Arkansas Medical Leaders Address Health Disparities for the Marshallese Community

FAYETTEVILLE, ARK. – The North Street Clinic, on the first floor of the University of Arkansas medical building, is not rushing patients. In fact, the average query can take about an hour.

That’s because it’s a student teaching clinic, offering free consultations to people with difficulties accessing care, including the local Marshallese community.

Northwest Arkansas is widely regarded as the most populous center for the Marshallese community outside of Hawaii. Many islanders found work at the Tyson chicken factories and food processing facilities in the 1980s and the community continued to grow.

On Thursdays, the North Street Clinic is dedicated to Marshall patients primarily seeking care for diabetes or high blood pressure. On a Thursday in September, a family sits in the waiting room as students and their clinical advisors discuss diagnoses in a mission-control style room.

Students reported a patient with long-term COVID and ongoing symptoms, and another patient who needs insulin for diabetes. The observations, possible remedies, and underlying health conditions of future doctors, nurses, physical therapists, and pharmacists combine as students learn from each other and their counselors.

Many patients who come to the clinic do not have health insurance or are unaware that they may be eligible for Medicaid.

Arkansas expanded Medicaid in 2017, which first affected the state’s Marshallese children who became eligible, while adults did not get coverage until 2021 after Congress restored coverage for Compact of Free Association island residents living in the United States. U.S. The compact is an agreement between the United States and the Marshall Islands, Palau, and the Federated States of Micronesia that grants island citizens the right to live and work in the United States, as well as some financial assistance to the islands.

The Medicaid restoration and expansion hasn’t made the North Street Clinic any less busy; in fact, quite the opposite. Now students and physicians check with patients to see if they are eligible and try to enroll them in Medicaid coverage if they are.

The clinic will cover the costs of care if a person is not eligible, but with Medicaid coverage, patients can be referred for more specialist care and potentially have more comprehensive coverage with their health plans.

On that Thursday in September, a patient in their 30s walks into the clinic with some real concerns: They were hospitalized a few weeks earlier and are running out of insulin for their diabetes.

The student and medical team reviews your options.

They are not sure if the patient qualifies for Medicaid, but if they do, they may be able to get coverage for a specific brand of insulin. Either way, they need to help the patient understand that their prescription will change from the brand of insulin they were given in the hospital, as Medicaid is unlikely to cover it.

Students are learning in real time the barriers their patients face.

The patient had such low blood sugar levels that the doctors were relieved that the patient arrived at the clinic on time and they want to see her again the following week.

From the islands to Arkansas

This direct contact with the Marshall community and the opportunity to teach the next generation of physicians to think beyond the exam room is part of what brought Dr. Sheldon Riklon from Hawaii to northwest Arkansas.

He is the only Marshall doctor who practices in the lower 48 states.

For Riklon, he has seen the clinic’s impact on the local Marshall community since arriving in Fayetteville in 2016.

“The fact that it’s free really helped with their access, and because we also used translators and health professionals from the Marshall community, it made it even more accessible to patients,” said Riklon.

The clinic was founded in part due to the research and work of Pearl McElfish, director of research at the University of Arkansas for Medical Sciences.

McElfish learned about the large Marshallese community in Springdale while researching his doctorate and while working at the University of Arkansas School of Medicine, and his data collection laid the foundation for the North Street Clinic.

McElfish helped conduct a community needs assessment of northwest Arkansas. This survey reached 6,000 people through surveys and focus group interviews. When it was published, the Marshallese community ranked highest in health disparities.

The clinic began with a focus on diabetes, after a rough estimate from that assessment found that about a third of the local Marshall community needed treatment.

“That’s how growing up seeing so many people with diabetes, ethically felt like, how can I say to a community, ‘Thirty percent of you have diabetes, go take care of it,’ when there was no infrastructure to do that?” said McElfish.

To make the clinic fully interprofessional and welcoming, it was important to include community health workers who could speak the language, translate during consultations, and help patients understand their treatments and care plans.

Invest in community health agents

Terry Takamaru has been with North Street Clinic almost since its inception, working as a community health worker.

Explaining America’s complicated health care system is part of her job. Many diagnoses, conditions or treatments are not translatable into Marshallese, which means she has to sit down and take the time to explain the anatomy and diagnosis in descriptive detail.

“I feel the need to explain everything I do to them, and the fact is, my supervisors let us do that,” said Takamaru. “We sit down with these customers and explain everything to them.”

