New report reveals communities denied insurance also have higher rates of health disparities

April 30, 2015

Estephanie Sos prepared to christen her 4-month old son Jepwete Chusauo during a service at the Chuuk Logos Community Church.

Kasil Kapriel is a single mother raising teenage boys on minimum wage.

For the past eight years Kapriel, armed with a high-school diploma, has pushed wheelchair-bound passengers through Portland International Airport.

Her work doesn’t come with the benefit of health insurance, so when she's sick she takes Tylenol and prays that she feels better soon.

“I am always stressed out, especially if I don’t go to work for two days,” she says. “Then it really scares me.”

She doesn’t see a doctor for routine check-ups or teeth cleanings. When a tooth began to hurt so badly she couldn’t work, Kapriel went to a Multnomah County dental clinic and had it pulled. 

She says she been lucky nothing has propelled her to an emergency room. She doesn’t know what she would do if faced with the bill.

Digging up the $25 to get a tooth pulled was enough of a struggle.

“My life is on the edge,” she says.

The Affordable Care Act with its expansion of Medicaid has made it possible for nearly all families living in poverty to get health insurance. But Kapriel can't qualify for coverage because she is from the from the Micronesian island of Chuuk.

Because of a 1996 federal welfare reform act, people who immigrated from three Pacific Island nations are excluded from many federally funded services -- including Medicaid.  Despite being legal residents with the right to work, they are barred from public assistance and even most federal loans for college.

That prohibition hits particularly hard in Oregon, where the Pacific Islander community is growing faster than any other group. And, where they are hard hit by poverty and poor health.

A new Health Department report "Health Disparities among Pacific Islanders in Multnomah County,'' released April 30 shows the devastating toll on working families who fall into that gap.

“The numbers represent lives - the lives of siblings, parents, co-workers, aunts, uncles, friends and neighbors to us all,’’ said Health Department Director Joanne Fuller. “And until now, they have been all but invisible.”

Joe Enlet, a community engagement coordinator at Health Share of Oregon doubles as the pastor of the Chuuk Logos Community Church

The Pacific Islander community in Oregon has been largely hidden by research that has historically lumped Pacific Islanders in with the broader “Asian” racial category.

The new “Health Disparities among Pacific Islanders in Multnomah County’’ is a supplement to the 2014 Report Card on Racial and Ethnic Disparities. The data shows Pacific Islanders living here are twice as likely as whites to reach adulthood without a college education and three times as likely to be unemployed. Pacific Islander children are more than twice as likely to live in poverty.

Women are more likely to become pregnant when they are still teens, much less likely to seek prenatal care and more likely to give birth to babies below a healthy weight.

“You try to explain there’s a problem and people ask, ‘where’s the data to back that?’” says Virginia Luka, co-chair of the Micronesian Islander Community of Oregon. Her group, along with the Asian Pacific American Network of Oregon, worked with Multnomah County Health Department to produce the report.

“The more you disaggregate the data the more you see the unique set of disparities that Pacific Islanders face,” said Rujuta Gaonkar, manager of the Health Equity Initiative at the Health Department. “We’ve been able to see where the disparities are masked.”

Concentrated on Portland’s less expensive east side  - and largely absent for the local political and social discourse - is one of nation’s largest diaspora of residents from Palau, the Federated States of Micronesia and the Marshall Islands.

Together, their homelands are often called the COFA nations. That’s because they hold agreements with United States called Compacts of Free Association.

Under the agreements, the United States military occupies land and surrounding waters of these island nations. In exchange, the U.S. government provides security, promises emergency relief funds, and pays restitution for health and environmental damages done during the decade following World War II. That’s when the military displaced communities in order to detonate the equivalent of 7,200 Hiroshima bombs in island waters.

The historic agreement between the COFA citizens and the United States allows COFA citizens to live, work and study here. Most Pacific Islanders who arrived never expected to need government assistance to get by. They came to Portland to work in canneries, lumber yards and airport concessions, in warehouses and on construction sites for a median hourly wage of $11.

