Choi says she’s trying to be pragmatic as well as optimistic, which is why her group is setting a goal for 2021: Make the Senate bill a bipartisan effort, targeting GOP lawmakers like Alaska Sen. Lisa Murkowski and Utah Sen. Mitt Romney, who have reputations for compromise—and islander populations living in their states. One strategy is shifting how advocates talk about the COFA issue with Republicans, focusing less on the moral argument of restoring Medicaid and more on the national security implications of working well with the Marshallese. (The Marshall Islands remain a strategic launching point for U.S. military forces in the Pacific Ocean, a fact not lost on Chinese officials, who themselves are trying to woo the Marshallese.)
Paired with the surging enthusiasm in the House, just a few more Republican votes in the Senate could make the difference to restoring the islanders’ Medicaid.
But if Democrats win two seats in the Georgia Senate elections next month, allowing them to retake the chamber, Choi may not need to worry about shoring up GOP support. That’s partly because Hirono has spent years pestering Senate Minority Leader Chuck Schumer — with the Hawaii senator joking that she brings up the Medicaid issue so often with Schumer, the top Democrat has learned to greet her by saying, “I know, I know—the COFA migrants.”
Schumer himself vows: He’s on board.
“I fully support Sens. Hirono and Schatz in their push to finally restore Medicaid coverage to COFA migrants,” Schumer told POLITICO. “I have continually and closely worked with them to advance this issue, and will not rest until it is signed into law.”
And the Marshallese should have an ally in the White House next year. As a presidential candidate this year, Joe Biden promised to restore the islanders’ access to Medicaid, with his campaign saying that Biden’s health plan to boost availability of coverage would encompass the COFA migrants, too.
Meanwhile, the advocates have a wish list of other goals to help the islanders during the pandemic, like winning more support for language services to help the Marshallese navigate an often confusing health system.
“I’m just begging for our political leaders to have the political will to allocate resources—even translated materials—as our country is bracing for the next bad wave of Covid this winter,” Choi says. “But the fact that we have political leaders willing to advocate to restore Medicaid, that’s a really good thing.”
Big bills, few answers
But the uncertain future of Washington legislation doesn’t help islanders in the Iowa heartland like Nathan, who when we first spoke this winter, was facing nearly $120,000 in coronavirus-related bills for his late wife’s care and increasingly urgent warnings that payments were due in just days—even though there’s no conceivable way he could pay.
Money is very tight, Nathan says through an interpreter. After he lost his job as a part-time hotel employee in April, and the death of his wife just days later, he had to move in with one of his sons, who counts chips at a local casino in Dubuque, and has struggled to find steady work since. The hotel where he and his wife worked until the pandemic has given him “nothing,” he added, although the manager did provide some food after the burial of Nathan’s wife.
“I’ve gotten nothing to help out with anything,” Nathan reiterates, asking me why the bills are still coming and what he should do about them.
It wasn’t supposed to be this way. President Donald Trump and his aides spent the year bragging about protecting the uninsured like Nathan and his wife from Covid-19 costs. Under the CARES Act, a coronavirus rescue package that passed in March, $175 billion was set aside for what’s known as the Provider Relief Fund. Health care providers were subsequently invited to apply to cover the costs of providing care for uninsured Covid-19 patients.
“When the COVID-19 pandemic hit, my Administration implemented a program to provide any individual without health-insurance coverage access to necessary COVID‑19‑related testing and treatment,” Trump wrote in an executive order in October.
And here in Dubuque, the mounting bills facing the Marshallese caught the attention of local health workers, including Mark Janes, a pulmonologist who started a GoFundMe campaign in May.
“We have a population of Marshallese here who have become ill with SARS-COV-2,” Janes wrote, touting the fundraiser. “They have no insurance. We are a small community and they will need help.”
Within a week, more than 400 donors had poured in more than $25,000. Janes quickly handed off the funds to the Dubuque Foundation, a local nonprofit that could better handle donations for tax purposes.
But when I reached Nancy Van Milligen, head of the Dubuque Foundation, in December, she shared a surprising admission: The money raised for the Marshallese fund has been largely untapped.
“It’s been kind of hard to give this fund away,” Van Milligen said. “If anyone has a bill, they’re supposed to contact us and we’re supposed to take care of it … but we haven’t heard anything recently.”
But she also insists that the Marshallese shouldn’t be getting billed at all, citing the CARES Act provision that created a fund for providers to get compensated.
“All of the health care has been free, even to the Marshallese,” Van Milligen said. “The hospitals are supposed to be covering people for this care.”
