PRINGDALE, Ark. — Thousands of people in this northwestern corner of Arkansas, many of them working poor, are from a faraway constellation of islands, the most famous of which is known as Bikini.
They can live and work here without visas. Their children attend local schools. They pay federal and state taxes, just like the rest of the community.
But in all but the fewest cases they will never be able to qualify for Medicaid or Medicare under current law.
The large community of people here from the Marshall Islands, located roughly halfway between Australia and Hawaii, fall into a peculiar gap of the US health care system — and it has left a great many of them in the most precarious of limbos.
While some have health insurance through their work, those who aren’t working or are elderly do not. Many don’t see a doctor unless it’s an emergency — a risky approach in a community where type 2 diabetes is startlingly common.
“Most, by the time they see us … their chronic conditions are way out of control or they have other things that could have been caught by health care maintenance, like cancers. By the time they’re seen, it’s advanced,” explained Dr. Sheldon Riklon, a family medicine doctor who is one of only two Marshallese doctors in the US and who was recently recruited to practice in northwest Arkansas.
The special status of the Marshallese is conferred by a treaty called the Compact of Free Association, commonly known as COFA. (It also covers the nations of Palau and the Federated States of Micronesia.) It was struck when the Marshalls, formerly under a US trusteeship, gained their independence in 1986.
Some see the treaty as a debt payment of sorts. For a dozen years after World War II, the US used the Marshall Islands as a nuclear testing ground; 67 nuclear tests were conducted there. Some parts of the country — whose islands have a combined landmass about the size of the District of Columbia, but stretch over 4,500 square miles of ocean — remain uninhabitable.
To this day, the US maintains control over the waters of the Republic of the Marshall Islands and retains a naval base there.
Arkansas happens to be home to the largest community of Marshallese in the continental United States. Many work in Springdale’s ubiquitous factories, where they process chickens or make candles or package baby wipes. But they aren’t US citizens and so don’t legally qualify for social safety net programs.
Some states have tried to address the situation. Oregon has passed a law adding COFA migrants back into its state Medicare program, and similar legislation is working its way through the Washington state legislature. But even without the passage of new legislation in Washington, access to health care seems easier there for the Marshallese than in Arkansas, which has not amended its Medicaid and Medicare programs.
In Springdale, people will tell you that if a family member gets really sick, they’ll head out of state.
“If their health deteriorates and they know their health condition is deteriorating, they will leave us to go to Seattle because they know that they can have better health coverage in Seattle,” said Robin Thomas, administrator of a community clinic in Springdale that serves the Marshallese community. “As long as they can work and make money, they want to be here.”
Michael Duke is an anthropologist at the University of Memphis who is studying the health needs of the Arkansas Marshallese. As he sees it, there’s inequity in their situation.
“They pay federal income taxes but they don’t get back a lot of these services that citizens get,” Duke told STAT. “It would be one thing if they didn’t pay into the system. But they are paying into the system and subsidizing Americans, and not being able to benefit from those [services] themselves.”
Some in the community need health services badly.
Riklon splits his time among several clinics in cities that are strung along Interstate 49 like beads on a necklace. Fayetteville, Springdale, Lowell, Rogers, and Bentonville, the corporate home of Walmart.
One of those clinics cares for Marshallese diabetes patients; it is operated with grant funding by the University of Arkansas for Medical Sciences, at its Fayetteville campus. “When I treat them and I know that they have no insurance, I do my best to keep them off insulin. Because insulin is very expensive,” Riklon said.
Melisa Laelan knows that too well. Laelan, 38, is the director of the Arkansas Coalition of Marshallese, a group that advocates for the community. She is also a court translator, the first certified Marshallese court translator in the country.
A few years ago she was working at a baby wipes factory. Her mother, who was living with Laelan, had diabetes. She did not have insurance, and she didn’t qualify for Medicaid. She died of complications of diabetes.
“Her insulin was costing me $300 a month. … There were times that we had to go without those,” Laelan admitted.
Jirkai Tatak, 52, is also a diabetic. He works as a pressman, printing the local issue of the Democrat Gazette. To avoid the penalty the Affordable Care Act levies on people without health insurance, Tatak purchases the cheapest plan available to him. It covers little, he said.
Tatak cannot afford to buy insurance for his wife and their two children who live with them; the premiums would leave the family nothing to live on.
What does he do if he gets sick? “That’s the question,” Tatak replied. “That’s the question.”
It’s a question the Marshallese here have been asking for years, one echoed by local health service providers who struggle to cope with the community’s health needs.
Local lawmakers appear to have heard their concerns. In mid-March the state Legislature passed a resolution calling for the inclusion of Marshall Islands-born children in ARKids First, Arkansas’s Medicaid program for children under 19.
The state health department is drafting the rules change that will be submitted to the Centers for Medicaid and Medicare Services for approval. Backers of the resolution hope the change can be implemented by the end of the year, if not sooner.
Sandy Hainline Williams, a nurse coordinator for the Marshallese and Latino communities at a Springdale clinic, said getting the Marshallese children into ARKids is a good place to start. Trying to get the state to change its Medicaid and Medicare rules to allow low-income Marshallese adults to qualify is a tougher challenge.
“It’s been difficult to ask to put this population into our Medicaid program as adults because we don’t have a firm grasp on how many there are. So we’re asking for an unknown sum,” she said.
Some people estimate there are between 8,000 to 10,000 Marshallese in Springdale and the surrounding area. Others say the figure may be approaching 14,000. Whatever the actual number, the city has a good-sized chunk of the global Marshallese population, estimated to be around 85,000.
Outreach workers from the Arkansas Coalition of Marshallese have been signing up members of the community for the Affordable Care Act if they can. Not everyone can afford it.
The Marshallese could qualify for Medicaid or Medicare if they become US citizens, but the path to citizenship is difficult, if not impossible, for many.
The size and makeup of Marshallese families contribute to the dilemma. People tend to live in multigenerational households — a great-grandmother and grandmother might be living with two related families in the same dwelling. A Marshallese man with a job might be helping to support his sister’s children. But insurance policies don’t typically allow people to add on grandmothers or nieces and nephews. Even if they did, the costs would be out of reach for these families.
Some of the newcomers speak little English, and don’t understand how health care delivery works in the US. In the Marshall Islands, people who need care go to a clinic, where the consultation, tests, and medicines prescribed will typically cost about $5.
“They arrived here and they did what they know how to do. They went to the emergency rooms. You can’t hit an emergency room just to be triaged for under $280 anymore. So they were mounting up $1,000 bills for nothing and just got overwhelmed financially,” Hainline Williams said.
A number of Springdale’s hospitals have charitable programs. But the application process is complex, often requiring documentation that the Marshallese don’t have.
“If you hand them a packet of papers 30 to 70 pages long, they don’t get them completed. So a lot of them didn’t make applications,” Hainline Williams said.
Jebé River, 61, a slender woman who is looking after her 12-year-old grandson, finds the situation bewildering.
Through a translator, she explained that she tried to apply for the ACA, but missed the enrollment period.
“It’s a lot easier in the islands,” she acknowledged.
An earlier version of this story incorrectly described the steps that some states have taken to provide access to Medicare and Medicaid to Marshallese.