Health / In an earlier version of this story, the names Lillian Koller and Linda Smith were misstated. Honolulu Weekly deeply regrets the errors.

Retired cook Calvin Nelson says that when he came to Hawaii from Kwajalein after the United States had seized his home for a new missile range, he was told, “everything will be covered.” But 20 years later, he learned that a new health program that the state government was issuing for himself and thousands of other Micronesian immigrants wouldn’t pay for the kidney dialysis that kept him alive.

He vowed that if that happened, he would go back and reclaim his home on the missile range.

“Well, I guess I don’t have any choice but to go home and to go to heaven. There’s no other way for me to receive treatment,” he told the Weekly.

Trucy James was in a similar situation, except there was no home left for her to return to. It was destroyed in a nuclear bomb blast–one of 67 such nuclear tests that devastated much of the island chain. Now, like Nelson, she faced a cutoff of her dialysis, without which both would be dead in a matter of days.

Nelson, James and approximately 108 other legal Micronesian immigrants on dialysis got a last-minute reprieve from the governor on August 31, when Senior Policy Advisor Linda Smith and Department of Human Services Director Lillian Koller told a group of Micronesian protestors outside Lingle’s office that their kidney dialysis would be covered for the next two years.

Not so lucky, perhaps, were 130–160 Micronesians, including Marshallese nuclear test refugees, who need radiation therapy or chemotherapy for cancer. According to a Health and Human Services press release, the dialysis patients could be treated because Federal courts had ruled dialysis an “emergency treatment” and the Federal government would eventually reimburse the State for such treatment–but “We cannot cover chemotherapy in the same way because the Federal Government does not consider it an emergency.”

“We are working with the American Cancer Society and other providers to find a way to continue chemo treatments,” said the press release. Queens Medical Center said Tuesday it will continue to treat Micronesian cancer patients at no cost, for now.

Hundreds of Micronesian immigrants may lose their benefits entirely, because they didn’t file the proper paperwork on time.

Who pays?

At the heart of the Micronesian health crisis is the state’s budget crunch and a dispute between the U.S. and the State over who should foot the bill for the immigrants. The U.S. is obligated to provide for Micronesian immigrants’ health needs under the Compact of Free Associations, which guarantees residents of the former U.S. Trust Territories of the Pacific Islands access to some U.S. domestic programs and services in exchange for military concessions from the Federated States of Micronesia, Republic of Palau and Republic of the Marshall Islands–including the missile range at Kwajalein. Under COFA, the federal government also divides $30 million of “Compact Impact” money annually among Hawaii, Guam, American Samoa and Northern Mariana Islands to help defray the cost of providing services to Micronesian immigrants. The Lingle administration maintains that it spent over $101 million to provide such services in 2007, but only got $11 million in Compact Impact payments from the U.S. government.

In response to this gap, the Lingle administration is removing Micronesian immigrants over the age of 18 from a program that provided the equivalent of QUEST (Medicaid) coverage, and is enrolling them instead under a new program called “Basic Care Hawaii,” which provides only a fraction of the former coverage. The administration claims it will save $15 million dollars by making the change. Critics contend, however, the change will force the immigrants be forced to use hospital emergency rooms instead of their former health care providers, thus straining the ER’s ability to provide services to all residents.

From Eniwetok to Ocean View

Particularly hard-hit may be the Big Island–especially the rural district of Kau, where relatively cheap land prices and rental costs have lured thousands of Micronesians. According to Dr. Keola G. K. Dowling, who serves as Care Coordinator for COFA Immigrants at the Big Island’s nonprofit Bay Clinics, the island holds 2,000–3,000 Marshallese, 3,000 Chuukese, 1,500 Kosraeans, 150–300 Yapese, 1,500–1,800 Pohnapeians, and 200 Palauans. But Dowling believes those estimates are low. He says more than a thousand Marshallese reside in the remote Kau community of Ocean View alone.

