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COMPACT IMPACT: Policy And Planning Implications

COMPACT IMPACT: Policy And Planning Implications. Pacific Island Health Officers Association, 52 nd Meeting June 11-15. 2012 Agana , Guam Neal A. Palafox MD MPH Dept. of Family Medicine and Community Health John A. Burns School of Medicine University of Hawaii. Finding a new Paradigm.

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COMPACT IMPACT: Policy And Planning Implications

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  1. COMPACT IMPACT: Policy And Planning Implications Pacific Island Health Officers Association, 52nd Meeting June 11-15. 2012 Agana, Guam Neal A. Palafox MD MPH Dept. of Family Medicine and Community Health John A. Burns School of Medicine University of Hawaii

  2. Finding a new Paradigm • Foster a constructive dialogue which moves health sector towards more effective solutions to various health related challenges • Meeting participants take ideas to constituency • PIHOA – regionalism ,planning

  3. Compact Impact • Defining: Compact of Free Association (COFA) • Defining: Compact Impact • Evaluation of the Compact Impact • Current Response to Compact Impact • New paradigm : Problem Solving • Federal, State, Country, Jurisdiction, Community • Understanding Expectations and Plans • Urgency and Planning

  4. Colonial and Political Rule • Under Colonial Rule for 400 yrs • Spain 1500 Germany 1860 Japan end WWI • US, end of WWII, under UN Trusteeship Agreement, obtained Administrative Oversight of Northern Marianas, Palau, Truk, Yap, Kusaie, Ponape, and Marshall Islands • Became TTPI ( Trust Territory of the Pacific Islands) as “Strategic Trust of US” under UN Security Council

  5. Micronesian History • 1960 UN issued report that criticized US for not preparing Micronesia for self government • Mid 60’s US increases financial assistance to Trusteeship 10 fold • Many Federal and education programs started, and large contingent of Peace Corps • Public high schools see first graduates and increase in college bounds

  6. Freely Associated States (FAS) • 1977 offered political self –determination to Northern Mariana, Palau, Marshalls, Chuuk, Yap, Korsrae , Pohnpei • Net effect: Northern Marianas became Commonwealth (CNMI); Palau, Marshall Islands, FSM became FREELY ASSOCIATED STATES (FAS) • US TTPI last of all UN Trusteeship

  7. Freely Associated States • Formed Relationship with US Governed by COMPACT of Free Association (COFA): Each entity has own COMPACT with US • COMPACT with FSM and RMI – 1986-2001; extended to 2003; amended 2003 to 2023 • Republic of Palau – different cycle. Initial COMPACT 1994, renegotiate with US 2010 • Terms: COMPACT 1 and COMPACT 2 (Amended COMPACT)

  8. Definitions • Micronesian • Compact • Compact 1 and 2 (amended Compacts) • Migrant vs Immigrant • Freely Associated State (FAS) • COFA not COFAs

  9. Compact of Free Association-COFA • FAS Goals • Independence • Development, Health , Education, Infrastructure, Business, Welfare • Economic Self Sufficiency • US Goals • Democratic Governments • Strategic Denial / Military • Economic Self Sufficiency

  10. COMPACT • Economic Provisions • Federal Grants • Sector grants • Political Provisions • Postal Service, FEMA • FAA. Communications, Weather • Migration (Work, habitual residence) • Military • Strategic Denial and Security

  11. US GAO Reports on Compact 1,2FSM and RMI • Achieved • Democratic Stable Governments • Strategic Denial and Security of Region • Not Achieved and Unlikely to be achieved • Economic Self Sufficiency • Trust Fund Inadequacy

  12. USAPI Per Capita Total Expenditure on Health, 2007(in Purchasing Power Parity (PPP) terms, International $) WHO World Health Statistics 2010

  13. Metrics • US Government Accounting Office Reports • COFA 2003, 2006 • Compact Impact Nov 2011 • Hawaii Uninsured Project 2004 • Hawaii Compact Impact Committee 2008 • PIHOA and Country reports

