Beyond Iowa, the plight of the Marshallese has won sympathy in other communities across the United States—like Springdale, Arkansas, where health workers have found a similar pocket of chronically ill islanders—and attracted a small but growing number of champions in Congress.

The leader of that effort: Mazie Hirono, the Hawaii senator who first introduced a bill to restore the islanders’ Medicaid coverage when she was a House member about a decade ago and has reintroduced similar legislation in every subsequent session of Congress.

Hirono argues that the United States is effectively discriminating against the Marshallese and other islanders in the compact, which she finds particularly cruel given the history of the U.S. military’s nuclear tests—and given that some younger Marshallese even serve in the U.S. military now. “Don’t you think it’s important ... that when they do come to our country, they are able to live, work and access health care, like anyone else who is legally present in our country?” she said.

Hirono and other members of Hawaii’s delegation have been so focused on the problems facing the Marshallese and fellow islanders covered by the compact because so many islanders—nearly 20,000, by some estimates—have resettled in Hawaii and, like the population in Dubuque, need health care and other social services. Hirono has recruited other allies, like Rep. Tony Cárdenas (D-Calif.), who sits on the House’s powerful Energy and Commerce committee, which helps oversee Medicaid.

But they’ve struggled to win over colleagues and party leaders because of a simple legislative calculus: the islanders aren’t voters, and lack the key advocacy groups willing to go to war with Congress on their behalf. Under the COFA agreement, the Marshallese can live, work and study in the United States without needing visas—and while here, they pay taxes and even volunteer to serve in the military at higher per capita rates than many U.S. states. But they remain citizens of the Republic of the Marshall Islands.

After Democrats reclaimed the House in 2018, Hirono, Cárdenas and other supporters of the islanders planned out a new strategy as Congress hashed out a sweeping, year-end budget package in the fall of 2019. Cárdenas was tapped to lead the way, and his office developed a bill to restore Medicaid coverage. Meanwhile, the Asian & Pacific Islander American Health Forum and other advocates for the Marshallese took to the Hill, meeting with members of both parties.

The plan was partially successful. For the first time in more than a decade, the Democrats pushing the package won over a key Republican: Steve Womack, a House member who represents the Arkansas district where many Marshallese have relocated. A second Republican, Del. Aumua Amata Radewagen of American Samoa, also joined the package as a nonvoting member of Congress.

But the effort sputtered when they failed to win over Republicans on the relevant House committees, and Democrats also expressed concern about the cost to fund the provision, estimated at about $350 million over a decade, amid dozens of other health care budget battles.

Hirono and Cárdenas are aiming again for a budget bill currently slated for May. House Democrats also are eyeing a plan to raise the issue of the islanders’ lost Medicaid at an upcoming congressional hearing and further lay the groundwork for a legislative fix.

The fate of the Marshallese also will be shaped by multiyear, multination diplomatic talks that are now underway. The Trump administration has begun to renegotiate terms of its decades-old Compact of Free Association with the Marshall Islands and fellow nations ahead of the deals’ expiration in 2023 and 2024. Health care advocates are pressing the U.S. government to commit to covering the islanders’ health conditions as part of any final deal.

The Marshallese do have a card to play: Their islands and the two nearby nations covered by the compact, Micronesia and Palau, hold significant strategic value for the U.S. military, which currently enjoys exclusive access to the islands’ airspace and waters. That makes the Marshall Islands, which are about twice as close to Beijing as they are to Washington, D.C., a useful staging ground to project force when dealing with China and other Pacific rivals.

The Trump administration previously signaled some openness to boosting financial subsidies for the islands, especially as the Marshall Islands have made diplomatic overtures to China, and a bigger financial package could help subsidize residents’ health costs. But any resolution remains years away.

Back in Dubuque, residents say they’re committed to caring for the Marshallese—even if their project leads to a flood of islanders continuing to relocate to their small city, seeking subsidized health care, and the cost of the project mounts.

“If we have an influx … we can’t take it all on,” acknowledged Mary Rose Corrigan, the city’s top health official and a member of the board overseeing the island health project, saying that a surge of uninsured Marshallese would force tough decisions about whether to ration care and services.

But Corrigan added that Crescent wouldn’t turn away any new Marshallese arrivals, even if a surge of patients forced clinic leaders to seek out new financial support. “We have people in Dubuque who will help,” Corrigan predicted. “That’s the kind of community we are.”

One reason for Corrigan’s optimism: City officials annually identify the Marshallese plight as a top priority. “We look at the COFA agreement and say, the Marshallese should be granted Medicaid [and] entitlement program rights like everybody else,” she added. “They’re here in our community, they’re part of our economic engine.”

Meanwhile, the clinic has moved operations to a newer building across the street, where the patient rooms are bigger and the hallways are wide enough that staff aren’t stepping on each other, or on the hundreds of islander patients who flock to Crescent for their care.

“People keep coming. They keep coming here,” said Maun, the clinic’s representative to the Marshallese community. “Because they heard about this program.”