The U.S. Supreme Court has absolved Hawaii of paying for health coverage for noncitizens, which includes thousands of migrants from the Federated States of Micronesia, Palau and the Republic of the Marshall Islands.

The societal and policy issues at play transcend the merely legal, however, and the state must transition carefully to providing benefits that preserve both the health of vulnerable residents and the limited financial resources provided by taxpayers.

In the wake of the legal decision, the Hawaii Department of Human Services announced temporary emergency rules that rightly keep state-funded health coverage intact for up to 120 days. During this transition period, affected residents must sign up for new health plans through the Hawaii Health Connector. It is essential that outreach to the COFA popula- tion during this period be consistent and dogged, through all possible channels, including government agencies, nonprofits and other affiliated groups.

The coming changes will affect the healthiest members of this population. Noncitizen children and pregnant women and aged, blind and disabled individuals will continue to receive medical coverage at their current levels, uninterrupted, according to DHS. It is important to preserve aid for these most-vulnerable groups.

Community advocates fear that affected migrants’ out-of-pocket medical-insurance costs will rise substantially after the transi- tion period. If this added expense results in patients failing to seek preventative or early treatment and instead suffering full-blown health crises that require emergency intervention, any savings to the state will be lost. State officials must track medical costs in this new environment to determine the best long-term solution.

The high court decision, of course, did nothing to resolve the root problem, which is that the federal government has failed to pay the bills it generated by opening up unfettered U.S. residency to Pacific migrants under the Compact of Free Association (COFA), in exchange for exclusive military rights over more than 2 million square miles of ocean encompassing the three island nations.

It was utterly predictable that most of the people who left their home islands would end up in Hawaii, which is the closest U.S. state and has a similar environment and close cultural ties. Some migrants arrive needing health care, which their advocates consider a consequence of the dozens of nuclear tests the United States conducted in the Marshall Islands through the 1950s.

Hawaii’s congressional delegation must continue to push for all COFA migrants to be eligible for federal benefits such as Medicaid, as they were before the advent of welfare reform in 1996. COFA is a federal agreement; its attendant obligations should not be left to the states.

For years, COFA migrants, who are designated as legally residing non-citizen nationals and are free to travel the country without visa or time constraints, received the same state health care benefits as needy Hawaii residents who are U.S. citizens. As costs grew and the federal government cut its contribution, then-Gov. Linda Lingle sought to save money by limiting coverage. That led to the lawsuit resolved this week by the U.S. Supreme Court’s refusal to hear the Micronesian plaintiffs’ appeal of a lower court ruling in the state’s favor.

While the high court clarified that the state is not obligated to provide health coverage for noncitizens, it is just as clear that public health will suffer if a large segment of Hawaii’s population falls through the cracks. Careful changes for COFA’s healthy members might indeed be due — but fair, cost-efficient coverage must remain the goal.