  14. Compact Impact • Diaspora • Why:: health , education, opportunity • Effect (+ /-) on Host State / Jurisdiction • Health /Social / Impact • Military Impact / Security Impact • Financial Impact • Political Impact • Effect (+ /- ) on FAS • Brain Drain, resource, military

  15. Diaspora • 2008 Census Bureau - 56,000 Migrants Since Compacts 1986 (25% of population?) • 12% of Guam’s Population ( 12,000 migrants) • 1% of Hawaii , (15,000 Migrants) • CNMI • Arkansas, California, Texas, Washington • 9000 Marshallese Ark • 4000 Marshallese Costa Mesa, CA

  16. Compact Impact- Hawaii State Agency Costs • Health – State Medicaid, Education, Housing / Social Services, Legal System • 2002 – $32,000,000 • 2007 - $101,163,113 • 2008- $100,963,808 • 2010 – $114,912,326 • 25 million state health medicaid (QUEST)

  17. US Policy Changes that directly affect Compact Impact • FAS categorized by INS initially as “Qualified Aliens” who are “Permanently Under Color of Law (PRUCOL)”, means they are legal residents in the US under administrative discretion • 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) changed PRUCOL to “Non Qualified Aliens” status rendering FAS migrants ineligible for fed public assistance

  18. Compact Impact Funding • US Congress Appropriated $30 mil / yr for 20 years beginning in 2004 • Divided between Guam, CNMI and Hawaii • Based in relative impact • $10-11 million / jurisdiction / yr • Used in different ways – pay hospital bills, education costs, DOH?

  19. Health- Lightning Rod • Infectious- TB/ Hansen’s • MDR- TB • Fear • NCD • Dialysis, Cancer • Diabetes, Obesity

  20. Reaction • Federal • Legislation- reinstate Medicaid • Insular Affairs Interagency Group and HHS • Interagency Security • Recommendations • Dialysis, stop migration, increase screening • Sector grants to fund Compact Impact • Deportation • Hawaii • BHH, Federal pressure

  21. Understanding the Problem- Data • Enumeration: who??, how many , where , when • Who tracks and keeps data • Process of enumeration 2013 GAO (cost) • CNMI, Hawaii, and Guam between 2004-2010 stated over $1 billion in compact impact costs • Defining migrant • Accounting for Compact Impact Dollars • Accounting for migrant revenues

  22. Understanding the Solutions • FAS • Preparation for Migration • Screening • Education and Health Infrastructure • Regional Approach • Hosting State / Jurisdiction • Integration (3 pillars) • Federal • Medicaid, coordinated

  23. Lessons Learned • Failed Planning • Unintentional Consequences • Lack of Standards • Assets vs deficits model of evaluation • Issues of Accountability on both sides • 360 dialogue– silo conversation • Levels of engagement • owning the problem and solutions • People suffer- elephant

  24. Partners • White House Initiative • 3 PILLARS OBAMA • APIHF • Federal • State • Regional • Community , Community, Community

  25. Observations • States and Territories believe Federal Problem • Federal Believe it is Jurisdiction Problem • Federal Agencies believe they have limited oversight and guided by set Government policy • Jurisdictions believe migrants chose to move—its their issue • Migrants looking for fruition of new opportunity and health in Promise land • Affected area targetting new migrants coordiantion

  26. Regionalism • Globalization • Who is not affected • All partners (eg Am Samoa, CNMI) • Priorities and nationalism • Planning – Unintended Consequences • Textbook case • Levels of Integration, Military

  27. Going Forward • Proactive • Community • Assets / Deficits • COMPACT Impact Conference

  28. Urgency and Planning • Compact Structure • Federal Grants • Effect of Diaspora on FAS • Climate Change

  29. Darwin • It is not: • Strongest • Most intelligent • ……..

  30. The Beginning • Regional Planning • Bringing all stakeholders to the table

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