Going Off-Island: Marshallese Seeking a Better Life (and Better Healthcare) in a Place Not So Remote

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In January, National Public Radio, in partnership with Kaiser Health News, aired a story on the access issues that Marshallese immigrants face in obtaining health care while living and working on the U.S. mainland. While most immigrants to the U.S. are eligible for Medicaid eligibility after a five year waiting period, those citizens of the Compact of Association States are not.

Located approximately halfway between Hawaii and Australia, the Marshall Islands are a remote set of 29 atolls consisting of approximately 1,000 islets and roughly 54,000 human inhabitants. Today there are only three tertiary level health care facilities in the country (two in the capital city of Majuro and one on the island of Ebeye). Due to the low number of medical personnel, sub-standard hospitalization care, and poor rural medical infrastructure, the quality and quantity of health care that is currently available to the Marshallese is of significant concern. Due to low per capital income levels (estimated at just around US$2,500 per year), a high unemployment rate of 30%, and increasingly higher costs of living, most Marshallese Islanders can ill afford costly medical attention.

While an independent country for the last 14 years, the relationship between the Marshall Islands and America is one of mutual benefit. In exchange for the current American military presence on the Kwajalein Atoll and its surrounding waters, the recently renewed Amended Compact of Association, allows Marshallese citizens to travel to and work in the United States without undergoing the standard lengthy immigration process. In 2008, three percent, or some 1600 citizens, of the Marshall Islands left behind their beloved white sand beaches to travel across thousands of miles to America hoping to find access to better paying jobs, higher education, and health services. To escape the cyclical poverty, the Marshallese, like many of America’s new and historic immigrants, come to the mainland United States to seek a better life. Yet when they arrive in the U.S. and choose to settle (primarily choosing the states of Arkansas, Hawaii, California, and Oregon) what awaits is sometimes a surprise. Yet while the Marshallese are allowed to work and live in the United States, there are denied Medicaid eligibility.

The current version of the House reform bill, HR. 3960: Affordable Health Care for America Act, aims to equalize some of this inequality. On page 1082 in section 1736, a seemingly small, but nonetheless important amendment to the 1996 Personal Responsibility and Work Opportunity Reconciliation Act grants Medicaid eligibility for the citizens of the Freely Associated States of the Republic of the Marshall Islands, the Republic of Palau, and the Federated States of Micronesia. This would be a God-send for the thousands of Marshallese immigrants currently residing in the United States, most of whom while working full time, are unable to afford preventive and chronic medical care insurance and/or other health related costs. Whether or not this provision will make it into the final health care reform package is a matter that only time will tell. As for now, there is no mention of the provision or the Marshallese in the Senate’s version of the health reform bill.

Department of Defense: More than Defense, Healthcare in the Pacific

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The Compact of Free Association of the United States, amended in 2004, includes a provision that the Department of Defense’s medical facilities be made available to those patients from the RMI, the ROP, Guam, the Northern Mariana Islands, and American Samoa who are referred by local medical services. This program, which was initially funded in 1989 by Congress, first started serving patients in 1992 and has been very successful in helping rural and very remote patients obtain high quality U.S. specialist care. While it is common knowledge that the United States utilizes bases for training and strategic gains throughout the Pacific Islands, few Americans probably realize the role of the DoD in providing humanitarian assistance to islanders who live in U.S. Associated Pacific Islands (USAPIs). Under the auspices of the Pacific Islands Health Care Project (PIHCP), Tripler Army Medical Center in Honolulu, Hawaii is one of the DoD’s medical facilities which serves USAIP patients. Through the PHICP, from 1992 to 2007, some 3,664 referred USAIP-patients were seen at Tripler.

With the USAPIs limited infrastructure, poor sanitation levels, and increasing costs of health supplies and medication for many of these patients, medical evacuation was and continues to be a blessing. Yet while incredibly important to a limited number of patients, this type of medical evacuation program is a very resource intensive endeavor. To date many concerned health professionals and governmental representatives have called for innovative ways that both improve patient outcomes while reducing the overall health care costs that associated with providing off-island health care. In 2008, His Excellency Manny Mori, the President of the Federated States of Micronesia (FSM), explained that the costs of medivacing patients to the United States did not align with the future health priorities of the FSM. “While we are grateful for the assistance extended to us over the years, it is our interest that we combine our efforts to combat these challenges and concentrate on the root causes, rather than applying Band-Aids to the symptoms.” President Mori continued by noting that infrastructure investment and development was key for his country to obtaining better health outcomes overall.

Until medical professional capacity is scaled up to the suitable levels, some Islanders will continue to use PIHCP, while others will be seen, if not physically touched by DoD medical physicians and specialists. In part because the costs involved with patient transport to Hawai’i from USAPIs were and continue to be so high, a web-based telemedicine “store-and-forward” program was established in 1998. At the start of the project four sites in the USAPIs were given a digital camera, flatbed scanner, color printer, and various tele-diagnositic equipment. Today, the DoD now coordinates a host of Specific-specific telehealth projects that are aimed at effectively and economically diagnosis and/or referring patients in need and thus limiting patient travel (and undue travel associated stress) while providing health care access to significantly more patients. Some such programs include: Pacific Asynchronous Telehealth, Tele-Auscultation Heartsounds, Tele-Education Asynchronous Local/Overseas Hospital Academic System (ALOHA), Pediatric Diabetes Education Portal, and Telehealth Voice Therapy in Remote Regions of the Pacific Basin, and ICU Multi-Point Military Pacific Consultation Using Telehealth (IMMPACT) to name a few.

