COVID-19: A Disproportionately Devastating Disease for the Marshallese in Hawai’i
By Shannon Marcoux*
Published on April 13, 2020
Though there have been many news stories in recent days exposing the disproportionate impact of COVID-19 on communities of color throughout the U.S., the potentially devastating impact of the virus on one particular group warrants additional scrutiny. Due to high rates of poverty and underlying health conditions, the over 9,000 Marshallese people[i] living in Hawai’i face a heightened risk of contracting the virus, as well as suffering its most severe outcomes. The Marshallese in Hawai’i also face an added burden of statutorily-sanctioned inadequate access to affordable healthcare and social safety net programs due to their unique immigration status.
The Compact of Free Association (COFA) between the governments of the Marshall Islands, Micronesia, Palau, and the United States allows these islands’ nationals to migrate to the United States to live, work, and study without a visa. Consequently, approximately a third of the Marshallese population has done just that, with the plurality of Marshallese migrants calling Hawai’i home.[ii] Despite paying taxes, the Marshallese are excluded from most federal safety net programs—including Medicaid, Supplemental Nutrition Assistance Program (SNAP) benefits, and unemployment insurance—leaving them especially vulnerable in the COVID crisis.
High rates of poverty, participation in the service industry, overcrowding, and homelessness all make Marshallese residents of Hawai’i particularly vulnerable to contracting COVID-19 in the first place. Over half of all Marshallese individuals (51.1%) and 46.2% of Marshallese families living in Hawai’i are living in poverty. Per capita income of Marshallese people living in Hawai’i is just $6,000 compared with a per capita income of $48,000 for all Hawai’i residents. This remarkably low-income level inhibits Marshallese people from purchasing the supplies necessary to shelter in place for extended periods of time, and it means that they will be especially hard-hit by COVID-related medical expenses.
With two out of every five Marshallese workers employed in Hawai’i’s service industry, many are susceptible to the double-edged sword facing service industry workers across the country: either continue reporting to work and risk exposure to the virus or get laid off and risk not being able to pay rent. The unemployment rate among Marshallese in Hawai’i was 17% prior to COVID-19, and this rate will likely increase significantly in the wake of the virus’s economic impact. However, Marshallese do not qualify for the unemployment insurance program instituted to provide relief for COVID-affected workers.
Marshallese constitute a disproportionately large percentage of the homeless population in Hawai'i--a group that is particularly vulnerable amid the COVID-19 crisis. Pictured: A homeless community encampment in Honolulu. Photo by joel.achatz.
Due to low per capita income and the high cost of housing in Hawai’i, Marshallese residents also tend to have significantly higher household sizes than other groups, and this overcrowding poses challenges if one family member in a large household contracts the virus. The average owner-occupied household in Hawai’i is 3.17 people or 2.83 for renter-occupied properties, but the numbers for Marshallese households in Hawai’i are over double that: 16.45 for owner-occupied properties and 6.15 for renter-occupied properties. This averages out to approximately 7.67 people per household—about three times the national average.[iii] These large households render social distancing effectively impossible and create a situation in which the virus can spread rapidly to the many other cohabitants, even if strict precautions are taken.
While COFA residents (including all Marshallese, Micronesians, and Palauans) make up just over one percent of the population in Hawai’i, they comprise approximately eleven percent of the population utilizing homeless services. Other estimates are much higher; some homelessness services NGOs in the state estimate that 20-50% of their clients at a given time are COFA residents. Due to inadequate access to sanitation and hygiene facilities, homeless individuals are more likely to be exposed to the virus, and poor health outcomes for homeless individuals suggest that they are more likely to die from COVID-19 if they contract it.
Beyond being especially vulnerable to contracting the infection, the high rate of underlying health conditions in the Marshallese community—many of which result from dietary issues related to the United States’ decades-long degradation of the Marshallese environment and economy—increases the likelihood that they will face severe complications or die from such an infection. The rate of diabetes—one of the underlying health conditions associated with severe COVID-19 symptoms—has been estimated as being between 25-50% in the Marshallese community, which is significantly higher than the rates in the United States (8.3%) and globally (4%). Furthermore, Marshallese face disproportionately high cancer rates, which are at least partially attributable to the radiation from the U.S. nuclear testing program and can lead to an increased likelihood of mortality from COVID-19.[iv] Finally, Obesity, hypertension, cardiovascular issues, renovascular issues, and tuberculosis—all underlying health conditions that are higher in the Marshallese community than in the general population—also put those infected with COVID-19 at greater risk for severe complications or death.
