KENNEWICK – On a hot summer day last August, a Kennewick Church of Jesus Christ of Latter-day Saints was open but not for a church service. Instead, the church gym was being used by the Pacific Islander Health Board, which had been traveling around the state trying to enroll community members in health care.

“Io̧kwe aolep. Em̧m̧an mour?”

A friendly Marshallese greeting and welcome call from the wellness navigator, a person trained to help people find health insurance, lit up the faces of community members as they entered the gym. This happened many times that afternoon, as people unfamiliar with the Health Board team could tell that they were in the right place and welcome anyway.

Community members estimate that around 200 Marshallese live in the Tri-Cities.

Despite the heat, word had spread that the Health Board was there, and some came to sign up for health plans or get infant formula.

On Aug. 11, 20 people enrolled in Apple Health plans. Citizens of the Compact of Free Association, which includes the Marshall Islands, Palau and the Federated States of Micronesia, were originally entitled to coverage before welfare reforms in the 1990s cut them out of the Medicaid program. COFA is an agreement between the United States and the island nations that provides island citizens the right to live and work in the United States, as well as some financial assistance to the islands.

In the middle of the pandemic, Congress restored Medicaid access for COFA islanders. Since then, state agencies and local community groups have been working to get families signed up for coverage .

The Marshallese community in Eastern Washington was hit hard by the pandemic. In Spokane County, the group accounted for one-third of the COVID cases at one point in 2020, but less than 1% percent of the population.

Marilyyn Jima Tison has lived in the Tri-Cities since 2015 when she moved from Hawaii. She found belonging at her church and has remained an active part of the community, especially when it comes to health care.

When Tison became pregnant in 2016, she found a local navigator to help enroll her in Medicaid. Washington covers all children and pregnant women through Medicaid, regardless of where they are from. Since then, Tison has become a local expert on the health care system for the Marshallese living there. She said she gets calls asking for help finding doctors or translating during appointments.

Enrollment has depended on community members, like Tison, getting the word out, in coordination with groups like the Pacific Islander Health Board. Since 2021, when COFA Islanders became eligible for Medicaid again, community advocates and health workers say Medicaid restoration has led to more community members seeking health care.

Previously, many Marshallese who could not get health coverage through their jobs simply went without. For elders in the Marshallese community who do not qualify for Social Security or Medicare, Medicaid access is vital to fill the gap.

Disparities driven by nuclear testing

The health disparities, including COVID rates, among the Marshallese living in Eastern Washington did not happen in a vacuum. Instead, the inequity is a result of the United States’ relationship with the group of islands situated in the Pacific Ocean southwest of Hawaii.

In the 1950s, the United States used the Marshall Islands to test dozens of nuclear weapons and bombs, permanently damaging some islands, ecosystems and leaving lasting consequences on health and quality of life for the Marshallese.

“When they did the nuclear testing program in the islands, much of what we used to eat wasn’t there anymore. Right? It was contaminated,” said Dr. Sheldon Riklon, a medical doctor at the university of Arkansas who is the only Marshallese physician practicing and teaching in the lower 48.

Fish, the main food source for islanders, was effectively ruined, leading to an influx of packaged and canned food sent by the United States to the islands. These foods contain few nutrients and eventually led to poor health in the community.

Decades later, the Marshallese have disproportionate rates of cancer, diabetes and obesity, rooted in the United States’ nuclear testing on their homelands. Many of these conditions put people at higher risks of complications from COVID-19.

Challenges accessing care predated the pandemic in the Marshallese community, as the family-first mentality often takes precedent over personal needs, said Rensa Mailo, a navigator at the Pacific Islander Health Board.

Marshallese community and health agency leaders hope that Medicaid restoration can help reverse the trajectory and get people with chronic conditions access to the care they need.

Relying on the community

When Congress restored Medicaid for COFA Islanders, Washington state quickly enlisted the help of community organizations to reach the people who needed coverage.

The Health Care Authority, which administers Washington’s Medicaid program, granted the Pacific Islander Health Board a two-year contract starting in 2021 to host enrollment fairs for Pacific Islanders, particularly COFA Islanders, around the state.

The navigators on this team represent COFA island nations in the Pacific, all with unique languages and cultures.

Participation in enrollment events rose in 2022. Partnering directly with locals, like Tison and other church members, has been the key to getting people to come out to events.

The Pacific Islander Health Board also held a few enrollment events in Spokane in 2022.

Health board members praised Tison for volunteering so much of her time, noting that much of what she does is similar to what paid navigators accomplish. Tison often refers people who qualify for Apple Health to the navigator she found when she was pregnant in 2016.

“We really do need help with that,” Tison said, noting the lack of a Marshallese navigator in the Tri-Cities.

East of the Cascades, though, there is just one Marshallese navigator: Carlinda Jabjulan.

Getting the word out

Jabjulan is based in Spokane and an employee of Better Health Together, a nonprofit contracted by the state’s Medicaid agency. But she also works with the Spokane Regional Health District.

Her work is cut out for her: enrolling as many people as possible in Apple Health benefits, granted that they qualify along income guidelines. After Medicaid restoration in late 2020, Jabjulan realized she could not do the work alone and enlisted community leaders who are trusted in the Marshallese community: local pastors.