“Almost all of the Eniwetok refugees live there,” he says. “Some Bikinians too. They definitely consider themselves nuclear refugees.”

The U.S. Eniwetok and Bikini were used as nuclear testing grounds, setting off 67 open-air atomic and hydrogen bomb blasts that equaled, Dowling says, “1.7 hiroshima-sized bombs every morning 12 years…One of the islands in their homeland was turned into white light. It was vaporized.”

“Of 160 Micronesians who are under chemotherapy in Hawaii, most of them are from the Marshall Islands, and most of those came from where they blasted those bombs on Eniwetok and Bikini,” Dowling notes.

Bureaucracy vs. culture

The Micronesians’ supporters also claim that many immigrants didn’t know to register for the new program, thanks to a combination of cross-cultural difficulties and poor government planning.

“Their exposure to bureaucratic systems and the necessity of doing paperwork has been pretty limited,” says retired UH-Hilo Professor Craig Severance, who has lived in Micronesia and who wrote a letter to Lingle supporting a delay in the implementation of the new program. He notes that while “Those that have been here for a while are well adjusted,” newcomers from the outer islands have trouble with bureaucracy, and “part of the trouble is not so much their fault as it is the agencies…It’s the responsibility of the agencies to make that transition easy, and not difficult. It’s also to make the translation and the communication of expectations clear, rather than simply stereotyping all Micronesians as being the same.”

When members and supporters of Micronesians United called an ad hoc to discuss the health crisis, some participants brought stories of immigrants who were stymied in their efforts to get their paperwork in for the transition, because they were referred to automated phone services that were either entirely in English or were so badly translated that Marshallese islanders didn’t recognize the reputed Marshallese phone recordings as their own language.

“A lot of them that did call them said that the recording was automated and ‘We didn’t understand it, says Leilani Resureccion of the nonprofit Alii’s Hale, which works with Pacific islanders in Kau. “If you don’t get your form in, then you will lose your health care for yourself and for your family.”

Both Severance and Resureccion note that state law requires the government to supply translators for those who need them.

But translation wasn’t the only problem. Ocean View has no post office. Many of the immigrants get their mail at post office boxes in Kona, 40-plus miles away, and many do not have cars, so they don’t often check their boxes often. So many may not have gotten the notification letters and forms that were mailed out.

Resureccion notes that the Marshallese are a “very communal” people and that the best way to get the word out was through meetings.

“Did the health workers actually come out here and hold meetings to inform them of the change?” she asks rhetorically. “You know what the answer is? No.”

So the Lingle administration may save even more money than it anticipated, by dropping many members from its health care rolls entirely.

Cream-skimming

Participants at the August 31 meeting accused the Lingle administration of achieving the savings it claimed by essentially cream-skimming–keeping Micronesian patients who were unlikely to cost much and dumping high-expense, chronic care patients. One noted that the State of Hawaii was probably actually making a profit off under-18 Micronesians, who required little health care.

“Migrants under 18 are not being taken off of Quest because they get two-for-one matching funds from the Feds,” he claimed.

Downing also notes that the Lingle Administration could have saved money simply by reducing bureaucratic waste. He notes, for instance that both Bay Clinics and another organization got grants to do redundant studies of the immigrants’ needs.

“There was a third entity called the COFA task force, and they had very big funding. As far as I know, they’ve never published anything of what they did,” he adds.

PR problem

On top of their bureaucratic woes, Micronesians in Hawaii are also battling the same image problems that many immigrant groups face. When the Honolulu Advertiser ran a story about the health care crisis, online comments ran heavily in favor of the cuts; many of those commented made remarks to the effect that the Micronesians were freeloading.

That’s far from the truth, according to their supporters. Resurecion says that in Kau, many of the Micronesians work as macadamia nut and coffee harvesters.

“Most of the Micronesians we know are working and some of them are working in professional capacities,” says Severance.

Downing agrees.

“We do not want people ever to be saying of Micronesians that they were victims.”