Chuukese patients in Hawaii often encounter discrimination from health care providers and may not seek necessary medical care for fear of being unable to afford it, according to a new qualitative study by researchers from the University of Hawaii and the College of Micronesia.

The study, based on interviews with eight health care providers and nine Chuukese community members, found that like other immigrant communities, Chuukese patients in Hawaii often struggle with linguistic and cultural barriers when seeking medical care.

But some also believe they face a degree of prejudice when navigating the state’s health care system.

“I can just tell right away that they’re so discriminating on the Chuukese,” the study quoted one provider saying of his or her colleagues. “They say, ‘Oh these Micronesians, they have to learn what to eat.’”

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Poor handling of language barriers led to “babies getting circumcised when the moms didn’t want it… and people waking up from surgery and not really knowing what happened.”

Chuuk is an island state that’s part of the Federated States of Micronesia in the western Pacific. The country is one of three island nations, along with Palau and the Marshall Islands, that gives up its surrounding waters and airspace to the U.S. as a national security buffer protecting Hawaii and the continent.

The treaties known as the Compacts of Free Association allow people to migrate legally to the U.S. without having to obtain visas. Many come every year seeking jobs, education and health care services.

But accessing health care has been challenging for some poor patients. Hawaii has switched health care coverage for low-income citizens of COFA nations three times over the past decade, sowing confusion and leading some patients to avoid filling needed prescriptions.

“There are certainly lots of stories floating around of people who gave up on health care,” health care providers told researchers. “I think partly it’s that health insurance coverage is so messed up and so confusing that they just think, ‘I don’t want to be a burden so I’ll just quit… I’ll quit my dialysis, I’ll quit my medicine.’”

According to Census data from 2017, less than 4 percent of all Hawaii residents have no health insurance, compared to 23 percent for Hawaii residents who self-identified as Micronesian. The figure fluctuates annually and had a margin of error of nearly 7 percent.

While the study focused on racial discrimination in health care, every provider interviewed and most of the community participants also had seen or experienced racial discrimination outside of medical services, some as frequently as every day.

“In one case a mother and child fleeing an abusive partner were not assisted by a domestic violence hotline because there was no interpreter,” the study said. “Consequently, the mother and the child slept overnight at a bus stop.”

Changing Health Care Plans

Citizens of COFA nations who move to the U.S. and are low-income used to rely on Medicaid. But the 1996 Welfare Reform Act made them ineligible for the program, and the State of Hawaii consequently covered them under Med-QUEST, the state’s health insurance program for low-income people.

But as costs mounted and budgets shrunk, former Gov. Linda Lingle’s administration switched citizens of the FSM, Palau and the Marshall Islands to a new plan called “Basic Health Hawaii.”

The 2009 change meant insurance would not cover more than a set number medical visits and procedures a year, forcing low-income patients relying on dialysis or ongoing cancer treatments to shoulder the costs of their own health care.

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A lawsuit forced the state to move low-income people from Palau, the Marshall Islands and the FSM back to Med-QUEST. But former Gov. Neil Abercrombie’s administration continued to appeal the ruling and ultimately won.

In 2015, Gov. David Ige’s administration shifted the low-income Micronesian community to health insurance purchased under the Affordable Care Act, which provides some federal tax credits to patients depending on their income. Those who are elderly, blind, disabled or pregnant may continue to rely on Med-QUEST.

Health care providers told researchers that “unequitable healthcare policies, whether intended or not, sent the devastating message, ‘We don’t care if you live or die.’”

“I really felt personally that when the state singled out our community to put us on a different health plan, it’s almost like it’s giving permission to the (general public) to lash out on us,” one Chuukese health care provider told study researchers.

Continuing Challenges

On Friday morning, about a dozen people line up at We Are Oceania, an organization in Kalihi run by Micronesians in Hawaii dedicated to helping other Micronesians. Program director Josie Howard sits at a white folding table at the front of a classroom, explaining how to sign up for health care coverage in both English and Chuukese. It’s the second-to-last day of open enrollment for ACA health care plans, otherwise known as Obamacare.

Puanani Crabbe-Parker, health care outreach branch manager in the Med-QUEST division of the state Department of Human Services, says the state has been working hard to improve outreach and partner with organizations like Howard’s to make sure that people get health insurance.

She noted COFA citizens aren’t the only immigrants who have to sign up through HealthCare.gov — if you’re a legal immigrant and you’ve been in Hawaii for less than five years, you have to follow the same system.

But while legal immigrants from other countries can eventually become eligible for Med-QUEST and Medicaid after five years of living in the U.S., citizens of COFA nations can live in Hawaii legally and pay taxes for decades and never be eligible for either program.

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Joakim “Jojo” Peter, community advocacy manager at We Are Oceania who is originally from Chuuk, believes sick, low-income Micronesians are the casualties of a political fight between the state and the federal government over who should fund their health care.

Ige’s administration advocates restoring Medicaid benefits for citizens of COFA nations and Hawaii Sen. Mazie Hirono is seeking to do so in Congress. Peter supports that too but says in the meantime, the system forces impoverished people to make choices that they shouldn’t have to make.

Megan Kiyomi Inada, the study’s lead author, was inspired to conduct her research after observing racism against Chuukese people and reflecting on the prejudice her grandparents endured in internment camps.

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“The Micronesian community is very humble and they don’t want to cause trouble. They don’t want to complain and so they hold a lot of that hurt themselves,” she said.

A Chuukese colleague once asked Inada to call a venue to book a room for a work event. “They won’t rent to me because my name is Chuukese and they said we’re all dirty and loud,” her colleague explained.

Inada says she knows there’s a “feeling of scarcity” in Hawaii and that many local families are struggling to make ends meet. But she doesn’t think there should be a choice between one community or another receiving health care.

“Everyone should get affordable health care,” she says.

Carlie Procell contributed reporting to this story.