For approximately 100,000 islanders living in the U.S., this text is the difference between being admitted to Medicaid and another year of being banned from health insurance due to a pandemic that hit them with more ferocity than any other race or ethnic group.
“When I got the news it was over, I broke down and cried,” said Josie Howard of We are Oceania, a Hawaii-based advocacy advocate for the recovery of Medicaid. “All memories of all the endeavors – and of friends and families who died during the fight – came back to me.”
Lawmakers and supporters told POLITICO, which has been following the struggle to restore islanders’ Medicaid coverage in 2020, that the plight of Pacific islanders found a more sympathetic audience and attracted more attention earlier this year than the pandemic increased their influence. But it still took a tremendous effort to blow the bill after 20 previous attempts failed.
“It’s a very emotional thing,” said Sen. Mazie Hirono, the Hawaii Democrat who was recognized by her colleagues as the main driver of the solution. “I’m more than relieved that this finally happened.”
Find the right legislative partner
From the point of view of Hirono and other lawmakers, their work felt like a moral imperative, as the United States has been shabbily treating islanders for decades.
The U.S. military first irradiated the Marshall Islands and tested dozen of atomic bombs using the island chain in the 1940s and 1950s. Then US officials promised that residents of the islands – along with residents of nearby Palau and Micronesia – would have access to Medicaid through a 1986 pact known as the Compact of Free Association (COFA). The pact also allowed islanders to easily move to the United States while remaining foreign nationals.
But Congress in 1996 robbed islanders of their access to Medicaid through the U.S. Personal Responsibility and Job Opportunities Act, better known as the Welfare Reform Package, worked out between President Bill Clinton and Republican leaders. The decision has been described as legislative scrutiny, but it haunted the Marshallese and made them extremely vulnerable to the Covid-19 pandemic.
Since 2013, the battle to restore the islanders’ Medicaid has been led by Hirono, a Hawaiian lawmaker who has seen firsthand their challenges. Approximately 25,000 Marshallese and other islanders have moved to their state, and their lack of access to health care has forced them to rely on the emergency room instead of undergoing regular checkups. The researchers also found that the islanders The death rate in Hawaii had increased after losing access to Medicaid.
Brandishing a short bill – a single paragraph and several changes known collectively as the “Covering our FAS Allies Act” – Hirono pushed for seven years each year to include their Medicaid recovery language in immigration laws, health laws, and even the National Defense Authorization Act.
“I tried to put it in the NDAA, I tried to get it out of the Senate Finance Committee in something, I tried to put it in the tax expansion bill,” Hirono told POLITICO before listing her additional attempts to read the text squeeze into legislation. Beyond the moral implications of restoring Medicaid, the Senator argued that good relations with the Marshall Islands and surrounding nations should be a foreign policy priority; The U.S. military has used the islands as a crucial seat to position forces in the Pacific for decades.
But Hirono’s efforts in the Senate repeatedly failed, and her House colleagues’ record was just as poor as the Hawaii Congress Democrats repeatedly struggled to get the legislation off the committee.
Hirono, an outspoken critic of President Donald Trump, said she was beginning to worry that the fact that her name was being tied to legislation was putting Republicans off – a fear she believed murmured to cause that she heard after stuttering her previous pitches. Therefore, in July 2019, her employees were looking for a new contact person to solve the decades-old Medicaid problem. They picked Rep. Tony Cárdenas (D-Calif.) And effectively called him to do the pitch.
Hirono’s team concluded that “our strongest hand is walking through the house,” an adviser to the senator wrote in an email dated July 24 to a top Cárdenas employee, putting her on the scene. “Senator Hirono is looking for a strong House of Representatives sponsor who could help fit this policy into the Health Extender package or any other legislative tool that has a chance of making it through the Senate.”
Cárdenas had little direct connection with the subject. The Marshallese and other islanders made up a tiny fraction of his district – a few thousand at best out of the millions who live in Los Angeles County – and as citizens of other nations they could not even vote. In addition, Cárdenas staff were unfamiliar with COFA or the policies that excluded islanders from Medicaid.
However, Hirono’s team believed the California Democrat could be a valuable potential partner. He had a track record of struggling to expand access to health care and was a member of the House’s influential energy and trade committee that oversees Medicaid and regulates health insurance legislation. His team was quickly convinced to sign up.
