The Compact of Free Association (COFA) comprise a series of treaties between the United States and three countries: the Federated States of Micronesia (Yap, Chuuk, Pohnpei and Kosrae), the Republic of Palau and the Republic of the Marshall Islands.

The agreements have funding commitments from the federal government to the governments of what are called the "Freely Associated States"; these commitments will expire in 2023.

But the pacts themselves have no expiration date. COFA citizens are legally eligible to work in the U.S. for an indefinite length of time and are required to pay state and federal taxes.

"They are able to go through the same process of applying for LPR (legal permanent resident) status and eventually citizenship as any other foreign national if they meet the requirements and qualify," said Marie Sebrechts, spokeswoman for U.S. Citizenship and Immigration Services.

The three COFA countries were formerly part of the Trust Territory of the Pacific Islands, a territory formed in the wake of severe damage and fallout following nuclear testing at Eniwetok and Bikini atolls after World War II.

Because of fallout and diminished job opportunities in agriculture and other environmentally sensitive industries, residents were forced to relocate, many of them recruited by the military.

Although nuclear testing is no more, the region remains strategically important to the U.S. military. Experts expect the U.S. to maintain a military presence there, and to perpetuate the COFA agreements.

Medical coverage is a crucial consideration to COFA citizens, and the cause of legal battles in Hawaii when the federal government disqualified them from Medicaid in 1996. In 2009, the state moved to curtail coverage, a position that appellate judges currently have upheld.

Last year Hawaii spent about $42 million to provide coverage for COFA children, pregnant women, the aged, blind and disabled and other adults, said Kayla Rosenfeld, spokeswoman for the Department of Human Services. The outlay has grown by about $10 million for the current year because the beneficiary count and the per-person costs went up, she said.

Funds from federal programs for the poor cover 66.3 percent of the cost for children and 51.9 percent for pregnant women, Rosenfeld said.

The state covers public education: There were 6,776 COFA students in 2013 statewide, 3.7 percent of total enrollment. Micronesians also qualify for certain other benefits, such as federal housing subsidies, but are left off the list for various other safety-net programs such as food stamps.

This issue of health care in particular can’t be left to the courts, said the Rev. Francis X. Hezel, a Jesuit priest and author on Micronesia. The longtime director of the Micronesian Seminar, a nonprofit organization based in Micronesia, was in Hawaii recently for an East-West Center series.

While he acknowledged the fiscal problems Hawaii faces in paying for COFA health bills, Hezel said these people have few alternatives, especially for the hundreds on dialysis or needing other costly treatments.

"The only option is find a place that has the facilities and is kind enough to extend their use to others," as Hawaii did, Hezel told the Star-Advertiser via email. "Either that or start digging the grave and notifying relatives for an imminent departure.

"The court might well be right in its legal decision," he added."But perhaps the issue should not be decided on simply legal grounds. Pacific islanders have always responded to one another on other terms than merely legal."