She formed a committee of local pastors and leaders that meets quarterly to discuss health care and access to other resources in the community, like housing. Jabjulan has facilitated and organized trainings for these meetings to help community leaders better understand how Washington’s health care system and health plans work.

Some members work on troubleshooting issues for community members, such as if someone’s passport is expired or they don’t have a matching I-94 immigration form – both documents are necessary for a COFA Islander to access coverage.

Jabjulan’s work cellphone buzzes often as she gets daily calls from community members about enrollment or, once enrolled, where to go to the doctor. By formalizing the committee, Jabjulan hopes that a broader community of support can grow, with volunteer translators, coordinators and community health workers someday.

There is a planned training in April for volunteers to become community health workers, Jabjulan said. She hopes more navigators and community health workers can be hired in Spokane and paid for that work eventually.

“It would be so helpful because we have a lot of issues nowadays, so we really need those community health workers to be out there and working and getting paid for what they do,” Jabjulan said.

For now, getting the word out is key.

“I want my people to know what’s available to them,” Jabjulan said at the Pacific Islander fair in Riverfront Park last summer.

Enrollment jumps

State Medicaid data does not break down race and ethnicity, with Native Hawaiians and Pacific Islanders grouped together in reports. Statewide, this group makes up 3.6% of Medicaid beneficiaries or more than 84,000 enrollees.

In Spokane County, that group makes up nearly 3% of Medicaid beneficiaries, with just under 6,000 people enrolled.

In Spokane, CHAS employs two Marshallese community health workers that connect people directly to care.

Jimmy Jacob, who also is a pastor, is one of them.

Even before Medicaid was expanded, Marshallese community members could get discounted care at CHAS, which is required by federal law to care for those who are uninsured or underinsured.

Since Medicaid has been restored to COFA Islanders, CHAS data shows a dramatic increase in local residents accessing care and getting covered by insurance, particularly Medicaid.

In August 2020, 192 COFA Islanders sought care at CHAS clinics. Of those, 83 were covered by Medicare. Every month since August 2021, CHAS has treated more than 200 COFA Islanders who have Medicare. In July 2021, CHAS treated 304 COFA Islanders, 240 of whom were covered by Medicare.

The number of COFA islanders covered by Medicaid has also increased in the past two years, CHAS data shows.

Jabjulan estimated that about 300 Marshallese community members have enrolled locally in Spokane since the restoration of coverage in 2021.

The local data indicates the work that people like Jabjulan and Jacob have done is working.

Before Congress restored Medicaid coverage for Marshallese adults, Washington state had started its small-coverage plan for this group called the COFA Health Plan.

The program insured just under 2,000 people statewide, and Spokane County had the most enrollees in the program, with more than 600 COFA islanders enrolled at the most recent point for which data was available.

Residents enrolled in the COFA Health Plan were automatically rolled into Medicaid, or Apple Health, when Congress reauthorized access during the pandemic.

But the Health Care Authority stopped short of sharing data about COFA Health Plan enrollees with navigators, who are employed by the Washington Benefit Exchange, a different state agency. This means Jabjulan has no roadmap to see who might be living in households with other eligible people.

For now, social media (particularly Facebook) and word-of-mouth comments through community leaders are the main avenues to connect people to coverage.

Once a person has Apple Health, they are assigned a doctor based on the health plan they selected.

Access barriers

Learning how to use health insurance can be challenging for some community members, especially if they are accustomed to the health care system in the Marshall Islands.

From choosing a doctor’s office to finding transportation or translation services, there are many additional barriers that Jabjulan, Jacob and other community members help patients navigate.

Mailo said three patients who came to an enrollment event in Longview last fall didn’t know their insurance had expired in 2018.

In the Marshall Islands, there is one main medical center where everyone goes when they are sick. There is no primary care, urgent care or specialty care – and often times if people need specialty treatment, they have to relocate.

Riklon traveled to the Marshall Islands during their first COVID outbreak last summer.

If they tested positive, he gave them instructions for caring for themselves, potentially a Paxlovid prescription, and sent them home. If they tested negative, they could get vaccinated or boosted.

The one-stop shop for health care is drastically different than the American health care system.

Medicaid will cover transportation, for example, but elders who do not speak English as their first language are hesitant to take Spokane Transit Authority to appointments or even call an Uber. Jacob calls patients before their appointments to make sure they have a way to get there.

Sometimes it falls to family members or relatives to take elders to doctor’s appointments, even serving as translators in exam rooms.

CHAS does not have in-person translators for Marshallese patients, and the clinics use an electronic service in the exam room. If Jacob or Betline Akeke, the other community health worker, are available, they can translate.

Efforts are underway to boost translation services, and community stakeholders are trying to get the next generation interested in translating.

Jabjulan hopes to have a program soon to train younger people, including high school students, to be translators in health care settings.

Jacob, of CHAS Spokane, said Medicaid has helped encourage Marshallese citizens to seek treatment.

“A lot of people are coming here and getting more healthy here,” he said.

Arielle Dreher is a former health reporter at The Spokesman-Review. This story is a part of a reporting fellowship sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund.