OAKLAND, Calif. Set on a gritty corner of Oaklands 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 in need of a basic dental exam.
It also provides a window into one of the challenges for state officials who are trying to implement the Affordable Care Act, President Barack Obamas sweeping health-care overhaul.
Understanding the law is a challenge even for governors, state lawmakers and agency officials, 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 states with large and diverse immigrant populations.
For Zaya Jaden, a 35-year-old from Mongolia, getting free care for her sisters persistent migraine was a much higher priority than considering how the expansion of the nations social safety net through the Affordable Care Act might benefit her.
The sisters crammed into the clinics waiting room, sandwiched between families chatting in the indigenous Guatemalan language Mam, and discussed whether enrolling in Medicaid under the Affordable Care Act would work for the familys finances.
It was a good idea that Obama had, but I dont know if it will work for me, said Jaden, who gets private insurance for her family through her job as a laundress at an Oakland hotel and currently makes too much money to qualify for Medicaid. If I make less than what I make to try to qualify for the government program, how could I pay my rent?
Jadens ambivalence demonstrates the cultural and language hurdles that California and several other states are facing as they build exchanges or health-insurance marketplaces and try to expand coverage to ethnic and hard-to-reach populations.
California has the largest minority population of any state, about 22.3 million people. Thats followed by Texas with 13.7 million, New York with 8.1 million, Florida with 7.9 million and Illinois with 4.7 million.
In Illinois, where nearly 1.2 million residents dont speak English well, the task of translating information about the health-care overhaul into other languages has fallen to nonprofit groups and community organizations.
So far its fallen to us, and we dont know what (the states) capacity will be to go beyond Spanish, said Stephanie Altman of Health and Disability Advocates.
The state intends to submit an outreach plan to the federal government this spring. Illinois officials expect federal grant money eventually will be available to help reach non-English speakers, said Mike Claffey, a spokesman for Democratic Gov. Pat Quinn.
The U.S. Census estimates that more than 55 million people speak a language other than English at home. Nearly 63 percent of those are Spanish-speakers, with the highest concentrations in Texas, California and New Mexico. Chinese was the third most commonly spoken language, with large populations in California, New York, Hawaii and Massachusetts.
In Colorado, with a population of 4.5 million people older than age 5, 339,000 speak English less than very well. In La Plata County, estimates show a total population of 48,011 older than age 5. Of those, 3,106 speak Spanish at home, and 658 speak English less than well.
Also in La Plata County, an estimated 48 Russian speakers dont speak English well, as well as 47 Chinese speakers and 62 Native American language speakers.
In California, two-thirds of the estimated 2.6 million adults who will be eligible for federal subsidies in the health-care exchange will be people of color, while about 1 million will speak English less than very well, according to a joint study by the California Pan-Ethnic Health Network and the UCLA Center for Health Policy Research and the University of California, Berkeley Labor Center.
With such diversity in cultures and language, the authors said the success of health-care reform hinges in large part on how well the state conducts culturally and linguistically competent outreach and enrollment efforts.
If the exchange did no targeted outreach, there could be 110,000 fewer limited-English proficient individuals enrolled, said Cary Sanders, director of policy analysis for CPEHN, an Oakland-based multicultural health-advocacy group.
Even the relatively mundane task of developing a brand for Californias new health-care exchange has prompted some angst.
The exchanges staff members tried to come up with a name that signified health insurance and would translate well into Spanish, Chinese, Tagalog, Vietnamese and other languages commonly used in California.
The exchanges five-member board settled on Covered California and is testing tag lines to see which words resonate best in focus groups. Advocates disappointed by the name are hoping the board selects a tag line that will be simple to understand and translate.
Jaden, for instance, said she had no idea how Covered California would translate to Mongolian.
More importantly, they want Covered California to launch an inclusive marketing and outreach campaign in a place where a majority of the population is not white and nearly 7 million residents speak limited English.
Covered California translates to California Cubierto in Spanish, but what exactly does it mean? said Laura Lopez, Street Level Health Projects executive director, who immigrated to the United States from Peru years ago. Its not just providing a piece of paper that says this is what is covered. Its really having people on the ground talking with the community.
Californias exchange isnt shying away from the challenges.
Its executive director, Peter Lee, recently announced that new federal funding will be used 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.
The exchange is making $43 million available for community-based organizations, faith-based groups, nonprofits and local governments to compete for outreach and education grants.
California is unique from every other state not only geographically because our population is spread out, but you have multiple ethnic populations that are traditionally hard to reach, and they need their own custom way to be reached, said Oscar Hidalgo, the exchanges communications director.
The exchange estimates that 5.6 million Californians are without health insurance, or 16 percent of the population younger than age 65. Of that number, 4.6 million are eligible for coverage under the Affordable Care Act, while the rest are not because of their immigration status.
Advocates say California should refine its efforts to reach non-English speakers.
Doreena Wong, who promotes health access for immigrants at the Los Angeles-based Asian Pacific American Legal Center, is among those urging the exchange to build a website that is not just in English and Spanish, but to offer translations in other languages prevalent throughout the state: Arabic, Armenian, Chinese, Farsi (Persian), Hmong, Khmer (Cambodian), Korean, Russian, Tagalog and Vietnamese.
According to the U.S. Department of Health and Human Services Office for Civil Rights, organizations that receive federal funding have to provide written notices in English, Spanish and other languages spoken by 5 percent of the population or 1,000 people, whichever is less.
Wong recently told the board that many people eligible for the exchange arent proficient in English, have limited education or have never had health-care insurance. Other groups have requested the exchange, at a minimum, add Chinese.
Hidalgo said the states health exchange website, www.coveredca.com, is being created in such a way more languages can be added later. He said the exchange first needs to launch an introductory website where consumers can learn about impending health-care changes, such as federal subsidies for working families and tax credits for small businesses.
Its very challenging to put together a website thats consumer friendly in English, and then to do it in 13 languages is a very, very big task, he said. I think whats important for us is to take a step in English and Spanish and figure out what the feedback is. ... We dont have all the answers at this moment, but were going to find them.
Lin reported from Sacramento. Associated Press writer Carla K. Johnson in Chicago contributed to this report.