Hawaiʻi’s health equity gaps are as unique as our geography. One of our greatest unmet obligations is honoring the needs of our COFA population.

The Compacts of Free Association (COFA) are a series of treaties between the United States, the Federated States of Micronesia, the Republic of Palau, and the Republic of the Marshall Islands. These treaties were partially established as compensation for the loss of life, health, land, and resources following U.S. nuclear testing in the South Pacific from 1946 to 1958. Under COFA, all citizens of those nations have a unique immigration status, allowing unrestricted entry into the U.S. as legal migrants in exchange for U.S. military access to their islands. However, federal benefits available to U.S. citizens have historically been denied to COFA migrants due to frequent rule changes and bureaucratic inconsistencies.

In 2020, Congress fixed a long-standing flaw in the Medicaid statute and made COFA citizens residing in the U.S. eligible to apply for and receive Medicaid benefits. At the same time, Pacific Islanders in Hawai‘i were experiencing disproportionately high COVID infection and death rates, underlining the dire need for equitable access to medical services.

In response, the Fund for Health Equity was established at HCF, in partnership with several other donors and foundations, to fund grantmaking for the COFA Health Outreach Program.

The goals of the COFA Health Outreach Program are:

1. To increase the enrollment of eligible COFA migrants in either Medicaid or other health insurance coverage.
2. To build and strengthen the capacity of the COFA community to facilitate greater access to effective, culturally aligned health and well-being programs.
3. To strengthen the organizational sustainability of COFA-led and COFA-serving nonprofit organizations.

HCF recognizes the critical role that community-based organizations play in outreach and information for historically excluded populations, as well as helping the health system to understand community needs. This project provides additional support to organizations conducting Medicaid outreach to the COFA population with an emphasis on building their capacity to empower and engage community members to be the providers, educators, interpreters, and leaders of the outreach effort.

Grantmaking

The COFA Health Outreach Program most recently issued grants in August, 2024, funding a cohort of 20 Hawaiʻi nonprofits over the course of three years.

2024 – 2027 COFA Health Outreach Cohort members:

For additional information on the COFA Health Outreach Program, email Ananda Luttet at aluttet@hcf-hawaii.org, or call (808) 566-5536.

To donate to HCF’s COFA Health Outreach Program, click here, and select “The Fund for Health Equity” from the “I want to support” drop-down menu.

How Medicaid Works in Hawaiʻi

According to research by the Kaiser Family Foundation, lack of insurance coverage leads individuals and families to forgo or delay medical care, which is associated with adverse health outcomes and higher costs. To address this, Medicaid provides no-cost health coverage for income-qualified individuals.

Medicaid is a complex partnership involving the federal government, the State of Hawaiʻi, Managed Care Organizations (MCOs), providers, and—increasingly—community-based organizations (CBOs), who work together to ensure access to quality healthcare for all. Eligibility for Medicaid is determined by Med-QUEST, a program of the Hawaiʻi State Department of Human Services. In Hawaiʻi, nearly 30% of the population relies on QUEST for access to healthcare. QUEST also pays for around half of all births in the state.

QUEST enrollees are assigned to MCOs, who are not merely payers, but act as hands-on care navigators. They coordinate communication among care teams, support transitions of care, address social determinants of health, arrange medical transportation, provide language support, deploy community health workers and peer specialists, enable behavioral health support, and identify and intervene to more intensively support high risk members.

This traditional health care system is beginning to acknowledge the need for CBOs in fostering healthy communities and overcoming social determinants, but partnerships are frequently informal and ad hoc. The future of health equity requires integration of CBOs as empowered, engaged, and sustainably funded partners.