The prairie town of Enid, Okla. — population 50,122 — is best known as the state’s “wheat capital.” Enid is also home to a community of around 2,000 people who were born in the Marshall Islands. Most are low-income and struggling to get health care.

After WWII and until the 1980s, their homeland in the South Pacific was a U.S.-administered territory, and for a part of that time, Americans used some islands in the region as a bombing range for testing nuclear weapons. Partly because of that history, a treaty now allows Marshallese to live and work in the U.S, as “indefinite legal residents.”

But in Oklahoma, as noncitizens, the Marshallese aren’t eligible for many state and federal health services. And that’s a big problem says 42-year-old Terry Mote, who was born on the islands, but moved to Enid in 2007.

“I just want my family to be treated like the rest of those who are eligible for Medicaid, says Mote, who works as a Micronesian health adviser at the Garfield County Health Department, and lives in Enid with his wife, Lynn, and their five kids. His mom, Mojina, lives with them, too.

“Why the government came to our island to do [testing of] 67 bombs,” Mote says, “and then they are just going to let us die over this?”

Between 1946 and 1958, after relocating whole villages to other islands to clear the way for weapons testing, the U.S. detonated 67 nuclear weapons at sites across the Marshall Islands and other territories.

Enid resident Daina Joseia is in her 60s. She has a childhood memory of what she later was told was the test of the Castle Bravo thermonuclear device on March 1, 1954 — the biggest and most destructive nuclear bomb detonated — 1,000 times as powerful as the bomb dropped on Hiroshima.

“It’s like a real bright color, like a fire,” Joseia says through a translator.

Clouds of radioactive, pulverized coral dust drifted across the islands, coating homes and people. Joseia says that, in the aftermath of the test, she remembers seeing people whose bodies were covered in burns, and others with their hair falling out.

In the following years, some people from the affected islands developed thyroid problems and cancer. Babies were born deformed.

Joseia sees a direct connection between her diabetes and the nuclear tests — not because there’s a link between nuclear radiation and diabetes, but because the bombs contaminated the Marshall Islanders’ traditional foods, like coconuts, fish and breadfruit. When their traditional diet too dangerous to eat, she explains, the Marshallese started to consume processed, imported foods — like spam and white rice.

Terry Mote is too young to remember the bombs being tested. He does, however, remember what they ate in the decades afterward.

“We begin to be [thinking] eating canned meat is a good thing,” Mote says. “But then, at the end of the day, it’s not good.”

Today the Marshallese have among the highest rates of diabetes in the world.

Like Joseia, Mote’s mother Mojina has diabetes, too. And like Joseia, she’s uninsured. For Mote and his family, this became a huge problem when his mother had to go into the hospital for treatment and ended up needing to stay there for months.

“We had little knowledge on, you know, when you stay in the hospital for certain days — the bill is running,” says Mote. “So by the time she got out from the hospital, I was so surprised.”

The bill for treating the complications of her diabetes was $50,000, Mote says, and he could only pay part of it. It was only when he tried to enroll his mom in Medicaid or Medicare, that he found out Marshallese don’t qualify for these programs.

The special relationship between the U.S. and the Marshall Islands — now the sovereign Republic of the Marshall Islands — is complicated, to say the least.

In 1983 the Marshall Islands, the Federated States of Micronesia and Palau signed the Compact of Free Association with the U.S., which allowed people from these island nations to settle in the U.S. with limited legal status.

This means that while a path to citizenship is available to them, those who resettled in the U.S. under the treaty were not automatically made citizens. Instead, they were classified as “nonimmigrants.” At the time the Marshallese and other COFA communities in the U.S. were eligible for federal health programs.

But that changed in 1996, when Congress passed the Personal Responsibility and Work Opportunity Act. This major piece of welfare legislation effectively reworked the eligibility of people who came to the U.S. under the COFA agreement, stripping Marshall Islanders and other similar communities of their federal health benefits.

After the 1996 legislation was passed, some states, including California and Oregon, used state funds to continue to provide health care services to COFA migrants, according to the Asian and Pacific Islander American Health Forum.

The state of Oklahoma did not choose to do so, which means even longtime legal residents of the state are not eligible for Medicaid and Medicare in Oklahoma if they happen to be Marshallese.

“People turned to me and ask for help,” Mote says. “And they said, ‘Hey, can the church help me pay my bills?’ So I’m like, ‘Hey, you know what? There’s a lot of problem here.’ “

Mote spends much of his time these days thinking about health problems in his community. He’s reached out to lawmakers for help, but his attempts to get state legislation introduced that would get health coverage for Oklahoma’s Marshallese community have so far failed.

It’s a hard sell, he says, because Marshallese can’t vote. And the path to citizenship, he says, is tough for a myriad of reasons.