Finally, the Marshallese community is not only uniquely vulnerable to becoming infected with COVID-19 and suffering some of its worst outcomes, but the financial burden of that medical care will be devastating for Marshallese families. Under the 1996 Personal Responsibility and Work Opportunity Act (PRWORA), COFA residents were reclassified as “non-qualifying immigrants” and consequently stripped of their eligibility for most federal social safety net programs, including Medicaid and the Children’s Health Insurance Program (CHIP).[v]
Hawai’i formerly provided healthcare coverage for impoverished Marshallese people, but in 2010 the state government repealed that healthcare coverage and instead provides a plan called Basic Health Hawai’i for COFA residents.[vi] This plan provides premium payment assistance for adults who fall below the Federal Poverty Level,[vii] but this provides no payment assistance for deductibles or co-pays. Though some private insurance companies have committed to covering all out-of-pocket costs for COVID-related hospitalizations, others have made no such commitment and insurance purchased through the Affordable Care Act is likely to leave hospitalized COVID patients with around $2000 in out-of-pocket expenses. Given that the per capita income of Marshallese residents of Hawai’i is only $6,000 per year, a $2,000 would be financially overwhelming.
If steps are not taken to ensure that Marshallese and other COFA migrants[viii] receive financial help with preventative measures and any necessary COVID-19 treatment, the virus will have a uniquely devastating impact on the Marshallese community in Hawai’i. As climate change is likely to force many more Marshallese to migrate to the United States in the coming years, the United States must be prepared to fulfill its own COFA obligations by providing at least the most basic rights to these islanders. The COVID-19 pandemic has shown that the United States is nowhere near prepared to do this.
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* Shannon Marcoux is a JD candidate at Columbia Law School pursuing a career in human rights and environmental justice. Prior to law school, Marcoux was a secondary school teacher in Chuuk, Micronesia, where she worked with students from all three COFA nations: the Federated States of Micronesia, the Republic of Palau, and the Republic of the Marshall Islands. She wrote this piece as part of her work with Columbia Law School's Human Rights Clinic.
The Columbia Law School Human Rights Clinic works to advance human rights through partnerships with civil society organizations and communities. It brings together innovative education, social justice work, and scholarly research, and students are trained to be strategic human rights advocates.
[i] The Marshallese are only some of the 16,680 COFA residents living in Hawai’i. Other COFA residents come from the Federated States of Micronesia and the Republic of Palau, and these communities face similar the same legal and financial hurdles to obtaining adequate healthcare. This post narrows in on the Marshallese community due to the limited availability of data for non-Marshallese COFA residents and the uniquely high rates of certain underlying health conditions in Marshallese residents due to U.S. nuclear testing in the Marshall Islands.
[ii] There are large Marshallese communities in Oregon, Washington, and Arkansas. As healthcare and safety nets vary between states, a state-by-state analysis is required to assess the impact on Marshallese communities in other states. This post focuses on Hawai’i in particular because it is the state with the largest population of Marshallese migrants and other COFA residents.
[iii] The average U.S. household size is 2.63 persons.
[iv] Studies have suggested that approximately nine percent of all cancer cases expected to develop among Marshallese people who were living in the Marshall Islands between 1948 and 1970 may be attributed to radiation from the U.S. nuclear testing program there.
[v] While some children, pregnant women, and persons who are elderly, disabled, or blind may still be eligible for Medicaid, most Marshallese adults are ineligible for Medicaid, including many of those who are most susceptible to severe complications arising from COVID-19 infection. This means that they must enroll in an employer-sponsored health plan, purchase private insurance or subsidized insurance through the Affordable Care Act (ACA), or pay the penalty that the ACA sets forth for being uninsured. It is estimated that at least twelve percent of Marshallese people living in Hawai’i are uninsured.
[vi] This change was challenged in federal court, and the Ninth Circuit determined in 2014 that the state of Hawai’i was not obligated under federal law to continue providing state-funded Medicaid-like services for COFA residents who were not eligible for Medicaid under federal law. The Supreme Court refused to hear the case, so the Ninth Circuit’s ruling stands.
[vii] This benchmark is important because the Federal Poverty Level (FPL) is significantly lower than the Poverty Level Guideline for the state of Hawai’i (HPL). For example, the FPL for an individual is $12,760 annually, or $39,640 for a family of seven (the size of the average Marshallese household in Hawai’i). The HPL is $14,680 for an individual and $45,580 for a family of seven. This disqualifies many people who would be qualified if the state of Hawai’i used its own poverty metric to determine poverty for the sake of COFA healthcare coverage.
[viii] While this post focused largely on the Marshallese community, other COFA communities in Hawai’i—the Micronesians and Palauans—will be similarly impacted.