They came to the United States because the infrastructure could offer better schools, better healthcare, better roads. They came to Portland because their families were here.

“It’s so easy to come, and the situation back home is so dire,” said Joe Enlet, president of the COFA Alliance National Network. “Our hospitals are where people go to die. On our islands, we run out of medicine and they say, ‘put a patch on it’ or ‘drink a lot of water.’”

In the United States, some adults are able to get health insurance through their employer. And children born in here become eligible for the Oregon Health Plan/Medicaid.

But thousands are left out of the health insurance system. Today more than 9,000 Pacific Islanders live in Multnomah County; about 40 percent of those residents identify as Micronesian. That includes Chuukese.

Enlet, a community health worker and reverend of a Chuukese-language church, often listens to families talk about working full-time without benefits, unable to afford health insurance or pay mounting bills.

People wait until they can’t anymore. Then they call 911 or visit the emergency room.

Senetonia Samor of Chuuk has lived in Oregon for a quarter century. Her mother is 67 and suffers from diabetes. 

“There's a lot of fear, especially for my mom,” she said. “We’ve taken her to the hospital three times and it’s very expensive. They have been sending bills. But I can't pay them.”

Because her mother lacks health insurance, Samor takes her to a Multnomah County Health clinic for doctor visits and prescriptions. As the community’s safety net, Multnomah County will treat anyone who needs care, regardless of whether they qualify for coverage or can afford to pay the bill.

Unlike a hospital or specialist, Multnomah County won’t try to recover unpaid bills by sending a person to collections.

“No one should be denied access to healthcare because they can’t afford the copay or prescriptions,” said Multnomah County Chair Deborah Kafoury. “That’s not the kind of place where I want to live. And it’s not the kind of government I want to lead.”

Many uninsured Pacific Islanders said they didn’t know they could go to a county clinic. And without more outreach and improved access to health care, the disparities will continue to rise.

That’s why APANO Executive Director Rev. Joseph Santos-Lyons and Policy Associate Kristina Narayan asked the Board of County Commissioners to invest in an audit to better identify gaps in access.

In response, the Multnomah County Health Department worked closely with the community to produce the report, the first of its kind specific to this community. The Health Department has also proposed in its 2016 budget a permanent position to promote health equity in partnership with the Pacific Islander community.

The county is also supporting a legislative effort to provide health insurance to all of Oregon’s COFA citizens.

One bill, HB 2934,  would require the Oregon Health Authority to draft a blueprint for a Basic Health Plan to cover lawful residents whose immigration status makes them ineligible for Medicaid, including some COFA citizens.

Another, HB 2522, would direct OHA to develop options that would provide all COFA citizens access to affordable healthcare. The bill sits in Ways and Means with a do-pass recommendation following an emotional appeal in the House Committee on Health Care.

“Please vote for this bill,” said community member Simon Simeon told legislators. “Many of our people are dying because they cannot see a doctor even though they are working hard and paying taxes.”

The legislation is also earning support from health advocacy groups, lawmakers and even the World War II veteran involved in nuclear testing in the Marshall Islands.

“You can debate the morality all day long but our government did a grievous harm. We destroyed their homeland and a lot of people have come down with cancer,” said Gary Smith, who testified on behalf of the legislation. “They pay taxes. They serve in our Armed Forces. They’re good citizens. Our government has an obligation these citizens.”

Brad Avakian, Commissioner of the Oregon Bureau of Labor and Industries, encouraged lawmakers to pass the bill.

“COFA citizens are legal residents of the U.S., pay U.S. taxes and were originally contemplated as Medicaid eligible,” he wrote in a letter of support. He denounced the 1996 Federal Personal Responsibility and Work Act that stripped COFA citizens of previous eligibility for Medicaid.

“They are hardworking, loyal, productive members of our community,” he wrote. “Oregon must act on the promise our federal government has failed to keep.”