Mote says most Marshallese in his community find the citizenship application process intimidating — and unaffordable. There’s the language barrier, he says, and, maybe because the community is close-knit, there tends to be little sense of urgency to assimilate.

Plus, Mote says, most Marshallese believe it’s taboo to talk about being sick.

“I feel frustrated,” he says. “Because these people need to be healthy — need to be treated like human beings.”

He is not giving up.

Mote says he is now applying for citizenship — because he wants to run for City Council and help give Marshallese in Enid a voice.

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The partial government shutdown that started Saturday will affect quite a few activities of the Food and Drug Administration.

Although most of the agency’s employees weren’t working over the weekend and on Monday and Tuesday because of federal holidays, FDA will furlough some 40 percent of its staff starting Wednesday.

However, much of the agency’s workforce will continue through the shutdown, with more than 10,000 FDA employees — nearly 60 percent — reporting to work, according to numbers released by the agency Friday.

The majority of those people are doing work funded by user fees paid by pharmaceutical and medical device companies, according to an analysis by the Alliance for a Stronger FDA, an advocacy group representing patient and consumer advocates as well as trade associations.

Here is a quick breakdown of how the shutdown will affect the agency’s work.

Activities that will continue during the shutdown

The FDA will continue work that’s critical to public health and safety. It will be able to respond to emergencies, like the flu and foodborne illnesses. It will continue recalls of any foods, drugs and medical devices that pose a high risk to human health.

As FDA Commissioner Scott Gottlieb tweeted over the weekend, the agency will also continue to screen “food and drug imports” and inspect any facilities that might pose “an imminent threat to health and life.”

Some criminal and civil investigations where there is an immediate risk to public health will also continue through the shutdown, as will all of the agency’s work that is funded by user fees.

For example, the agency will continue to oversee the manufacturing and distribution of all tobacco products. “The tobacco program is 100 percent user-fee funded,” says Steven Grossman, deputy executive director at the Alliance for a Stronger FDA.

Similarly, much of the agency’s work with new products is funded by fees paid by industry, so the FDA will continue reviewing and approving drugs and medical devices where the fees have already been paid. It will also continue to review requests for clinical research and issue any necessary guidance.

Activities that will stop during the shutdown

Broadly speaking, all activities that are less likely to have an immediate impact on health and safety of consumers will come to a halt. For example, routine regulatory and compliance work for medical products, animal drugs and most foods will be paused, according to a contingency staffing plan put forward by the Department of Health and Human Services.

Routine inspections of facilities and all work related to cosmetics and nutrition will also be paused during this period.

And the shutdown may affect some aspects of the drug review process as an estimated 30 percent of that work is funded by appropriations, according to the analysis by the Alliance for a Stronger FDA.

Should consumers be concerned about food and drug safety during the shutdown?

Probably not, at least not for now, says Grossman. “In the short term, consumers should not see much of an impact,” he says. That’s because “anything that could affect human health and safety [in the near term] will be staffed.”

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Rural hospitals close when they don’t have enough paying patients to care for, but they’re also dinged when the same patients show up over and over again. That puts outlying medical facilities in the precarious position of needing to avoid repeat customers.

Charlotte Potts is the type of patient some hospitals try to avoid. She lives in Livingston, Tenn. — a town of 4,000, tucked between rolling hills of the Cumberland Plateau.

“I’ve only had five heart attacks,” Potts says with a laugh. “I’ve had carotid artery surgery. Shall we go on? Just a few minor things.” She jokes that she’s “a walking stent.”

The heart trouble has affected the way Potts deals with her health problems. She spends much of her day in a recliner in her apartment, tethered to a pulsing oxygen machine, and listening to the radio.

Fortunately, her apartment sits within spitting distance of Livingston Regional Hospital — a 114-bed facility large enough to have a dedicated cardiac unit. But the hospital doesn’t want to see her every time her heart flutters.

So last time she landed in the ER, they helped her connect with a few companies that could provide care at home.

“If I’m going to have certain things going on here in my chest, I call for help, and they’re there,” Potts says of the home care team she chose.

A new era in hospital management

There were days when the hospital might have viewed a home health agency as a competitor. Not anymore.

“When I started this almost 40 years ago, the mission was different,” says Tim McGill, CEO of Livingston Regional. “We wanted patients in the hospital. That was the incentive. We were paid for it. Now you’re not.”

Hospitals used to run on a so-called fee-for-service model with virtually no limit to how many times they could see a patient. But, under pressure from private and government insurance programs, that model is transitioning to one in which hospitals are rewarded for safety and efficiency — which often results in a patient spending less time in the hospital.

