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 does not rush patients through. In fact, the average appointment can take an hour or so.

That’s because it’s a student teaching clinic that offers free appointments to people with barriers to accessing care, including the local Marshallese community.

Northwest Arkansas is widely thought to be the most populous hub of the Marshallese community outside of Hawaii. Many islanders found work at Tyson chicken factories and food processing facilities there in the 1980s, and the community has continued to grow.

On Thursdays, the North Street Clinic is dedicated to Marshallese patients predominantly seeking treatment for diabetes or hypertension. On a Thursday in September, a family sits in the waiting room while students and their clinical advisors talk about diagnoses in a mission-control-style room.

The students reported on one patient with long-term COVID and persistent symptoms, and another patient who needs insulin for their diabetes. The observations, possible remedies and underlying health conditions from future doctors, nurses, physical therapists and pharmacists all combine as students learn from each other and their advisors.

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

Arkansas expanded Medicaid in 2017, affecting only the state’s Marshallese children who became eligible, while adults only gained coverage in 2021 after Congress restored coverage to Compact of Free Association islanders living in the United States. The compact is an agreement between the United States and the Marshall Islands, Palau and the United States of Micronesia, which gives islanders the right to live and work in the United States, as well as some financial assistance to the islands.

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

The clinic will cover the cost of care if a person is ineligible, but with Medicaid coverage, patients can be referred for more specialty care and potentially have more comprehensive coverage with their health plans.

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

The team of students and clinicians review their options.

They are not sure if the patient qualifies for Medicaid, but if they do, they may be covered 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 received in the hospital, since Medicaid likely won’t cover it.

The students learn in real time the barriers their patients face.

The patient had such low blood sugar levels that the clinicians are relieved that the patient came to the clinic on time and they want to see her again the following week.

From the Islands to Arkansas

This direct outreach to the Marshallese community and the opportunity to teach the next generation of doctors how to think beyond the exam room is part of what brought Dr. Sheldon Riklon from Hawaii to Northwest Arkansas.

He is the only Marshallese physician practicing in the lower 48 states.

For Riklon, he has seen the impact of the clinic on the local Marshallese community since he arrived in Fayetteville in 2016.

“Being free really helped with their access, and since we also use Marshallese health workers and translators, it made it even more accessible to patients,” Riklon said.

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

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

McElfish helped conduct a community needs assessment for Northwest Arkansas. That research reached 6,000 people through surveys and focus group interviews. When published, the Marshallese community ranked highest in health disparities.

The clinic started with a focus on diabetes after a rough estimate from that assessment showed that about a third of the local Marshallese community needed treatment.

“That’s kind of how it grew to see so many people with diabetes, ethically it felt like, how can I tell a community, ’30 percent of you have diabetes, take care of it,’ when there was no infrastructure to do it?” McElfish said.

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

Investment in local health workers

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

Explaining the complicated American health care system is part of her job. Many diagnoses, conditions or treatments cannot be translated into Marshallese, meaning 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 thing is, my supervisors let us do it,” Takamaru said. “We take the time to sit down with these customers and explain everything to them.”

That’s how she and her colleagues built trust, Takamaru said. Although she is a Marshallese reader, it still took more than a shared language to build trust with patients at first, a process she said has taken several years.

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

“Their knowledge is my knowledge,” Takamaru said.

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

The University of Arkansas offers college credit for community health worker certification, which McElfish hopes will prompt a number of Marshallese students to pursue that career path.

The community clinic in Springdale and the Children’s Hospital of Northwest Arkansas employ Marshallese health care professionals to help patients feel comfortable and communicate more easily with providers.

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

The paths between Springdale and Spokane don’t seem obvious, but many in the close-knit island community have family or friendship 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, had 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 options. Because Washington State created its own Marshallese health program, some people would move to the Pacific Northwest for the health benefits.

A small world

While Arkansas’ Marshallese community is much larger than the community in Spokane, Spokane health leaders have turned to Arkansas providers for help before.

McElfish and Riklon recalled speaking with Spokane Regional Health District leaders during the pandemic to discuss shifting resources 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 delivered in faith-based settings is being conducted in Arkansas, Hawaii, and Washington. Washington State University is evaluating how the program works.

Improved communication

The efforts of certain parts of the health care system in Northwest Arkansas to include and accommodate the Marshallese community are critical to those who need treatment for chronic conditions or need health coverage in an emergency.

Many Marshallese in Arkansas expressed concern about accessing health care because of the potential for medical debt. There is a precedent in society that when you seek medical care, especially in the emergency room, it will put the family in debt, which in turn deters people from seeking care at all.

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

There is community distrust of the local health care system as a result, and Pedro has heard people refer to the ICU as “I-Kill-U” for people without insurance.

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

When Congress restored Medicaid access for COFA Islanders, there was no system-wide announcement of the change. Some Marshallese community members continued to be denied entry despite meeting income requirements, staff at the Arkansas coalition said.

The Arkansas Department of Human Services, which administers the Medicaid program, was understaffed, advocates say, making it even more challenging to get enrollment questions answered.

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

But now there is another challenge.

States will have to review their Medicaid rolls starting this spring to begin a redetermination process, potentially jeopardizing some of the health care workers’ hard work. The federal government allowed states to keep their Medicaid enrollees continuously enrolled throughout the pandemic, but that will stop in April, when states will begin checking everyone’s eligibility, including all the Marshallese who gained coverage in the past two years.

Pedro said the Arkansas Coalition for the Marshallese has started to see an increase in community members at their Springdale office with letters asking what to do.

The Department of Human Services plans to meet with the Arkansas Coalition for Marshallese about the redetermination process, Pedro said.

Although much progress has been made in enrollment efforts, maintaining this coverage is the next challenge for healthcare professionals in Arkansas and Washington.

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

Arkansas medical leaders address health disparities for the Marshallese community

Leave a Reply

Your email address will not be published. Required fields are marked *

Scroll to top