Stepping off the U.S. Mainland for a Post (or More)

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When most of us think of rural and remote areas of the United States, images of bucolic rolling hills, wide open plains, and farm houses typically fill our minds. Yet rural existence has quite a different meaning for those living on the remote Pacific islands of American Samoa, Guam, the Northern Mariana Islands, the Republic of Palau, the Federated States of Micronesia, and the Republic of the Marshall Islands. These islands, with their varying degrees of American association, present numerous challenges for the provision of rural and remote health care. During the next few weeks, this blog will look at the rural and remote health care needs, actors, and policies that affect the residents of these “American” islands.

Rural Pharmacists Needed (Part Two of a Two Part Series)

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The average American needs to fill a prescription of one type or another on a regular basis. Yet how far do they travel to get their prescriptions filled? Is it two miles, five miles, or ten miles away? It’s unlikely that it was much more than ten miles if they live in an urban or suburban setting. Yet for many rural Americans, the necessity of traveling increasing longer distances for prescription refills is becoming more and more common.

Have you ever asked your pharmacist why he or she choose to live in your community? Or, rather, thanked them for working so close to where you work and live? If you live in a metro area of America you probably answered no to both. Yet some states in rural America are starting to say thank you to their pharmacists in a very large way. To combat a shortage of rural pharmacists, the state of Minnesota for example, has launched the Minnesota Rural Pharmacist Loan Forgiveness Program. A subset of the state’s larger loan forgiveness program for health care workers, this program aims to attract and retain pharmacists to rural areas of the state where residents are making do with only a limited number of community pharmacists. Qualified participants receive $16,000 of loan forgiveness for each year that they work in one of Minnesota’s designated rural areas (for a minimum of three years, with a maximum of $64,000 in total loan forgiveness). With the average pharmacy student graduating with approximately $100,000 in loans, this type of forgiveness program could be exactly the ‘thank you’ that helps to re-staff rural areas.

Yet however enticing they are on paper, loan forgiveness programs are unlikely to entirely sway students who have had little or no previous rural experience. In an effort to give pharmacy students a better understanding of what they can expect in such a setting many schools in primarily rural states are pursing different avenues for increasing rural pharmaceutical exposure for their students. One example of such a program is the University of Idaho’s College of Pharmacy’s Rural Ambulatory Primary Care Pharmacy Residency program. This one year, postgraduate training program exposes pharmacy students to a range of rural practice environments including clinics and pharmacies across rural Idaho. The primary goal of these rural experience programs are to help fill state pharmaceutical gaps by helping students to make informed professional decisions about the advantages of working in rural settings.

It’s clear that access to prescriptions is not enough. To help avoid common medical errors and adverse drug interactions, a pharmacists’ advice should be incorporated into a patient’s care whether they choose to live in the ‘big city’ or a remote community. To this end, it is critically important that national health reform be passed with substantial financial incentives for rural pharmacists and increased funding for rural pharmacy residency programs.

Rural Pharmacies Needed - No Walls Required (Part One of a Two Part Series)

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Pharmacies and the pharmacists that staff them play a critically important role in caring for millions of Americans each year. Yet with profit margins falling and diminishing incentives for rural pharmacists, pharmacies are being forced to shut their doors. As pharmacists leave or choose not to serve in rural and remote communities, patients in need of critical pharmaceutical assistance are being left making potentially life-altering decisions without medical oversight.

Across America it is generally recognized fact that rural communities are more likely to have higher rates of older residents. Overall, this demographic has more chronic illnesses which require one or more prescription drug treatments. As in any population, as the number of drug regimens increase, there is a higher risk that potentially harmful drug interactions could occur. For most urban or suburban Americans under the care of a physician and with prescription health insurance, this element of risk is reduced by the presence of a local pharmacist who is familiar with a patient’s medication profile and can caution patients away from potentially fatal interactions.

While critically important to thousands of communities around the country, rural pharmacies are being forced to shut their doors due to low Medicare/Medicaid reimbursement rates (which tend to produce low profit margins) and more professional and personal opportunities for pharmacists in urban areas. As rural pharmacies shut down or relocate to higher populated areas, rural residents are being left in the lurch because of the intrinsically important role that pharmacists play as one of the only sources of medical advice and care in a community.

Some would argue that the arrival of the internet and mail-order pharmacies are the perfect solution for those who are unable to find transportation to pharmacies which are increasingly further afield. Yet with the uptake of mail-order prescriptions has come the concern that quality care (including detection of medical errors, management of interactions, and provision of preventive education) is being diminished by the lack of pharmaceutical oversight of individual patient regiments.

A Solution to the Dilemma? A New Wall-less Pharmaceutical Model

To counteract the ill effects of the loss of pharmacies, the PharmAssist program was launched in Montana in 2006. Based on a successful, but now budget-defunct program in Wyoming, Montana’s PharmAssist program sends pharmacists out to areas across the state for rural patient consultations. Through PharmAssist, Montana’s patients have access to the advise of a community pharmacist who can assist them with finding ways to manage prescription cost, drug interactions, and prescription side effects. Furthermore in an effort to improve patient-pharmacist-physician communication, after a PharmAssist consultation, pharmacists send a letter detailing recommendations to a patient’s prescribing physician. Regardless of age or income status, these consultations are made free of charge to patients by a revenue funding stream from state garnered tobacco taxes. The currently 27 participating PharmAssist pharmacists are specially trained to handle the unique to the road responsibilities through a certification program at the University of Montana at Missoula. (To learn more about this program, please click here).

Needless to say there are many issues that plague rural pharmacy, yet innovative models are being tested to improve existing systems. In part two of Rural Pharmacies Needed - No Walls Required, issues surrounding pharmaceutical workforce recruitment, training, and retention will be addressed.