Tucked into Congress' end-of-year spending package — beginning on page 4,724 of the 5,593-page spending bill that President Donald Trump signed into law on Dec. 27 — are a few paragraphs of legislative text that some health advocates are hailing as a Christmas miracle.
"MEDICAID COVERAGE FOR CITIZENS OF FREELY ASSOCIATED STATES," the text begins, promising to allow natives of the Marshall Islands — the Pacific island chain left riddled with radiation after United States nuclear testing — and citizens of nearby island nations to get covered by the low-income health program.
For Democrats, getting those paragraphs into legislation emerged as a must-do priority this fall, with lawmakers driven to act after reports that Congress had accidentally stripped the islanders' Medicaid coverage in the 1990s, heightening their risks during the Covid-19 pandemic. But getting those words into the bill required committee leaders to navigate months of debate over the fate of a coronavirus stimulus package, their own deliberations about which policies they were willing to trade off and last-minute pressures from Senate Majority Leader Mitch McConnell, who warned Democrats that they were putting too many Medicaid provisions in the year-end spending package.
For about 100,000 islanders living in the United States, that text is the difference between now being eligible for Medicaid and another year of being barred from health coverage amid a pandemic that struck them with a greater ferocity than any other racial or ethnic group.
"When I got the news that it passed, I broke down and cried," said Josie Howard of We Are Oceania, a Hawaii-based advocacy group that pushed for Medicaid restoration. "All the memories of all the efforts — and friends and families who died during the fight — came back to me."
Lawmakers and advocates told POLITICO, which has tracked the fight to restore the islanders' Medicaid coverage across 2020, that the plight of the Pacific Islanders began to find a more sympathetic audience early in the year, and gained further attention as the pandemic tightened its grip. But it still required an extraordinary effort to push the bill over the hump, after 20 previous attempts had failed.
“It’s a very emotional thing,” said Sen. Mazie Hirono, the Hawaii Democrat credited by her colleagues as the primary driver of the fix. "I'm more than relieved that this finally happened."
Finding the right legislative partner
From the vantage point of Hirono and other lawmakers, their work felt like a moral imperative, since the United States has treated the islanders shabbily for decades.
First, the U.S. military irradiated the Marshall Islands, using the island chain to test dozens of nuclear bombs in the 1940s and 1950s. Then, U.S. officials pledged that the islands' residents — along with citizens of nearby Palau and Micronesia — would have access to Medicaid through a 1986 pact known as the Compact of Free Association, or COFA. The pact also allowed the islanders to easily relocate to the United States while remaining foreign citizens.
But Congress in 1996 stripped the islanders of their access to Medicaid through the U.S. Personal Responsibility and Work Opportunity Act, better known as the welfare reform package hammered out between President Bill Clinton and Republican leaders. The decision was described as a legislative oversight, but it haunted the Marshallese and left them extraordinarily vulnerable to the Covid-19 pandemic.
Since 2013, the fight to restore the islanders' Medicaid has been spearheaded by Hirono, a Hawaii lawmaker who has witnessed their challenges firsthand. About 25,000 Marshallese and other islanders have relocated to her state, and their lack of health care access had forced them to rely on the emergency department rather than getting regular medical check-ups. Researchers also found that the islanders' death rates in Hawaii had spiked after they lost access to Medicaid.
Brandishing a short bill — a single paragraph and several amendments that would collectively become known as the "Covering our FAS Allies Act" — Hirono pushed every year for seven years to get her Medicaid restoration language included in immigration bills, health legislation and even the National Defense Authorization Act.
"I tried to get it into the NDAA, I tried to get it into anything out of the Senate Finance Committee, I tried to get it into the tax extenders bill," Hirono told POLITICO, before listing off her additional attempts to squeeze the text into legislation. Beyond the moral implications of restoring Medicaid, the senator argued that a good relationship with the Marshall Islands and nearby nations should be a foreign policy priority; the U.S. military has used the islands for decades as a crucial perch to position forces in the Pacific Ocean.
But Hirono's efforts in the Senate repeatedly stalled, and her counterparts' record in the House was just as bad, as congressional Democrats from Hawaii repeatedly struggled to advance the legislation out of committee.
An outspoken critic of President Donald Trump, Hirono said she began to worry that having her name associated with the legislation was scaring Republicans away — a fear that she believed was backed up by grumbling she'd heard after her previous pitches sputtered. So her staff in July 2019 searched for a new point person to fix the decades-old Medicaid problem, settling on Rep. Tony Cárdenas (D-Calif.) and effectively cold-calling him to make the pitch.
