GARAPAN, Saipan — Bing Salanga leans over a black sink and scrubs it clean in the back of the hair salon where she’s worked for 29 years.

It’s a daily ritual — wash the bowls that hold hair dye, disinfect them with alcohol, wipe down the sink and surrounding area with a purple cloth. She does this every time a customer is late, anytime she has a few minutes in between clients coming to her for facials and haircuts.

It’s repetitive work, but Salanga is grateful she has it. She’s one of thousands of guest workers in the Commonwealth of the Northern Mariana Islands, a U.S. territory made up of every island along the Marianas Trench except for Guam.

Salanga doesn’t take for granted the fact that she is able to work on Saipan, or has the strength to do it. Two years ago, she was diagnosed with breast cancer and told she needed a mastectomy.

Before the pandemic, the cancer may have forced her to move back to her native Philippines to better access health care. She can’t afford insurance on her annual salary of less than $17,000, and her employer isn’t required to provide it for her.

But a temporary pandemic program allowed her, along with an estimated 20,000 non-U.S. citizens in the commonwealth, to access public health insurance for the first time.

That access is scheduled to end in October, unless President Joe Biden extends the public health emergency. Patients and health care providers are waiting and hoping the program, known as presumptive eligibility for Medicaid, will be continued.

“It’s helped so many people that didn’t have insurance at all,” says Darleen Aldan, operations manager at Marianas Medical Center, a clinic on Saipan. “A lot of our patients are so worried (about) after October, what’s going to happen?”

More Than Doubling the Number of Insured Patients

The presumptive eligibility program is an expedited process to allow people to qualify for the public health insurance program as long as they earned below a certain annual income. In 2020, this was $21,144 for a couple.

Unlike regular Medicaid, the presumptive program doesn’t require applicants to be U.S. citizens or green card holders.

The low income threshold wasn’t a problem for Salanga, who earns $8.08 per hour and has only been able to work a handful of hours each week since she got sick and started cancer treatments. She couldn’t afford to pay $200 or more per month for private health insurance when her employer stopped covering part of it years ago.

Salanga’s low income isn’t unusual in the Northern Mariana Islands, where the median household income was just $19,201 in 2016, even before the pandemic shut down hotels and restaurants and drove up unemployment.

Nearly half of the adult population lacked health insurance — 46% in 2016. The overall uninsured rate including children was 34%, nearly four times the national uninsured rate that year, and more than nine times the uninsured rate in Hawaii.

Part of the reason the uninsured rate is so high is that thousands of people like Bing earned less than the Medicaid threshold but were ineligible because they aren’t U.S. citizens.

Paradoxically, the pandemic improved access to health care. Even as thousands lost their jobs, presumptive Medicaid eligibility suddenly enabled those who hadn’t had access to health insurance before to go to the doctor, dentist and eye clinic for free.

Medicaid enrollment, including presumptive eligibility, grew from about 16,000 people prior to the onset of the pandemic in 2020 to an estimated 38,000 today, according to Vicenta Borja, a claims examiner at the Northern Mariana Islands’ Medicaid office.

“It has tripled the workload,” she said.

A Boom In Health Care Services

Presumptive eligibility for Medicaid is usually an optional program for U.S. states — a temporary way to get patients onto Medicaid for a couple of months before they finished their enrollment.

The Northern Mariana Islands wasn’t previously included, says Esther Muña, executive director of the commonwealth’s only hospital. When the pandemic program went into practice in June 2020, the effect was immediate.

“Every medical and every dental and every eye care clinic on the island got slammed with patients,” said Donna Krum, who runs Paradise Dental clinic on Middle Road, Saipan with her husband, Nelson. She and other providers were suddenly overwhelmed by calls from “people who had never been able to take care of themselves before,” she said.

Aldan estimates that Marianas Medical Center’s patient load grew between 50% and 60% as patients sought help for diabetes and high blood pressure and got physicals for the first time in years.

Medicaid in the commonwealth doesn’t cover all dental care — just fillings, extractions, exams and X-rays. The program used to cover more, but last year the commonwealth shrunk its Medicaid reimbursement for dental care to reflect Hawaii’s more limited program, Nelson Krum said.

But that still was a huge help to patients who had been unable to afford dental care for years and sometimes decades. At Paradise Dental, the demand for fillings and extractions skyrocketed. So many people needed emergency dental care that the Krums suspended all tooth cleanings, which aren’t covered by Medicaid, for four months.

“Some had never been to the dentist before. I don’t know how they slept at night. They were in such pain,” Donna Krum said.

