Becoming an independent country with a Compact of Free Association (COFA) with the U.S. is one of the status options available to Puerto Rico. Although unusual, this arrangement is not unprecedented. There are three nations that currently have COFAs with the United States. Examining these COFAs may be a good way to get a sense of how Free Association might work for Puerto Rico.
No Federal Health Programs or Protections
The Republic of Palau, the Republic of the Marshall Islands (RMI), and the Federated States of Micronesia (FSM) were part of a group of islands called the Pacific Islands Trust Territory that was administered by the United States on behalf of the United Nations following the second World War.
The three freely associated states do not qualify for federal health programs. There is no Medicaid, no Medicare, and no private health insurance protections under federal law.
The RMI and FSM negotiated Compacts of Free Association with the United States in 1986. The agreements were to last for 15 years. They were renewed in 2003 and then again in 2024. Palau’s compact was signed upon its independence in 1994 and then renewed in 2010 and 2024.
Under the COFAs, the three nations receive minimal foreign assistance from the United States. Sector grants – including for health care sector support – is a significant area of this limited support. A recent publication by the General Accounting Office (GAO) reports that all three countries propose to use the majority of their COFA funding to support their education and health sectors, including efforts to enhance healthcare infrastructure, such as new construction and building maintenance.
Marshall Islands Nuclear Legacy
Between 1946 and 1958, over 65 nuclear weapons were dropped in the RMI as part of U.S. nuclear testing, exerting a force comparable to dropping 1.6 Hiroshima-size bombs each and every day for the twelve-year duration.
The Marshallese people were relocated from the damaged atolls to other parts of the islands, but a study from the National Cancer Institute concluded that people received radiation doses of as much as 1,000 mGy (mGy, or megagray, is the standard unit of measurement of radiation absorbed). By comparison, normal levels of exposure in the U.S. are around 1 mGy. Some residents had acute radiation sickness immediately, while others seemed well in the immediate aftermath. The long term effects of radiation were not well understood at that time, but in hindsight exposure to nuclear bomb testing has been described as walking around for the rest of one’s life with a machine gun inside – one never knows when it will go off.
The National Cancer Institute has concluded that people living in the Marshall Islands at the time of the nuclear testing had an increased chance of suffering from cancer later in their lives. Cancer, especially of the thyroid and leukemia, has been prevalent on the islands, as have birth defects. Ongoing epigenetic illness is suspected but more research is needed to document its scope. Locally-produced food has a history of risk.
The renewed 2024 COFA provided additional resources as the RMI continues to address the ongoing impact of the nuclear legacy, particularly in the effected atolls. The COFA contains funding for increased access to records of the U.S. nuclear program as well as for a museum on the U.S. nuclear program and its legacy. There is no explicit funding for health care related to the nuclear legacy in particular beyond general sensitivity to ongoing health needs inherent in the nuclear legacy as part of the broader pools of resources.
Veterans’ Health Care on Hold
The U.S. Department of Defense actively recruits in the three Freely Associated States (FAS), and FAS citizens serve in the U.S. Armed Forces at rates that generally exceed those of any state. After military service ends, however, FAS citizens have been unable to receive health services from the U.S. Department of Veterans Affairs (VA) if they return home, effectively forcing most to live within the United States.
The 2024 COFAs included a provision that requires the VA to enter into agreements with each FAS to provide healthcare, but the VA has indicated that it will not pursue these agreements, opting instead to treat U.S. veterans living in the FAS like others outside of the U.S. (except for the Philippines and Canada, where the U.S. Veterans Affairs Department provides services). Recent reporting has indicated that the situation represents “a breach of trust” by the U.S. and is “very critical at the moment.”