And in a twist that the staff didn’t recognize until later, Cárdenas’ participation would bring an unexpected level of symbolism. Cárdenas’ office in the Rayburn House Office Building was previously occupied by Newt Gingrich – the former GOP House speaker who was the architect of the 1996 social reform package that accidentally stripped the islanders of their Medicaid. Cárdenas and his team, developing strategies from the same rooms more than 20 years later, would help reverse what Gingrich and his own deputies had established by law.
A breakthrough in Congress
The attempt to build a coalition fell to Meghann Galloway, a lawyer who served as Cárdenas’ health worker.
Studying the previous failed attempts in the House of Representatives, which had often focused on lining up Hawaiian Democrats and other close allies, Galloway believed that the most likely route to success was to secure a broader base of support. The aide created a table of potential Congressional goals, broken down by factors such as legislature region, party affiliation, and committee membership. Galloway said she was trying to strike a balance between members who islanders had in their districts but also had influence over the legislation.
“I mainly addressed people on the Energy and Trade Committee, but also external relations and the armed forces,” Galloway said, adding that the aim was to “really support the argument that this is a national security issue in addition to an equity issue underpin. ” “”
Under her plan, Galloway persecuted influential Democrats like Rep. Adam Smith (D-Wash.), The chairman of the House Armed Services Committee, who signed, and Eliot Engel (DN.Y.), chairman of the House Foreign Affairs Committee, who did not .
The Cárdenas office also secured the primary goal of getting the bill bipartisan by quickly winning over two Republicans, including GOP MP Steve Womack, whose Arkansas district included about 10,000 Marshallese – one of the largest parishes in the United States, that of Potential jobs at were attracted to meat packing plants and other factories.
While Galloway was harassing its employees, Womack simultaneously heard from supporters such as the Arkansas Coalition of Marshallese and pushed their case into local meetings.
“I remember being in Rep. Womack’s office when a young Marshall leader, Fressana Lawin, told a very vivid and powerful story about her grandmother – who as a little girl had a daydream that turned into a nightmare, when she saw snow fall on her South Pacific island, “said Melisa Laelan, the coalition’s executive director. “Her grandma went out and caught the snowflakes with her tongue, only to find out later that it was due to nearby US nuclear tests. She suffered from thyroid cancer later in life.”
“There was no dry eye in this congressional office, and Rep. Womack emerged from that meeting as an advocate for our legislation,” added Laelan.
In Washington, a January 2020 POLITICO story about the plight of the islanders also became part of Galloway’s pitch, either as a basis for talks or as a mailing to Congress officials working for lawmakers who were on the fence.
“It humanized the problem,” said Galloway. “I felt like getting people involved was a turning point.”
Galloway’s Biggest Target: Rep. Cathy McMorris Rodgers (R-Wash.), Who previously served on the House’s leadership, represented a Washington state district that included thousands of islanders and became the top Republican in the energy industry. and Trade Committee appointed in 2021.
“She was my white whale,” said Galloway.
Back in her district, McMorris Rodgers was also approached by stakeholders such as the Asian and Pacific Islander American Health Forum, the Children’s Alliance, and the COFA Alliance National Network. In January, she hosted a meeting with several lawyers in her Washington office.
“I remember the Congresswoman feeling inspired,” said David Anitok, a Marshall man and lawyer who attended the meeting. McMorris Rodgers promised to solve the Medicaid problem and then appealed to their shared beliefs. “She asked to end the meeting with all of us, hold hands and pray over this act in order to restore Medicaid for COFA,” Anitok said.
McMorris Rodgers officially signed the bill on February 10th. That makes her the most famous Republican to have yet to join the effort, and marks a moment when proponents began to believe that Medicaid could finally be restored.
A spokesman for McMorris Rodgers said the advocacy push helped win the congressman. “Her story caught on with her, which is why she joined the legislature,” added the spokesman. “She wanted to fix this problem.”
Disappointment followed by success
After gaining bipartisan support and high profile champions like McMorris Rodgers, the islanders’ Medicaid Restoration Act was incorporated into the HEROES Act, the $ 3 trillion coronavirus aid package that the House passed in May. It was the first time in more than 20 years that the Chamber presented a solution to the plight of the islanders.