Under the Affordable Care Act, Medicare began to ding hospitals if too many patients are readmitted to any hospital within 30 days of discharge. The measure is broadly unpopular with the hospital industry, since so much falls outside a hospital’s control. Medicare has even walked back the rules for safety-net facilities, which tend to treat a sicker population.

The penalty is meant to encourage hospitals to get it right the first time. In Livingston, the hospital operates on the thinnest of margins — just 0.2 percent in the most recent figures. And “readmissions” have been a drag on the bottom line.

One in five patients with heart failure was back within the month. The hospital has paid the maximum penalty in some years — nearly $200,000. So leaders started asking a basic, unifying question of other providers in town, McGill says: “What can we do together so they’ll stay out of the hospital and stay healthier in their home setting? That’s where the work is.”

Collaborating instead of competing

The work took the form of quarterly lunch meetings at the local library.

Mary Ann Stockton, a nurse at the hospital, invites all the home health agencies as well as hospice providers and the leaders of nursing homes.

At one meeting, she applauds the other providers for increasingly meeting patients inside the hospital before they’re discharged. She says it helps patients and families accept these home health workers.

“We know in our area, people don’t like to have a total stranger come into their home,” she says.

The group brainstorms how to generate the same kind of acceptance for hospice care, which — as one doctor in the meeting puts it — some families view as assisted suicide.

And on this day, the groups spends much of its time reviewing the value of flu shots, especially for the staff in nursing homes. Stockton says elderly patients with bad lungs become a hospital emergency room’s “frequent fliers.”

“Flu starts off, goes into pneumonia, COPD exacerbation — and they are a revolving door in our hospital,” Stockton says. “They’re hitting that ER a couple of times a week.”

Advance directives are on the agenda for next time — another way to keep people near the end of life from becoming ER regulars.

Livingston’s parent company, LifePoint Health, is launching this community approach in many of its 80-or-so markets, which are primarily in the Southeast and almost all rural. LifePoint vice president Cindy Chamness helps hospitals find willing partners.

“We were very frustrated for many years,” Chamness says, “because we weren’t able to impact readmissions just working on it by ourselves, as a hospital.”

“Are we saving ourselves right out of business?”

The solution looks different from one town to another. In Lake Havasu, Ariz., paramedics now visit discharged patients to make sure they’re following doctors’ orders. The house calls also cut down on government-funded ambulance rides.

It’s not just rural hospitals — all hospitals can be penalized for readmissions now. And threatening the bottom line in that way does seem to be effective. Readmissions have been falling across the board, according to the latest research.

But rural hospitals, which already treat fewer patients than urban hospitals, wonder if they’ll have enough patients to survive, says Michael Topchik of the Chartis Center for Rural Health.

“[A] CEO from Montana said to me, ‘The problem is, when we do the right thing, are we saving ourselves right out of business?’ ” says Michael Topchik of the Chartis Center for Rural Health.

The focus on cutting readmissions — by definition — cuts overall admissions too, he notes.

“So, this is the real inherent tension and challenge: Hospitals get reimbursed for doing ‘sick care,’ ” Topchik says. “But more and more they’re being asked to do population health, and really focus on ‘wellness.’ “

To make up the volume, the Livingston hospital is expanding its maternity ward and general surgery offerings.

There is also some immediate financial upside to reducing readmissions: Livingston Regional has cut readmissions more than any other rural hospital in Tennessee and even the nation, according to data compiled by Chartis.

As a result, the hospital’s Medicare penalty in the coming year will be reduced to 0.3 percent of its reimbursements — down from the maximum of 3 percent, which was roughly $200,000 a year.

That’s all because patients like Charlotte Potts now can safely stay home.

“I got a real bad tightness in the chest,” Potts recalls about a recent episode. She’d questioned whether to call an ambulance. “I was very uncertain about what was going on.”

But she phoned her home health agency, took a nitroglycerin pill as the agency advised, and instead of going to the ER, was able to get back to sleep.

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Sure, they’re less expensive for consumers, but short-term health policies have another side: They’re highly profitable for insurers and offer hefty sales commissions for brokers.

Driven by rising premiums for Affordable Care Act plans, interest in short-term insurance is growing, boosted by Trump administration actions to ease Obama-era restrictions and possibly make federal subsidies available to consumers to purchase them.

Short-term plans can be far less expensive than ACA plans because they set annual or lifetime payment limits. Most of these plans exclude people with pre-existing medical conditions, don’t cover prescription drugs and exclude in fine print some conditions or treatments. Injuries sustained in school sports, for example, often are not covered.

These plans can be purchased at any time throughout the year, which is different than plans sold through the federal marketplaces. The open enrollment period for those ACA plans in most states ended Dec. 15.

The rising demand for short-term plans is boon for insurance brokers, who often see commissions on such policies hit 20 percent or more.

