State lawmakers are looking for ways to improve healthcare for Micronesian residents, many of whom seek care at Hawaiʻi emergency rooms which often results in the state paying for their treatment.

Under a 1986 treaty known as the Compact of Free Association, residents of the Federated States of Micronesia, the Republic of Palau, and the Republic of the Marshall Islands are allowed to legally live and work in the United States.

The treaty was signed as a result of environmental damage to the region from U.S. nuclear weapons testing after World War II.

Many COFA citizens, as they are known, arrive in Hawaiʻi and other states seeking better healthcare, but struggle to navigate the system.

Communities in COFA nations have some of the highest rates of tuberculosis and Hansen’s disease in the world.

On Thursday, advocates, state officials, and representatives from the healthcare industry presented their recommendations to lawmakers.

One of those speaking was family physician Neal Palafox, who lived in the Marshall Islands for more than 10 years. He is now on staff at the University of Hawaiʻi’s cancer research center.

Palafox said cramped living conditions and lack of access to healthcare in COFA nations has led to the high rates of communicable diseases, but also non-communicable ailments like diabetes.

Representatives from the Queen’s Health System told lawmakers they see around 1,300 COFA citizens every year, some of whom racked up $10 million of emergency room expenses.

Officials from the state Department of Health said the unpaid hospital expense see cost taxpayers earning around $38 million annually. (CAN YOU CHECK THIS SENTENCE PLS?)

Palafox advised against jumping to conclusions based on that number alone. He pointed out that many COFA citizens in Hawaii are employed and pay state taxes.

Nearly every person testifying before the committee cited the federal government’s failure to uphold its obligations under the COFA treaty as a major contributor to poverty and poor health outcomes for Micronesians in the United States.

House health committee chair John Mizuno summarized the testimony, identifying three major areas in which Hawaiʻi’s COFA residents are falling through the cracks.

“Three things need to be intertwined: education, civic engagement, healthcare. We’re working with a broken system and we need a better mindset,” he said.

Lawmakers are considering the creation of a task force to oversee the various services involving COFA citizens.