Arkansas medical leaders address health disparities for Marshallese community

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

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

Northwest Arkansas is largely thought of as the most populous hub for the Marshallese community outside of Hawaii. Many islanders found work at the Tyson chicken plants 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 care for diabetes or hypertension. One Thursday in September, a family sits in the waiting room while students and their clinical advisers talk about diagnoses in a mission-control style room.

The students reported on one patient with long COVID and ongoing symptoms, and another patient who needs insulin for their diabetes. The observations, possible remedies and underlying health conditions from soon-to-be doctors, nurses, physical therapists and pharmacists all combine as students learned from one another and their advisers.

Many patients who come to the clinic don’t have health insurance or don’t know that they might 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. The compact is an agreement between the United States and Marshall Islands, Palau and the Federated States of Micronesia that provides island citizens the right to live and work in the United States as well as some financial assistance to the islands.

Medicaid restoration and expansion has not rendered the North Street Clinic less busy; in fact, quite the opposite. Now, students and clinicians check with patients to see if they’re eligible and try to sign them up for Medicaid coverage if they are.

The clinic will cover the costs of care if a person isn’t eligible, but with Medicaid coverage, patients can be referred out for more specialty care and potentially have more comprehensive coverage with their health plans.

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

The team of students and clinicians runs through their options.

They aren’t sure if the patient qualifies for Medicaid, but if they do, they could 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 received at the hospital since Medicaid likely won’t cover it.

The students are learning in real time the barriers that their patients face.

The patient had such low blood sugar levels that clinicians are relieved the patient got to the clinic in 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 a part of what brought Dr. Sheldon Riklon from Hawaii to northwest Arkansas.

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

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

“ It being free really helped with their access, and then being that we also utilize Marshallese community health workers and translators, it made it even more accessible to patients,” Riklon said.

The clinic was founded in part due to the research and work of 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 degree and while she was working at the University of Arkansas Medical School, and her data collection laid the groundwork for the North Street Clinic.

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

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

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

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

Investing in community 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 a part of her job. Many diagnoses, conditions or treatments are not translatable into Marshallese, which means she needs 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 that my supervisors let us do that,” Takamaru said. “We take our time sitting down with these clients and explain everything to them.”

This is how she and her co-workers built trust, Takamaru said. Even though she is Marshallese, it still took more than a shared language to build trust with patients at first, a process she said has taken several years’ time.

Learning how to communicate to her patients what was happening, particularly with a condition like diabetes, also means that 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 setting with professors and students from all disciplines has helped, she said.

“Their knowledge is my knowledge,” Takamaru said.

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

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

The local community clinic in Springdale and the children’s hospital in northwest Arkansas employ Marshallese community health workers 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 roads between Springdale and Spokane don’t seem obvious, but many in the tight-knit island community have familial or friend connections to Arkansas and Eastern Washington . The Pacific Northwest and the West Coast in general are popular places for Marshallese to move off the islands.

Takamaru, for example, had been living and working 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 offerings. 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, health leaders in Spokane have reached out to Arkansas providers for help before.

McElfish and Riklon recalled speaking to leaders at the Spokane Regional Health District during the pandemic to discuss getting resources translated and prioritize how to coordinate a response when the community was hit hard with the virus.

Research also connects the two communities.

A research project aimed at evaluating diabetes treatment and education delivered in faith-based settings is being conducted in Arkansas, Hawaii and Washington. Washington State University is evaluating how the program is working.

Improved Communication

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

Many Marshallese in Arkansas expressed concerns about accessing health care due to the potential for medical debt. There’s a precedent set in the community that when you seek medical care, particularly in the emergency room, that 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’s a sentiment that “I’d rather die than have that debt on my family.”

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

Organizations like 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 systemwide notification about the change. Some Marshallese community members continued to be denied access despite meeting income eligibility requirements, staff at the Arkansas coalition said.

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

As of late 2022, those issues have largely worked out, and state data from Northwest Arkansas show a marked increase in Native Hawaiian and Pacific Islanders getting Medicaid coverage.

But now, another challenge looms.

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

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

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

While a lot of progress has been made around enrollment efforts, maintaining that coverage is the next challenge for community health workers in Arkansas and Washington.

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