COFA citizens living in the U.S. are also U.S. citizens, including naturalized citizens and children of COFA migrants. COFA citizens come to the U.S. for many reasons, some of which include economic or educational opportunities, health care access, family, or concerns from climate change.

Health Coverage for COFA Citizens

In 1996, the Personal Responsibility and Work Opportunity Reconciliation Act, removed COFA citizens’ Medicaid eligibility by changing the categories of who is eligible for public benefits. The policy was active until December 27, 2020, when Congress restored COFA citizens’ full Medicaid eligibility.

In August 2021, the Colorado Department of Health Care Policy and Financing (HCPF) implemented a system change to ensure that COFA citizens would be determined as eligible when applying for health coverage. In addition, HCPF reran eligibility for all COFA citizens who had applied for coverage while the policy was active from December 27, 2020, through August 8, 2021, and sent new Notices of Action with updated eligibility determinations.

Barriers COFA Citizens Face in Accessing Health Care

As with other immigrants, COFA citizens experience a range of language and cultural barriers that may prevent them from accessing health coverage and care. COFA citizens speak a variety of languages, most commonly Marshallese, Palauan, and Chamorro. Due to the small number of people who speak these languages in the U.S., documents are often not available in a COFA citizen’s native language. Adding another layer of complexity, words in English, such as “stress” often do not have direct translations.

When assisting clients, it is important to understand the individual’s cultural norms. COFA citizens encompass three distinct populations with separate cultures, though there are similarities. COFA citizens come from a society that highly values family obligations, respect for elders, and communal living and principles. The focus on family obligations could look like physically caring for the old and young, taking in family members, or paying bills for a family member. Migrants may have an additional sense of responsibility to support family members and send money home.

COFA citizens are also more likely to suffer from higher rates of obesity, diabetes, heart and kidney disease and cancer. This is often attributed to a poor diet after nuclear bombs irradiated the food supply on the islands. However, cancer, and death from cancer, can be uncomfortable topics among the older generations of COFA citizens. Additionally, topics such as reproductive care are seen as taboo, especially in mixed gender groups. Females may prefer to see a female physician for such care.

It may be helpful to ask for a variety of points of contact from your COFA clients. Due to housing instability or technological issues, phone numbers, email addresses, and home addresses may not be reliable. For those reasons, having multiple points of communication, knowing a client’s church affiliation or a child’s school, could help alleviate this issue. Additionally, religion is important to many COFA citizens and churches are often central hubs for the community and a good venue to conduct outreach to individuals.

This is not an exhaustive list, but we hope these tips and context are helpful in working with the COFA community. Leave any questions or comments below!

More reading:

Appel, et al. (2017) Hawaii’s COFA Islanders: Improving Health Access and Outcomes.
Cassel, K., Lee, H. R., Somera, L. P., Badowski, G., & Hagiwara, M. (2020). Cultural Considerations for Conducting the Health Information National Trends Survey with Micronesian Communities: Lessons from a Qualitative Study. Hawai’i journal of health & social welfare, 79(6 Suppl 2), 64–69.
GAO 20-491 United States Government Accountability Office (2020). Compacts of Free Association, U.S. Senate.
Ratlife, Katherine (2012). Family Responsibilities in Pacific Island Cultures: A Conflict of Values around Education.