Lorie Cerdeño, a 59-year-old housecleaner from Manila who has lived in Saipan since 1987, was among the patients who flocked to Paradise Dental.

By the time she got access to presumptive eligibility for Medicaid during the pandemic, it had been years since she last had health insurance. The dentist pulled three of her top teeth. For three months she ate only soup, until a former employer paid for dentures that Medicaid wouldn’t cover.

Cerdeño also went to the doctor and got medicine to help regulate her blood pressure and blood sugar. Once presumptive eligibility for Medicaid expires, Cerdeño doesn’t know if she’ll be able to pay for health insurance to continue receiving medicine. Her priority is sending money back to the Philippines to support her 12 grandchildren.

Some With Medicaid Access Still Face Challenges

Some on the presumptive program will be able to retain access to Medicaid even after the temporary program ends.

More than 2,500 citizens of Palau, the Federated States of Micronesia and the Marshall Islands live in the Northern Mariana Islands and many of them signed up through the presumptive program in 2020 after losing access to Medicaid in 1996. Their countries have treaties with the U.S. known as the compacts of free association that allow them to live and work in U.S. states and territories without visas.

Elfriede Suda, a Saipan resident from Chuuk, went house to house in 2020 encouraging her fellow Micronesians to sign up for the presumptive eligibility program and get long-awaited health care access.

Then in December 2020, Congress reinstated Medicaid access for citizens of those three island nations, in the wake of high rates of Covid deaths among the community. That means that citizens from the COFA nations can continue to get Medicaid even after the presumptive Medicaid program ends.

That’s great news for people like Suda, but citizens of COFA nations who are enrolled in presumptive Medicaid won’t automatically be moved over to the permanent program — and if they don’t proactively apply, they could face gaps in coverage.

Suda says getting insurance through the presumptive program was easy — patients could sign up at the hospital, the application was very short and simple and filling it out resulted in immediate access.

Medicaid applications are a lot more complicated and require passports and birth certificates that can take weeks or months to replace, she said. A lot of people in her community don’t have cars, Suda said, so driving them to and from the Medicaid office to get help during limited available hours is another hurdle.

Still, it’s one Suda is confident they can overcome.

Searching For A Solution

Guest workers from the Philippines aren’t so lucky. They aren’t eligible for regular Medicaid unless they obtain green cards, an often lengthy process.

The potential end of presumptive Medicaid if the public health emergency is lifted is part of a broader challenge U.S. territories face in accessing Medicaid funds.

Medicaid in the territories doesn’t work the same way as in states — states are paid based on how many people need access to the public health insurance program. But territories face statutory limits on how much they can receive regardless of need.

Federal Medicaid funding has jumped in recent years. Congressman Gregorio Kilili Sablan, the commonwealth’s only representative in the U.S. Congress, is a non-voting delegate in the U.S. House of Representatives. He says the increase is a result of advocacy from territorial delegates and their voting allies in Congress, as well as the Biden administration’s favorable reinterpretation of existing law.

Muña, the hospital executive director, said in addition to providing health care to thousands of guest workers, the new funding has helped the hospital establish oncology services that cancer patients previously had to fly to Guam, Hawaii or the Philippines to obtain.

The higher federal Medicaid match could revert back to lower levels this year if Congress doesn’t act.

Sablan is hopeful that it will be extended, and wants to find a longer term solution for accessing health insurance for all commonwealth residents.

Muña wonders if the Affordable Care Act could be extended to U.S. territories like the Northern Mariana Islands and with it, the option for people to buy health insurance on an online marketplace.

Sablan thinks that would require a lot of political will plus federal subsidies.

In the meantime, providers are expecting a huge drop in people seeking health care once the presumptive program expires. Krum says Paradise Dental expects to lose 40% of its patients.

Bing has another appointment in November. Her doctors told her they found something in her lungs — they aren’t sure what it is, and told her not to worry, but to come back for another look.

Whether or not she can afford to come back — and whether Medicaid will still be able to cover her — is an open question.

Still, she’s grateful for the health care she has received so far. For a while, she ignored the pain, even though it made it hard for her to work and sleep. She only learned that she was able to go to the doctor when a co-worker told her about presumptive eligibility.

She had considered flying back to the Philippines but was afraid of catching Covid in transit. She prayed and the program emerged as a solution. Being able to get the care she needed on Saipan enabled her to stay and recover at home.

“Without this presumptive, I don’t know what (would) happen to me,” she said.