Majuro—For decades, Marshallese migrants in the United States have lived with a paradox: though they enter the country under the Compact of Free Association and contribute to the U.S. workforce, they were denied access to Medicaid for almost 25 years. This exclusion left thousands without affordable health care despite having some of the highest rates of chronic disease in the Pacific.
In December 2020, Congress restored Medicaid eligibility for COFA migrants — a landmark victory for health equity. Yet, nearly five years later, the promise of that policy change remains uneven: many Marshallese families continue to face structural barriers and persistent disparities. Their experience reveals the deep connections between history, health and policy—and how justice requires more than legislation.
The story of Marshallese health disparities cannot be separated from the history of U.S.–Marshall Islands relations. Between 1946 and 1958, the United States conducted 67 nuclear and thermonuclear weapons tests in the Marshall Islands, leaving a legacy of displacement, radiation exposure and long-term environmental contamination. From this history emerged the COFA, an agreement granting Marshallese the right to live and work in the United States without visas, in exchange for U.S. military access and strategic partnerships in the Pacific.
Despite this special status, the 1990s Personal Responsibility and Work Opportunity Reconciliation Act stripped COFA migrants of Medicaid eligibility. Marshallese migrants, many of whom worked low-wage jobs without employer-provided insurance, were left unable to afford life-saving care. It was not until December 2020—amid the Covid-19 pandemic, which disproportionately affected Pacific Islanders—that Congress finally restored Medicaid eligibility. The decision was widely celebrated as a long-overdue correction of a historical injustice.
Marshallese diabetes rates are among the highest of any ethnic group in America, and related conditions such as kidney disease, hypertension and obesity are tragically common. Many of these illnesses are linked to the disruption of traditional diets following nuclear testing. When subsistence foods were replaced by imported processed staples like rice, flour and sugar.
These disparities appear across key Marshallese communities in the United States. In Arkansas, home to the largest Marshallese population in the country, hospitals report high rates of kidney disease and diabetic complications. In Hawaii, Pacific Islanders have some of the highest rates of premature death. Across Oregon and Washington, providers report similar challenges in managing preventable chronic illness.
The Covid-19 pandemic brought these vulnerabilities into stark relief, exposing inequities such as limited insurance coverage, crowded housing, language barriers and frontline employment in poultry plants.
In Arkansas, Marshallese residents made up a disproportionately high share of infections and deaths. At one point in the summer of 2020 at least one Marshallese family reported to have died every day for 37 consecutive days.
When I was the secretary of health for the Marshall Islands during the pandemic, I once saw a haunting photograph of a foot-long graveyard filled with Marshallese flags on freshly dug graves. It was one of the most painful reminders of structural inequities that can be matters of life and death.
Access to medical care remains inconsistent. Many clinics and health systems lack staff who can bridge language and cultural gaps persist. There are few Marshallese interpreters in hospitals and a tendency to miscommunicate about diagnoses, medications or treatment plans.
As Michelle Langmos of the Arkansas Coalition of Marshallese explains, quality healthcare has improved, but it can still be difficult. Interpreting and translation will also improve, yet challenges remain—especially when medical terminology is not uniform. For example, in the RMI, doctors use Marshallese terms like "mojeni" to explain certain patients' seek care for different reasons. This results in a lack of understanding and worse outcomes for many.
The Marshallese experience underscores lessons for beyond one community. It highlights how structural inequities—rooted in colonial history, nuclear testing and immigration policy—can shape health outcomes across generations. While Medicaid restoration was a historic victory, achieving true equity requires dismantling barriers within health systems, closing cultural gaps and investing in trust-building.
Globally, the Marshallese case is a reminder that health disparities travel with migration. Communities displaced or marginalized by global powers often carry disproportionate disease burdens, which are then compounded in host countries. In this sense the Marshallese story is both unique and universal: unique in its nuclear legacy, universal in its lessons about justice and inclusion.
The United States is to truly honor its commitments under COFA and its responsibility for the Marshall Islands' future; it is a duty to justice, and the recognition of a history that continues to reverberate across generations.
Jack Niedenthal is the former secretary of Health Services for the Marshall Islands, where he has lived and worked for 34 years. He is the author of “For the Good of Mankind: An Oral History of the People of Bikini” and president of KokoWave Films, which has produced award-winning feature films in the Marshallese language. Send feedback to jackniedenthal@gmail.com