Effects of COVID-19 Related Medicaid Policy Changes in the Marshallese COFA Migrant Population

ABSTRACT Access to healthcare is a persistent public policy concern, particularly for Marshallese Compact of Free Association (COFA) migrants in the United States. This research addresses the impact of Medicaid policy changes, prompted by the COVID-19 pandemic, on healthcare access for Marshallese COFA migrants

residing in Northwest Arkansas, where the largest settlement of this population (~15,000) exists. Despite their eligibility for Medicaid under the 1986 RMI-US COFA agreement, subsequent legislative changes, notably the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), resulted in a significant

portion (approximately 50%) of the Marshallese population being devoid of healthcare coverage. Even after the enactment of the Affordable Care Act and Medicaid expansion in 2014, which did not reinstate Medicaid coverage for COFA migrants, these disparities persisted. The Consolidated Appropriations

Act of December 2020 reinstated Medicaid access after a 25-year gap. However, the effectiveness of this policy change in ensuring enrollment and optimizing healthcare service utilization remains unknown. The overall objective of this study is to determine the effect of Medicaid policy changes enacted in

response to the COVID-19 pandemic for Marshallese COFA migrants. We will leverage our long-standing community-engaged relationship with the Marshallese community in Arkansas to collect primary data to generate important data on the barriers and facilitators to Medicaid enrollment for Marshallese COFA migrants,

and to inform effective community-based interventions. Our Specific Aims are: Aim 1: Examine the Medicaid enrollment process and identify barriers and facilitators to healthcare for Marshallese newly eligible under Medicaid policy changes. We will conduct four focus groups with 50 Marshallese to qualitatively

explore barriers and facilitators to Medicaid enrollment and accessing healthcare services. Aim 2: Conduct a needs assessment to assess barriers and facilitators to inform community-based interventions to improve Medicaid enrollment and use of primary and preventative healthcare services. We will develop

and administer a survey to 750 Marshallese to assess the need for community-based interventions to increase enrollment and the use of healthcare services. The survey will focus on barriers and facilitators to Medicaid enrollment and primary/preventative healthcare utilization, and use the themes that emerge in Aim 1 to direct

the selection of additional existing validated survey measures. The study's findings will contribute essential information for the development of community-based interventions tailored to enhance Medicaid enrollment and healthcare service utilization among COFA migrants and other underserved populations. The established

rapport with the Marshallese community uniquely positions us to implement and evaluate these interventions, fostering equitable healthcare delivery.