I press her on this, citing the case of Nathan and other local Marshallese who have spoken with me about the big bills facing their community. Van Milligan says she’ll look into it, and later sends me a note saying that her hospital contacts reassured her that the islanders’ care is covered.
“If a Marshallese patient is not insured, the hospital was/is able to get reimbursed by the Cares Act,” she tells me in an email.
So why is Nathan getting billed for his dead wife’s care? Most likely: human error. In many cases, hospitals and doctors haven’t done the work to submit claims for their uninsured patients, analysts say. Or the patient was diagnosed with something other than Covid-19 as a primary diagnosis, like kidney failure, making it impossible for the provider to claim any funds from the coronavirus relief package.
By far the biggest bill Nathan has received—nearly $93,000, covering his wife’s nine-day hospital stay—comes from Finley Hospital, a facility in Dubuque run by the UnityPoint health system. Identifying myself as a reporter, I repeatedly called UnityPoint to ask about the case of Nathan’s wife; finally, a clerk tells me that the bill will be submitted for review, with a determination coming no earlier than mid-January.
Meanwhile, Nathan’s gotten a $12,000 bill from Tri-State Dialysis, which happens to be a subsidiary of Grand River Medical Group, which separately billed Nathan’s wife $14,135. After several days of email and phone calls, a billing manager at Grand River Medical Group tells me that the $26,000-plus in total charges for Nathan’s wife will be covered by the CARES Act and that he doesn’t have to worry about the bills anymore.
It’s a vivid reminder of the roadblocks that face someone like Nathan, who doesn’t speak English, and other patients who may not know what to do. For instance, the federal Health and Human Services Department has posted a public data file of all the providers that have applied for funds to cover the Covid-19-related costs of their uninsured patients. The file lists more than 27,700 individual rows, with claims filed by hospitals and medical groups all over the nation; Finley Hospital shows up twice, claiming a total of $57,428. But Grand River Medical Group isn’t on there at all, suggesting that it hasn’t previously applied to get compensation for its uninsured patients.
That’s why it’s a misnomer to say that all Covid-19 costs are being covered for the uninsured, says Karyn Schwartz, an analyst at Kaiser Family Foundation who has studied why patients like Nathan’s wife keep getting billed.
“What HHS did is say we’ll use this $175 billion fund, and we’ll take some of the money to reimburse providers,” Schwartz adds. “But it’s not the same thing as health insurance, and it didn’t include the protections you’d need for it to be comprehensive.”
As a result, uninsured patients like Nathan’s wife can still end up facing large bills—regardless of what the president proclaims or Van Milligen believed.
“This fund wasn’t meant to be comprehensive,” an official at the Department of Health and Human Services who worked on it tells me. “As much as I’d like to solve the uninsured problem, this fund isn’t the answer.”
After Covid-19 ravaged their community in the spring, the Marshallese of Dubuque told me they tried to dutifully observe CDC guidelines, from better social distancing to vigilance around wearing masks. That’s borne out in the numbers; while the virus’ impact on the Marshallese is still outsize, their share of Covid hospitalizations and deaths has fallen as the virus has surged in Iowa this fall and winter.
“They’ve become really diligent about Covid-19,” says Stroud, the social worker who works with the Marshallese. “They know better than anyone how dangerous coronavirus can be.”
But try as they might, the islanders can’t escape the virus. As I was writing this story, one more member of the Marshallese community of Dubuque passed away—a 41-year-old that I’ll call J., who suddenly died in November. Multiple friends of J. told me his death was due to Covid-19. (Through a friend, J.’s family declined comment.)
J. let me shadow him last year, as I followed his pricey health care treatment and Crescent staff’s attempt to stabilize his vitals and get him health coverage. Suffering from kidney failure, with a wide smile that didn’t suffer despite his lack of teeth, he’d become somewhat of a project for the team; his English was spotty, but his enthusiasm didn’t need any translation. Later I realized that we’d likely crossed paths without knowing it—the chic restaurant near my hotel, where I had dinner at the bar several nights in a row last year, was also where J. worked as a dishwasher in the back.
Rickertsen says she can’t comment on specific patients, citing medical confidentiality. But as she describes one loss that stuck with her, I realize she’s describing J.—all the ways that Crescent staff tried to help him, until he was struck down in the fall wave of Covid-19 that swept through Iowa.
“For me, that was probably the hardest time,” Rickertsen said. “After that happened, I literally laid in bed all weekend. I was like, [to my husband], I can’t even get out. I can’t deal with this.”
The scars linger for the Marshallese too, who say they’ve been stigmatized ever since the wave of coronavirus swept over their community this spring—and the local news coverage that resulted.