On a policy costing $200 a month, for example, that would translate to a $40 payment each month. By contrast, ACA plan commissions are often flat dollar amounts rather than a percentage of premium and can range from zero to $20 per enrollee per month.

“Customers are paying less, and I’m making more,” said Cindy Holtzman, a broker in Woodstock, Ga., who said she gets 20 percent on short-term plan sales.

Large online brokers also are eagerly eyeing the market.

Ehealth, one such firm, will “continue to shift our focus to selling short-term plans and non-ACA insurance packages,” CEO Scott Flanders told investors in October. The firm saw an 18 percent annual jump in enrollment in short-term plans this year, he added.

Insurers, too, see strong profits from plans because they generally pay out very little toward medical care when compared with the more comprehensive ACA plans.

Still, some agents like Holtzman have mixed feelings about selling the plans, because they offer skimpier coverage than ACA insurance. One 58-year-old client of Holtzman’s wanted one, but he had health problems. She also learned his income qualified him for an ACA subsidy, which currently cannot be used to purchase short-term coverage.

“There’s no way I would have considered a short-term plan for him,” she said. “I found him an ACA plan for $360 a month with a reduced deductible.” (A federal district court judge in Texas issued a ruling Dec. 14 striking down the ACA, which would among other things affect the requirements of ACA coverage and subsidies. The decision is expected to face appeal.)

Consequently, short-term insurers don’t have to pay as many medical bills, so they have more money left over for profits. In forms filed with state regulators, Independence American Insurance Co. in Ohio shows it expects 60 percent of its premium revenue to be spent on its enrollees’ medical care. The remaining 40 percent can go to profits, executive salaries, marketing and commissions.

A 2016 report from the National Association of Insurance Commissioners showed that, on average, short-term plans paid out about 67 percent of their earnings on medical care.

That compares with ACA plans, which are required under the law to spend at least 80 percent of premium revenue on medical claims.

Short-term plans have long been sold mainly as a stopgap measure for people between jobs or school coverage. While exact figures are not available, brokers say interest dropped when the ACA took effect in 2014 because many people got subsidies to buy ACA plans and having a short-term plan did not exempt consumers from the law’s penalty for not carrying insurance.

But this year it ticked up again after Congress eliminated the penalty for 2019 coverage. At the same time, the premiums for ACA plans rose on average more than 30 percent.

“If I don’t want someone to walk out of the office with nothing at all because of cost, that’s when I will bring up short-term plans,” said Kelly Rector, president of Denny & Associates, an insurance sales brokerage in O’Fallon, a suburb of St. Louis. “But I don’t love the plans because of the risk.”

The Obama administration limited short-term plans to 90-day increments to reduce the number of younger or healthier people who would leave the ACA market. That rule, the Trump administration complained, forced people to reapply every few months and risk rejection by insurers if their health had declined.

This summer, the administration finalized new rules allowing insurers to offer short-term plans for up to 12 months — and gave them the option to allow renewals for up to three years. States can be more restrictive or even bar such plans altogether.

Administration officials estimate short-term plans could be half the cost of the more comprehensive ACA insurance and draw 600,000 people to enroll in 2019, with 100,000 to 200,000 of those dropping ACA coverage to do so.

And recent guidance to states says they could seek permission to allow federal subsidies to be used for short-term plans. Currently, those subsidies apply only to ACA-compliant plans.

Granting subsidies for short-term plans “would mean tax dollars are not only subsidizing commissions, but also executive salaries and marketing budgets,” said Sabrina Corlette of Georgetown University Center on Health Insurance Reforms.

No state has yet applied to do that.

For now, brokers are focusing on getting their clients into some kind of coverage for next year. Commissions on both ACA and short-term plans are getting their attention.

After several years of declining commissions for ACA plans — with some carriers cutting them altogether a couple of years ago — brokers say they are seeing a bit of a rebound.

Among Colorado ACA insurers monthly commissions have ” gone from about $14 to $16 per enrollee to $16 to $18,” said Louise Norris, a health policy writer and co-owner of an insurance brokerage.

Rector, in Missouri, said an insurer that last year paid no commissions has reinstated them for 2019 coverage. For her, that doesn’t really matter, she said, because once carriers started reducing or eliminating commissions, she began charging clients a flat rate to enroll.

Norris noted that some states changed their laws so brokers could do just that.

At least one state, Connecticut, ruled that insurers had to pay a commission, which she thinks is protective for consumers.

“Insurance regulators need to step in and make sure brokers are getting paid,” said Norris, or some brokers, “out of necessity,” might steer people to higher-commission products, such as short-term plans, that might not be the best answer for their clients.

Her agency does not sell short-term or some other types of limited-benefit plans.

“I don’t want to have a client come back and say I’ve had a heart attack and have all these unpaid bills,” she said.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

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