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Health Law Enrollment Efforts For Asian Americans Face Challenges Of Language Diversity, Cultural Differences

Nov 24, 2013

This KHN story was produced in collaboration with

Correction: An earlier version of this story misstated statistics comparing the rate of uninsured Asian Americans to the national average.

For the past few years Mari Yuan visited a doctor only when she went back to Japan to take care of her elderly parents.

A Covered California brochure in Chinese

Though her husband Wemin Yuan, 74, is insured through Medicare, 57-year-old Mari, who does not work or have access to health benefits through an employer, has no health coverage. Her history of breast cancer and several surgeries drove up the price of insurance for her on the individual market, making it unaffordable. And though she is healthy now, the North Carolina couple is nervous.

"To live in this country without insurance — it's scary," Wemin said. "Even if she takes the car out to go to the grocery, I literally worry."

Mari's situation isn't uncommon among Asian Americans: 15 percent, about 2.5 million, lack coverage, according to 2012 Census data. That’s 4 percentage points higher than the average for non-Hispanic whites.

Efforts to educate this population about the coverage options in the health law have proven both daunting and dramatically different than the Obama administration's much-touted outreach to the Latino community, which is largely united by the Spanish language.

"It's not one size fits all -- you have to tailor the messages," said Priscilla Huang, policy director with the Asian and Pacific Islander American Health Forum, a national advocacy organization based in Washington, D.C., that works to connect the population to health care.

Huang's group and one of its partners, the Asian Pacific Community Health Organizations, a network of community health centers, have conducted surveys, trained community clinic staff and created resources they hope will help fill the gap.

But there is no easy prescription for reaching such a diverse group. Health care workers and advocates must consider dozens of languages and dialects — from Bengali to Tagalog — when communicating with the approximately 3 million Asian Americans who have trouble speaking and understanding English. In addition, their religions, cultures and socioeconomic status add complexity to the challenge of developing educational campaigns.

About 12 percent of Asian Americans also live in poverty, but numbers often vary by country of origin. Chinese and Indian Americans, for example, have higher average incomes than their Vietnamese and Bangladeshi counterparts.

The White House's Initiative on Asian Americans and Pacific Islanders turned to language-specific Google video chats to reach the group and answer health law questions. The first one, held in August, was in Korean, the nationality with the highest number of uninsured people, and attracted about 500 people live. The second was held Nov. 6 in Vietnamese, and a Chinese Google hangout is scheduled for Jan. 23, 2014.

"Elevating it to this level, to this White House initiative, is helpful to everyone," said Maria Pastrana Lujan, who is an advisor on community engagement to the White House effort. "But the key to making this successful is (involving) the community."

Some states -- especially those with large numbers of Asian-American residents -- that have opted to operate their own online health exchanges have taken steps to reach specific immigrant groups. Covered California, for example, recruited Hmong speakers, among others, for this purpose. The New York State of Health also hired workers, known as "assistors," because of their outreach efforts and their work to engage the state's large Korean, Chinese and other Asian populations in the enrollment process.

This kind of focus is critical, said Perry Chan, who leads the Asian American Health Initiative in Montgomery County, Md.

Chan emigrated from China more than a decade ago with his mother and brother. The family didn't have health insurance, and, because his English was spotty, Chan didn't feel comfortable going to the doctor until his family found a Cantonese-speaking physician.

His firsthand experience has helped Chan, now 32, lead a team that provides interpreter services and translates paperwork for patients. The team also helps the Maryland health department train outreach workers, also known as navigators, who are helping guide people through the process of obtaining insurance now available as a result of the health law.

State and locally based Asian-focused initiatives like this one are often the only bridge between the community and the health law, especially for services and translations the federal government has yet to offer.

These initiatives are "just one way we are getting the word out on the Affordable Care Act to the community," said Rebecca Lee, an advisor to the White House Initiative on Asian Americans and Pacific Islanders. She added that they are working with "with federal, state, local and community partners on multiple ways to reach out to the Asian American and Pacific Islander community, including those with limited English proficiency."

Health and Human Services Secretary Kathleen Sebelius met with Spanish media outlets like Univision and introduced a Spanish version of the exchange website, Healthcare.gov, called CiudadoDeSalud.Gov. A limited version of it launched Oct. 1, but a more complete one - with enrollment tools - is expected to launch by the end of the month. The focus so far has been on connecting with Spanish speakers, partly because of the administration's push to market the health law to this group, which makes up 17 percent of the U.S. population, but 29 percent of the uninsured.

Most federal and state call centers, meant to field questions and guide consumers about health care enrollment, offer help in specific languages such as Chinese and Hindi, which together are spoken by more than 3 million people in the U.S., according to the Census. But other health law materials are only available in English and Spanish.

Huang also said none of the Asian American-focused groups that applied were awarded navigator grants, which provide funding for groups whose staff members act as in-person resources for people who are shopping for insurance on the exchanges. Meanwhile, the community clinics have started to produce their own campaigns to ensure the population doesn't get lost in the system.

She added that, since Oct. 1 -- the rocky launch of the health exchanges -- partner organizations have been "overwhelmed by calls and walk-ins from Asian Americans" who are trying to understand their options. Huang said her group, the Asian and Pacific Islander American Health Forum, and its partner organizations, have been testing the federal and state call centers for both the enrollment process and their language assistance. Asian Americans, like many others, have been dealing with long wait times -- 20 minutes and in one case, three hours -- especially for interpretation services.

"I think it's hard to think about how Obamacare impacts them when (Asians) don't see their communities talked about or represented," she said.

For families like the Yuans, it's not a language barrier but the broader confusion around the rollout of the health care law that will determine coverage. Wemin said he supported the health law and hopes that Mari can enroll in a health care plan as soon as possible.

But first, he wants to know what's going on.

"Once the clouds dissipate and I can see what's ahead, we will definitely be moving forward," he said.

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