The chances for a similar bill also looked increasingly promising in the Senate: Chuck Schumer, chairman of the Senate minority, had privately promised Hirono – and publicly POLITICO – that he would work on including the measure in the next coronavirus stimulus package.
But Schumer, Hirono and other lawmakers encountered a new problem: there has been no coronavirus relief for months. Attempts to reach an agreement failed in the spring and summer when Trump and Democrats argued over the size of the package and election year politics hampered efforts to reach an agreement.
Legislators have increasingly set a new goal for restoring Medicaid to islanders: to include the legislative revision in year-end spending, a must to keep the government functioning. As December drew near, staff from the House’s Energy and Commerce Committees, as well as the Senate Means and Ways and Finance Committee, worked together on the health provisions to be included in the year-end deal. Initially, Medicaid coverage of islanders was restored, and lawmakers such as Energy and Trade Chairman Frank Pallone (D-N.J.) Pushed hard for their inclusion.
“We had it on our short list of things that were bipartisan and that wouldn’t blow up [Congressional Budget Office] score and be significant political improvements, “said an aide from one of the committees.
But when the leaders of Congress tried to strike a deal in December, McConnell’s office complained privately that the roughly $ 40 billion health package was too extensive – and contained too many Medicaid provisions – and aides to that Sent back the drawing board.
“It was 50:50 whether the COFA fix would make it,” said an aide who was briefed on the deliberations.
Ultimately, the Democrats decided to keep pushing for the restoration of the islanders’ Medicaid, arguing that the $ 600 million price tag was a relative amount given the islanders swayed amid the pandemic. Aides said they also saw an opportunity to strike a deal with Republicans, who had a Medicaid priority of their own: the low-income health program would have to cover the incidental costs of patients for participating in a clinical trial. The measure was sought by health care stakeholders and supported by both parties. Medicare and private insurers already offer similar coverage.
Linking the two priorities has helped bring COFA across the finish line, according to staff.
Lawmakers involved in the process said they were too nervous to discuss the COFA outlook until the final bill was unveiled on December 21. “Until I actually saw them there, I didn’t talk about it in the final bill,” Hirono said. “Even Chuck [Schumer] told me it should be in there but don’t talk about it. “
And across the country Pacific Islanders were similarly superstitious about the prospect of a quarter-century Medicaid lockout – only after news spread that the leaders of Congress had reached an agreement did they gather in practically a mixture of shock and cheer.
“Many of our COFA leaders across the country have gathered through Zoom,” said Laelan, the executive director of the Arkansas Coalition of Marshallese. “The first few minutes were a moment of silence – in tears – but became a celebration afterwards.”
There was one more hurdle to overcome: lawyers had to wait another week for the change to become law as Trump refused to sign the bill before finally giving in on Sunday night.
“I personally received a call from Sen. [Ron] Wyden minutes after President Trump signed the bill to inform me that the work for the COFA judiciary was long overdue and this is just the beginning, “said Joe Enlet, president of the National network of the COFA Alliance.
“It has been a long time since this historic injustice was rectified,” said a spokesman for Wyden, the top Democrat on the Senate Finance Committee, adding that Wyden was “proud to have Sens. Hirono and.” [Brian] Sweetheart makes it over the finish line. “
Medicaid coverage now
Legislators said the bill should go into effect immediately, and Hirono said it has started working with local health officials to ensure the thousands of islanders who live in Hawaii can sign up for coverage.
Health officials and lawyers across the country are also making progress. Heather Rickertsen, who runs the pharmacies at Crescent Community Health Center in Iowa, which serves hundreds of Marshall patients, said her health center and other nearby providers will attempt to enroll Islanders in Medicaid next week.
“We have already started some preliminary implementation talks with state health officials and lawmakers,” Laelan, the executive director of the Arkansas Coalition of Marshallese, said Thursday.
But after two decades of waiting for Congress to restore Medicaid, the logistical challenge of actually enrolling in the program is welcomed as a welcome challenge.
“It’s a pretty new thing,” added Laelan. “Hopefully the process won’t be too long.”