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Health care reform opportunities and challenges

For highly diverse population with many languages

 Set on a gritty corner of Oakland's International Boulevard, the nonprofit Street Level Health Project offers free checkups to patients who speak a total of 22 languages, from recent Mongolian immigrants seeking a doctor to Burmese refugees needing a dental exam.

It also opens a window on one of the challenges for state leaders who are trying to implement the Affordable Care Act, President Barack Obama's sweeping health care overhaul.

Understanding the law and its possibilities for ordinary citizens is a task even for politicians and bureaucrats, but delivering its message to non-English speakers who can benefit from it is shaping up as a special complication. That is especially true in places

with large and diverse immigrant populations like the Bay Area, where about 1 million people live in households where the primary language is something other than English.


Even deciding what to call a health insurance program generates angst in a polyglot state. California's health-care insurance marketplace staff is testing "Covered California."

That would be "California Cubierto" in Spanish, but "what does it mean?" asked Laura Lopez, the Street Level clinic's executive director.

But the main feature of health care reform -- the state's health insurance exchange opening next year -- will require consumers to contrast and compare the features and costs of a range of private health insurance policies to select the one most

suitable for them.


That could be a tall task for native English speakers, but more so for residents who speak English "less than very well."

Zaya Jaden, a 35-year-old from Mongolia visiting the Oakland clinic, said she would not know how to translate it into her native language. Advocacy groups say the state should translate it into Arabic, Armenian, Chinese (Mandarin and Cantonese), Farsi (Persian), Hmong, Khmer (Cambodian), Korean, Russian, Tagalog and Vietnamese.

Jaden was in the clinic getting free care for her sister's migraine, a much higher priority than considering how the expansion of the nation's social safety net through the Affordable Care Act might benefit her.

"It was a good idea that Obama had, but I don't know if it will work for me," said Jaden, who has private insurance for her family through her job as a laundress at an Oakland hotel and makes too much money to qualify for Medicaid. She has questions about what health care reform might mean for her, asking "how could I pay my rent" if she took lower pay to qualify for an insurance subsidy.

Jaden's questions demonstrate the cultural and language hurdles for California and several other states as they build exchanges -- or health insurance marketplaces -- and try to extend coverage to ethnic and hard-to-reach populations.

California has the largest minority population of any state, about 22.3 million people. Texas follows with 13.7 million, New York with 8.1 million and Florida with 7.9 million.

The U.S. Census estimates that nationwide more than 55 million people speak a language other than English at home. Nearly 63 percent of those are Spanish-speakers. Chinese languages were the third most common.

Five other languages have at least 1 million speakers: Tagalog, French, Vietnamese, German and Korean.

In California, roughly 1 million of the estimated 2.6 million adults who will be eligible for federal subsidies in the health-care exchange

Loan Truong, left, who is Vietnamese, has blood drawn by Rechyle Torio, right, a phlebotomist, Friday, March 1, 2013 at International Community Health Services in Seattle. (AP Photo/Ted S. Warren) (Ted S. Warren)

speak English less than very well, according to a study by the California Pan-Ethnic Health Network and the UCLA Center for Health Policy Research and the UC Berkeley Labor Center.


The nine county Bay area itself counts some 1.1 million people who speak English "less than very well" according to 2007-2011 American Community Survey estimates.

With such diversity, the report authors said the success of health care reform hinges in large part on the cultural and linguistic competence of the state's outreach and enrollment.

Advocates disappointed by the name Covered California are hoping the board selects a name that will be simple to understand and translate.

More importantly, they want Covered California to launch an inclusive marketing and outreach campaign that goes well beyond just English and Spanish to at least 10 other languages. Other groups have requested the exchange, at a minimum, add the two main Chinese languages.

California's exchange isn't shying away from the challenges.

It will use new federal funding to support a multi-language campaign, build a network of community-based assistants who can guide people to the right health plan and multilingual call centers.

It is making $43 million available competitively for community- and faith-based groups, nonprofits and local governments for outreach and education grants.

Oscar Hidalgo, the exchange's communications director, said the state's health exchange website,, is being created in a way that permits adding more languages later. The exchange, he said, first needs to launch an introductory website.

"It's very challenging to put together a website that's consumer friendly in English, and then to do it in 13 languages is a very, very big task," he said. "We don't have all the answers at this moment, but we're going to find them."

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