That’s how she and her co-workers built trust, Takamaru said. Though she is Marshallese, it still takes more than a shared language to build patients’ trust in the beginning, a process she said took several years.

Learning to communicate to his patients what was going on, especially with a condition like diabetes, also meant Takamaru had to learn a lot about the condition, treatment, possible side effects, and anticipate possible questions patients might ask. This is where working in a university environment with faculty and students from all disciplines helped, she said.

“Their knowledge is my knowledge,” said Takamaru.

In addition to the North Street Clinic, McElfish’s research also contributed to a pattern of care at other clinics in northwest Arkansas and across the state: hiring and hiring community health workers who speak Marshallese or the language of communities most in need of access to care.

The University of Arkansas offers college credit towards the community health worker certification, which McElfish hopes will lead many Marshall students to pursue that career.

Local Community Clinic in Springdale and Children’s Hospital in Northwest Arkansas employ Marshall’s Community Health Workers to help patients feel comfortable and communicate more easily with healthcare professionals.

When Congress reauthorized Medicaid access for Marshallese in late 2020, the local health infrastructure in northwest Arkansas was staffed with community health workers to translate for patients and let them know they were eligible for coverage, rather than having to pay a possible fee out of pocket. pay or deal with large medical bills.

The roads between Springdale and Spokane don’t seem obvious, but many in the tight-knit island community have family or friend connections to Arkansas and eastern Washington. The Pacific Northwest and the West Coast in general are popular places for Marshallese to move from the islands.

Takamaru, for example, lived and worked in the Portland area before moving to Springdale.

Before Medicaid was reauthorized, it was common for families to make decisions about where to live based on health care offers. As the state of Washington created its own Marshallese health program, some people would move to the Pacific Northwest for the health benefits.

a small world

Although the Marshallese community in Arkansas is much larger than the community in Spokane, health leaders in Spokane have reached out to Arkansas providers for help before.

McElfish and Riklon recalled speaking with Spokane Regional Health District leaders during the pandemic to discuss resource translation and prioritizing how to coordinate a response when the community was hit hard by the virus.

Research also connects the two communities.

A research project aimed at evaluating diabetes care and education provided in religious settings is being conducted in Arkansas, Hawaii and Washington. Washington State University is evaluating how the program is working.

Improved Communication

Efforts by certain parts of the health care system in northwest Arkansas to include and accommodate the Marshall community are vital for those who need to access treatment for chronic illnesses or need health coverage in an emergency.

Many Marshallese in Arkansas have expressed concerns about access to health care due to the potential for medical debt. There is a precedent set in the community that when you seek medical care, particularly in the emergency room, the family goes into debt, which in turn prevents people from seeking care.

Michelle Pedro, community health worker and policy director for the Arkansas Coalition for the Marshallese, said there is a feeling that “I’d rather die than owe this debt to my family.”

As a result, there is distrust in the community about the local healthcare system, and Pedro has heard people refer to the ICU as the “I-Kill-U” for people without insurance.

Organizations like the Arkansas Coalition for the Marshallese are working to help drive home the importance of not only having health coverage, but also using it for checkups and other routine appointments before health issues become an emergency.

When Congress restored Medicaid access to COFA Islanders, there was no system-wide notification of the change. Some members of the Marshallese community remained without access despite meeting income eligibility requirements, Arkansas coalition staff said.

The Department of Human Services in Arkansas, which runs the Medicaid program, was understaffed, advocates say, making it even harder to get answers to enrollment questions.

By the end of 2022, these issues have largely been resolved, and state data from northwestern Arkansas shows a sharp increase in Native Hawaiians and Pacific Islanders receiving Medicaid coverage.

But now, another challenge looms.

States will have to go through their Medicaid lists starting this spring to begin a redetermination process, potentially putting some of the hard work of healthcare professionals at risk. The federal government has allowed states to keep their Medicaid enrollees continuously enrolled during the pandemic, but that will stop in April when states will begin checking everyone’s eligibility, including all Marshallese who got coverage in the past two years.

Pedro said the Arkansas Coalition for the Marshallese is starting to see an increase in community members coming to their Springdale office with letters asking about what they need to do.

The Department of Human Services is planning to meet with the Arkansas Coalition for the Marshallese on the redetermination process, Pedro said.

While much progress has been made in enrollment efforts, maintaining this coverage is the next challenge for community health workers in Arkansas and Washington.

This story is part of a reporting grant sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund.

Arkansas Medical Leaders Address Health Disparities for the Marshallese Community

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