Hirono's team concluded that "our strongest hand involves going through the House," an aide to the senator wrote in a July 24 email to a top Cárdenas staffer, pitching her on the plan. "Senator Hirono is looking for a strong House sponsor who could help push this policy into the health extenders package or some other legislative vehicle that has a chance of making it through the Senate."
Cárdenas had little immediate connection to the issue. The Marshallese and other islanders represented a tiny sliver of his district — at best, maybe a few thousand people among the millions who live in Los Angeles county — and as citizens of other nations, they couldn't even vote. Moreover, Cárdenas' staff wasn't familiar with COFA or the policy that had excluded the islanders from Medicaid.
But Hirono's team believed the California Democrat could be a valuable potential partner. He had a track record of fighting to expand health care access, and he sat on the influential House Energy and Commerce committee, which oversees Medicaid and handles legislation on health coverage. His team was quickly persuaded to sign on.
And in a twist that staff only realized later, Cárdenas's participation would carry an unexpected layer of symbolism. Cárdenas's office, located in the Rayburn House Office Building, was previously occupied by Newt Gingrich — the former GOP House Speaker who was an architect of the 1996 welfare reform package that accidentally stripped the islanders of their Medicaid. Strategizing from the same rooms more than 20 years later, Cárdenas and his team would help drive the effort to reverse what Gingrich and his own deputies had put into law.
A breakthrough in Congress
The job of trying to build a coalition fell to Meghann Galloway, a lawyer serving as Cárdenas' health aide.
Studying the previous failed attempts in the House — which had often focused on lining up Hawaii Democrats and other close allies — Galloway believed that the most likely path to success was securing a broader base of support. The aide built a spreadsheet of potential congressional targets, broken down by factors like lawmakers' region, party affiliation and committee membership. Galloway said she was trying to strike a balance of members who had islanders in their districts but also influence over legislation.
"I was targeting particularly folks on the Energy and Commerce Committee, but also Foreign Relations and Armed Services," Galloway said, adding that the goal was "to really bolster the argument that this was a national security issue on top of an equity issue."
Following her plan, Galloway pursued influential Democrats like Reps. Adam Smith (D-Wash.), the chair of the House Armed Services Committee, who signed on, and Eliot Engel (D-N.Y.), the chair of the House Foreign Affairs Committee, who didn't.
Cárdenas' office also secured a key goal of making the bill bipartisan by quickly winning over two Republicans, including GOP Rep. Steve Womack, whose Arkansas district included about 10,000 Marshallese — one of the largest communities in the United States, drawn by potential jobs at meatpacking plants and other factories.
Even as Galloway was pestering his staff, Womack was simultaneously hearing from advocates like the Arkansas Coalition of Marshallese, pressing their case in local meetings.
"I remember being in Rep. Womack’s office when a young Marshallese leader, Fressana Lawin, shared a very vivid and powerful story about her grandmother — who as a little girl had a daydream turn into a nightmare when she saw snow falling on her South Pacific island," said Melisa Laelan, the coalition's executive director. "Her grandma had run out and caught the snowflakes with her tongue, only to find out later that this was fallout from U.S. nuclear tests nearby. She suffered from thyroid cancer later in life."
"There wasn’t a dry eye in that congressional office, and Rep. Womack emerged from that meeting as a champion who cosponsored our legislation," Laelan added.
In Washington, a January 2020 POLITICO story about the islanders' plight also became part of Galloway's pitch, whether using it as a primer in conversations or sending it to congressional staff who worked for lawmakers that were on the fence.
"It humanized the problem," Galloway said. "I felt like it was a turning point in getting people involved."
Galloway's biggest target: Rep. Cathy McMorris Rodgers (R-Wash.), who had previously served in House leadership, represented a district in Washington State that included thousands of islanders and was teed up to be the top Republican on the Energy and Commerce Committee in 2021.
"She was my white whale," Galloway said.
Back in her district, McMorris Rodgers also was being pitched by advocacy groups like the Asian and Pacific Islander American Health Forum, the Children’s Alliance and the COFA Alliance National Network, and she hosted a January meeting with several advocates in her Washington state office.
"I remember the congresswoman feeling inspired," said David Anitok, a Marshallese man and advocate who attended the meeting, adding that McMorris Rodgers pledged to fix the Medicaid problem and then appealed to their shared faith. "She requested to close the meeting with all of us holding hands and praying over this act to restore Medicaid for COFA," Anitok said.
McMorris Rodgers formally signed on to the bill on Feb. 10 — making her the highest-profile Republican yet to join the effort, and marking a moment when advocates started to believe that the Medicaid could finally be restored.
