COFA Citizens:

A Tale of Social
Injustice

Level 6: Influencing Policy

and Legislation
Create Policy Champions by recruiting strong leaders in the community
to lobby for change in legislation in order to address the social justice
issue of denied access to healthcare coverage. Policy champions, who are
committed to promoting a policy issue such healthcare access, can
become important advocates for policy development and reform (The
Policy Circle, 2015).

For over 60 years, the U.S. military has conducted atomic nuclear tests in the
Pacific Islands. Currently, the radiation levels on these islands remains
extremely high. Individuals living on these islands suffer high rates of
radiogenic diseases, birth defects, endocrine disease, and cancer. The heavy
burden of these diseases has taxed the Pacific Island healthcare system
leaving them unable to treat everyone effectively (Simon, Bouville, Land, & Beck, 2010).
There are over 2,000 Compact of Free Association (COFA) citizens residing in
Marion County. These are immigrants from the Pacific Islands of the
Republic of Palau, Republic of the Marshall Islands, and the Federated States
of Micronesia. These citizens have the right to work, study, and live in the
U.S. in exchange for permitting the U.S. exclusive military positioning in their
homeland (Asian Pacific American Network of Oregon, 2015; Department of State, 2003).

Level 1: Strengthening
individual knowledge
and skills
Use community gatherings to access individuals in order
to disseminate information packets to:
Increase the individuals awareness of the health
services that are offered in their community such as
the Salem Free Clinics, Northwest Human Services,
Charity Care, Project Access, and MedAssist.
Enhance the individuals awareness of policy and
legislation. Enhanced knowledge has been shown to
encourage individuals to become an advocate for
themselves within their community and facilitates
increased involvement in health policies and current
legislation (Oregon State Legislature, n.d).
Encourage leaders from the community to participate,
collaborate, and contribute to the creation of social
programs that promote culturally competent health
education and connect individuals in their
community to health resources
(Stafford, 2010).

Neither American citizen nor illegal immigrant but defined instead as

permanent nonimmigrants they reside here legally and pay all local, state,
and federal taxes, including those that support health benefits for American
citizens; yet, due to their unique immigration status, adult COFA residents
lack equitable access to health insurance coverage (Department of State, 2003).
Lack of insurance coverage has resulted in significant hardships for these
community members as this severely limits their ability to access healthcare
services. Many COFA residents forgo preventative services, early
interventions, and long-term care of chronic illnesses (McElfish, Hallgren, & Yamada, 2015).
There are 1,299 COFA residents living in poverty in Marion County.
949 are uninsured (Community Health Needs Assessment, 2015).
All would be eligible for Medicaid, yet they are denied access to this service
due to exclusions established by the U.S. Congress in 1996 (Department of State, 2003).

Level 2: Promoting
community education
Hold community gatherings, such as health fairs at local
churches or within the community, in order to facilitate
community education and advocacy through the church
leaders/the elders. These gatherings reach a significant
portion of the COFA population in a social setting that is
familiar and comfortable to them (Choi, 2008).
Use social media as a platform for the COFA population to
communicate; specifically, offering peer and emotional
support while may potentially bring individuals together to
influence health policy (Moorhead et al., 2013).
Write an opinion piece or a letter to the editor to increase the
general communitys awareness of the issue regarding the
barriers COFA residents face when it comes to accessing
healthcare. Writing an opinion piece or a letter to the
editor serves as an efficacious platform for achieving
community awareness (National Association of County &
City Health Officials, 2015).

They are sick.

They need access to healthcare.
They need advocates to address this
social justice issue.

Increase awareness of this issue in the government through community

and coalition participation in advocacy, consultation, and dialogue with
policymakers. This includes attending public hearings, work sessions,
and lobby days at the Capitol. Community and other civil society
organizations are instrumental in creating and reshaping policy (The
Policy Circle, 2015).
Encourage members of the community to testify at public hearings, work
sessions, and lobby days. Personal testimony allows a first-hand account
of how laws and policies have a substantiated impact on a person, or a
community of individuals. Personal testimony has been shown to
influence the passage or revision of policies and regulations proposed by
state or federal legislatures (Oregon State Legislature, n.d.).
Initiate community-based participatory research (CBPR). This
collaborative approach to research involves community members,
organizational representatives, and researchers in all aspects of the
research process. This research approach has shown to greatly influence
health policy to eliminate racial and ethnic health inequities
(Cacari-Stone, Wallerstein, Garcia, & Minkler, 2014).

Level 5: Changing
Organizational Practices
Conduct a community health assessment separating COFA citizens
from Asian ethnic groups. Currently, data about the COFA citizens is not
funded, collected, or disaggregated by ethnic group. COFA citizen are
frequently grouped with Asian ethnic groups on surveillance data which
skews the data as Asian ethnic groups have a predominantly higher
economic status and better health outcomes than the COFA population.
Community assessments can formulate data that can assist in the creation
of community and economic development programs and policies that
address issues such as access to healthcare (Community Tool Box, 2014).
Coordinate a referral program between Salem Health and Salem Free
Clinics. A referral program reallocates patients care to a no-cost resource
in the community which can help to relieve the financial burden and
utilization of emergency services (Cunningham, Felland, & Stark, 2012).
Incorporate a Community Health Worker (CHW) at the Salem Free Clinics
and Northwest Human Services to target interventions and coordinate care
for COFA clients. The CHW bicultural capabilities have been shown to
increase client engagement and empowerment as they have similar
characteristics and life experiences as their clients. Furthermore, a CHW
can assist COFA clients in accessing and utilizing resources in the
community (Volkmann, 2015).
Encourage COFA coalitions to apply for the Community Partnership Grant
Program to support the health and well-being of low-income COFA
residents in Marion County. This funding allows recipients to address
specific health priorities and has been shown to improve the
quality of life for those most at risk in the community
(Community Health Education Center, 2014).

Level 4: Fostering Coalitions

and Networks
Level 3: Educating
providers
Use in-service training modules to:
Enhance health care providers cultural competence
regarding the COFA population by enhancing cultural
education including addressing relevant cultural customs
to equip providers with skills to provide culturally
competent care (Betancourt & Green, 2010).
Educate providers about the importance of using
professionally trained medical interpreters and abstain
from using family or friends of the patient to interpret as it
leads to poorer clinical outcomes (Rorie, 2015).
Educate providers/interpreters that some medical
terminology may not be translatable in their language, so
clarification of education should be a priority to ensure best
possible health outcomes (Rorie, 2015).
Include information packets that highlight low-cost
alternatives to medications and charitable foundations that
offer low or no-cost services to COFA residents
such as Salem Free Clinics, Project Access,
Charity Care, and MedAssist.

Create a network of COFA community leaders, such as chiefs,

church leaders, business owners, and professionals to facilitate
community involvement in advocacy. This large network of leaders
will have the ability to encourage individuals in the community to
come forward and share stories that illustrate the human impacts
of healthcare discrimination (Oregon State Legislature, n.d.).
Mobilize community partnerships and coalitions such as APANO
(Asian Pacific American Network of Oregon) and CANN (COFA
Alliance National Network) to build leadership in the community in
addition to developing campaigns that advocate for social justice
issues such as lack of access to healthcare. Communities benefit
from coordinated leadership particularly in the areas of public
policy advocacy (Israel et al., 2010).
Foster a partnership with Community Health Improvement
Partnerships (CHIP). This organization of community partners
assess, prioritize, and develop strategic planning in order to
implement interventions that address priority health issues for
populations within Marion County (Community Health
Improvement Partnership, 2015).

By
Erin Apodaca &
Laura Maxwell