Health Access for Immigrants

Updated Jan. 21, 2015 - Latest information on changes to Med-QUEST/health care coverage for COFA residents in Hawaii available at

Updated Nov. 10, 2014 - DHS issues emergency rules: The Department of Human Services has announced temporary emergency rules regarding health care coverage for COFA residents. DHS's Public Notice of Emergency Rules can be downloaded here. The Emergency Rules themselves may be downloaded here.

Updated Nov. 4, 2014 - On November 3, 2014, the U.S. Supreme Court denied plaintiffs' petition for certiorari in Korab v. Fink. Although the U.S. Supreme Court has declined to hear the case, the litigation on the matter is continuing. Because the State has yet to provide adequate assurances that cuts to critical health care benefits targeting COFA residents will not be implemented, we intend to continue our challenge on this life-or-death issue. Although the possibility of prevailing under the federal Constitution has been foreclosed, we believe that valid claims against the state continue to exist under the Americans with Disabilities Act and the Constitution of the State of Hawai‘i.


Since 2010, Hawai‘i Appleseed has sought to support Hawai‘i residents living here under the Compacts of Free Association and defend their right to equal access to health care. These members of our community, commonly known as Micronesians, face many challenges in the United States, including widespread discrimination.

The Republic of the Marshall Islands, the Republic of Palau, and the Federated States of Micronesia have special relationships with the United States, which are defined under Compacts of Free Association (COFA) between the U.S. and each of the three sovereign states. The U.S. and COFA states have reciprocal economic and military agreements that allow citizens of COFA states to live and work in the U.S. Hawai‘i is home to a number of Micronesian individuals and families, who work, attend school, and contribute to the strength and diversity of the islands. Hawai‘i Appleseed’s 2011 report, The Case for Justice for Micronesians in Hawai‘i, describes some of the history and experiences of Hawai‘i’s COFA residents.

Beginning in 1997, the state had covered eligible COFA residents through Med-QUEST programs, providing benefits equivalent to the federal Medicaid program. In response to reduced revenues, the state of Hawai‘i decided to save money by ending Med-QUEST coverage and creating a markedly inferior plan, Basic Health Hawai‘i. Annual coverage is limited to ten days of inpatient hospital care, twelve outpatient visits, and a maximum of four prescription medications per month. This level of coverage is inadequate for the typical Medicaid patient, let alone one with severe chronic illness. BHH’s meager coverage cuts off life-saving treatments such as chemotherapy and dialysis, making this cost-cutting measure literally a matter of life or death for Micronesian elders and people with disabilities. These residents have no access to comparable health care in their countries of citizenship and no means to afford expensive medical treatment.

Legal Challenges

The state first announced the new plan in 2010, but failed to provide sufficient notice of the changes or an opportunity for public comment. Hawai‘i Appleseed and its partners, Alston Hunt Floyd & Ing and Bronster Hoshibata, brought a class action lawsuit, Sound v. Koller, which successfully challenged the state’s actions as a violation of due process.

After the lawsuit, the state went through the necessary administrative procedures and implemented Basic Health Hawai‘i in July 2010. In response, Appleseed and its co-counsel brought a second federal class action lawsuit, Korab v. Fink (formerly Korab v. Koller), asserting that the cuts constituted discrimination on the basis of national origin and alienage and were in violation of the Equal Protection Clause of the U.S. Constitution.

In December 2010, the U.S. District Court in Hawai‘i granted a preliminary injunction that halted BHH and the more comprehensive Med-QUEST coverage. The State appealed to the U.S. Court of Appeals for the Ninth Circuit, and oral arguments were heard in September 2012. On April 1, 2014, the Ninth Circuit ruled that the state of Hawai‘i is not constitutionally obligated to provide state health insurance with the same level of benefits as the federally-funded Medicaid program covering non-COFA residents. The case is currently being appealed to the U.S. Supreme Court. According to a statement made April 8, 2014 by Attorney General David Louie, the state will continue to provide Med-QUEST coverage for COFA residents pending a final resolution of the litigation.

The lawsuits are only a small part of the advocacy on this issue, and many advocates and community members are pursuing broader strategies to build the public support and political will necessary to stop health care cuts and other forms of discrimination against Micronesians. Please go to to learn more about the latest developments and how to get involved. The implementation of Basic Health Hawai‘i will have a devastating effect on the health of Hawai‘i’s residents—taxpayers, workers, students, and members of our community—and all of us must make clear that denying equal access to life-saving healthcare on the basis of cost harms our entire community.

LEJ Executive Director Victor Geminiani is one of the featured interviewees in a documentary produced by UH masters student Keola Diaz about the Micronesian community and Basic Health Hawaii. You can view this documentary above.