A spokesperson for McMorris Rodgers said that the advocacy push helped win the congresswoman over. "Their story resonated with her, which is why she joined the legislation," the spokesperson added. "She wanted to fix this problem."
Disappointment followed by success
Having won bipartisan support and high-profile champions like McMorris Rodgers, legislation to restore the islanders' Medicaid was included in the HEROES Act, the $3 trillion coronavirus relief package that the House passed in May. After more than 20 years, it was the first time the chamber had ever advanced a fix for the islanders' plight.
The odds of a similar bill also looked increasingly promising in the Senate: Senate Minority Leader Chuck Schumer had privately pledged to Hirono — and publicly to POLITICO — that he would work to get the measure included in the next coronavirus stimulus package to come out of his chamber.
But Schumer, Hirono and other lawmakers ran into a new problem: There was no more coronavirus relief, for months. Attempts to reach a deal stalled across the spring and summer as Trump and Democrats quarreled over the package's size, with election-year politics complicating efforts to reach a deal.
Lawmakers increasingly set a new target for restoring the islanders' Medicaid: getting the legislative fix into the year-end spending bill, a must-pass package in order to keep the government operational. As December approached, aides on the House Energy and Commerce and Ways and Means committees and the Senate Finance Committee collaborated on the health provisions to be included in the year-end deal. Initially, restoring the islanders' Medicaid coverage made the cut, with lawmakers like Energy and Commerce Chair Frank Pallone (D-N.J.) pushing hard for its inclusion.
"We had it on our short list of things that were things that were bipartisan and not going to blow up the [Congressional Budget Office] score and be meaningful policy improvements," said an aide to one of the committees.
But as congressional leaders tried to strike a deal as December crept along, McConnell's office privately complained that the roughly $40 billion health package was too rich — and included too many Medicaid provisions — sending aides back to the drawing board.
"It was 50-50 about whether the COFA fix was going to make it in," said one aide briefed on the deliberations.
Ultimately, Democrats decided to keep pushing for restoring the islanders' Medicaid, arguing that the $600 million price tag was a relative pittance given how the islanders were reeling amid the pandemic. Aides said they also saw the opportunity to make a deal with Republicans who had a Medicaid priority of their own: requiring the low-income health program to cover patients' ancillary costs of participating in a clinical trial. The measure was sought by health care advocacy groups and had bipartisan support; Medicare and private insurers already offer similar coverage.
Tying the two priorities together helped bring COFA over the finish line, staffers say.
Lawmakers involved in the process said they were too nervous to discuss the COFA prospects until the final bill was unveiled on Dec. 21. "Until I actually saw it in there, in the final bill, I didn't talk about it," Hirono said. "Even Chuck [Schumer] told me, it's supposed to be in there, but don't talk about it."
And around the country, Pacific Islanders were similarly superstitious about the prospect after a quarter-century of being locked out of Medicaid — only assembling, virtually, in a mix of shock and jubilation after news broke that congressional leaders had reached a deal.
"Many of our COFA leaders across the nation gathered through Zoom," said Laelan, the executive director of the Arkansas Coalition of Marshallese. "The first couple of minutes were a moment of silence — in tears — but turned into a celebration after that."
There was one more hurdle to surmount: Advocates were forced to wait another week for the change to become law, as Trump refused to sign the bill before finally relenting on Sunday night.
"I personally got a call from Sen. [Ron] Wyden minutes after President Trump signed the bill to inform me that the work for COFA justice has been long overdue and this is just the beginning," said Joe Enlet, president of the COFA Alliance National Network.
"It was long past time to correct this historic injustice," said a spokesperson for Wyden, the top Democrat on the Senate Finance Committee, adding that Wyden was "proud to have helped Sens. Hirono and [Brian] Schatz get it over the finish line."
Medicaid coverage now
Lawmakers said that the bill was written to take effect immediately, and Hirono said she's begun working with local health officials to ensure that the thousands of islanders living in Hawaii can start getting signed up for coverage.
Health officials and advocates around the nation are moving forward, too. Heather Rickertsen, who leads pharmacy efforts at Crescent Community Health Center in Iowa, which serves hundreds of Marshallese patients, said that her health center and other nearby providers will attempt to start enrolling islanders in Medicaid next week.
"We have already started some preliminary conversations around implementation with state health officials and legislators," Laelan, the executive director of the Arkansas Coalition of Marshallese, said on Thursday.
But after two decades of waiting for Congress to restore Medicaid, the logistical challenge of actually signing up for the program is being hailed as a welcome challenge.
"It is quite a new thing," Laelan added. "Hopefully the process won’t be too lengthy."
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