Cultural Competency in Obamacare Implementation: Part I

Cultural Competency in Obamacare Implementation: Part I

Cultural Competency Blog Series

Part I: Linguistic Competency in Asian American and Native Hawaiian/Pacific Island Communities

This post is the first in a series ZeroDivide has designed to explore some of the opportunities to integrate cultural competency into each stage of the Affordable Care Act enrollment and implementation process. Be sure to read Part II: eHealth Tools and Cultural Competency.


As the nation makes last-minute preparation for the first open enrollment period of the Affordable Care Act and looks toward implementation early next year, we see the many opportunities to integrate cultural competency into each stage of the process. Our guiding framework, of course, considers the intersection of community and technology, and we’re particularly interested in exploring the various ways technology can play a transformative role in the integration of cultural competency.

This post is the first in a series designed to explore some of these opportunities. The focus today is a deep dive into the ACA-related linguistic competency needs of Asian American, Native Hawaiian and Pacific Islander (AANHPI) communities across the country. We’re talking with our partners in this work to highlight the and specific challenges and barriers these communities face, and to begin a national dialogue about designing and deploying inclusive, tech-driven solutions.

 ZeroDivide President & CEO Tessie Guillermo joined in conversation with Kathy Ko Chin from the Asian and Pacific Islanders American Health Forum, and Jeff Caballero from The Association of Asian Pacific Community Health Organizations to record a podcast on this topic. Below are highlights from their conversation; you can also listen to their full discussion on ZeroDivide’s YouTube channel

Barriers to Health & Wellness

Tessie Guillermo, ZeroDivide President and CEO:
With the imminent launch for enrollment in the Affordable Care Act, I know that both the Health Forum and APCHO have been taking on major roles to organize health and human services organizations in the outreach, education and enrollment of your target populations to the Marketplace.

To set the background and context for this work, what are the specific barriers to improved health and wellness facing AANHPI communities?

Kathy Ko Chin, President & CEO, Asian and Pacific Islanders American Health Forum:
Thanks Tessie for the invitation. There really are three main areas that create barriers to improved health and wellness for AANHPI communities: their overall lack of insurance, language barriers, and specific disease conditions disproportionately affecting AANHPI.

Lack of Insurance

Within the AANHPI community certain communities have disproportionately have high rates of uninsurance, particularly small business owners from the Korean, Bangladeshi, Pakistani and South East Asian communities, their families and employees.

Jeff Caballero, Executive Director, The Association of Asian Pacific Community Health Organizations:
From the perspective of the Association of Asian Pacific Community Health Organizations (AAPCHO), many of the patients seen in our health centers are coming from communities that are often not participating in mainstream systems. Many are poor and don't have insurance and can't afford to access the mainstream providers.

Language Barriers

We also know that 8 million speak AAPI languages at home, and more than 4 million across the country are considered limited-English proficient. This disparity plays out particularly when accessing health care. I just saw data about those who are uninsured in California: 50% of those uninsured are also limited-English proficient. So we see a need for language access, not only for enrolling in insurance, but also accessing health care and getting a range of services, including mental health services.

One of our clinics in Seattle, Washington serves patients in 52 different languages, and that really poses an incredible challenge to the clinics when trying to organize the various translation services and in-house staff, and make sure that they're available when patients are scheduled to come in.

For AANHPI communities, people trace their heritage to more than 50 different countries and speak more than 100 different languages. We unfortunately can't address all of that need, but are committed to working in nine different languages. That will compliment what the Center for Medicaid and Medicare Services (CMS) can do – we're shooting for something like AANHPI 12 languages.

The CMS does have a call center with interpreters in 150 languages, not just Asian-Pacific Islander ones.

Specific Disease Conditions

Like many other racial and ethnic minorities, health disparities abound in AANHPI communities: chronic diseases, diabetes, hypertension, cancer in specific sites and heart disease are all major challenges. Also, given the lack of insurance and the language barriers, there's less preventive care that AANHPI communities take advantage of. 

Two of the areas where we see a great deal of health disparity in our communities— tuberculosis and hepatitis— are diseases that don't show any symptoms unless you're really ill. So if folks are not aware that they're at risk for these conditions, they’re not trying to get preventative services until it's too late. 

How many uninsured AANHPI are we talking about throughout the United States and the Pacific, and how many are you hoping to enroll in this first round?

There are about just under 2.5 million uninsured AANHPI in the US. We're trying to reach a quarter million of them over the next 7 months, through outreach and education, and to ultimately enroll 50,000 of them. We recognize that with our populations, because of various barriers, it's going to take a lot longer to do the whole enrollment and application process. 

We feel this is a 3-year approach that we want to take, so we'll learn the best we can what it takes to serve our population, while still trying to reach the significant number of a quarter million people. Then we’ll turn around for the next open enrollment in October of 2014 to improve our systems, to improve our partnerships with CMS and the state-based marketplaces, and improve for the second and subsequent rounds of enrollment.

Barriers in Clinic Settings

Jeff, because AAPCHO is an association of community health centers, a lot of the information that you're sharing with us relates to patients who don't have insurance and often time the only place they have to get care is at one of your clinics.

Can you talk to us a little bit about what are the specific competencies that you think are important when addressing the complex profile of patients in the clinic setting?

Many of AAPCHO members have prioritized recruiting and developing staff to work in these facilities that represent the communities they serve. This isn't an easy task, given that many of these communities are located in underserved areas. Many of these health centers have developed pipelines, partnerships between the health center and community colleges, so that some staff positions can be filled by community members coming from the nursing programs or other local vocational programs.

Many of the health center staff also speak the languages of the patients they serve. For example, in one of our clinics in Oakland, California, 92% of the employees are either bi-lingual or multi-lingual. In addition to the language itself, it really helps the patients and the community members feel more comfortable when they walk through the door and see faces of people who look like them. This helps them become a lot more comfortable in the clinic setting and helps enhance the communication opportunities between the patients and the providers of that facility.

Overcoming Disparities

Kathy, for organizations on the ground that are working to support increased health access for Asian Americans, Native Hawaiians and Pacific Islanders, what cultural and linguistic competencies need to be in place to overcome the disparities, barriers and lack of insurance?

We had a recent advancement through the Federal Office of Minority Health, as they just released the National Standards for Culturally and Linguistically Appropriate Services in Health Care for all federally funded facilities. This is really a major breakthrough and advancement for cultural linguistic access services.

We also continue to see entities like the National Quality Forum and the Joint Commission for Accreditation who understand that cultural linguistic access is really critical to quality of care, health outcomes, and reducing disparities.

Immigration Status

With regards to the ACA, are there new or different barriers that surface for AANHPI communities as they prepare to enroll in a health plan, many for the first time? Or are they just more of the same? 

As I mentioned before the language barriers still remain; we need to advocate really strongly with CMS to make sure that enrollment information and applications are in as many languages as possible.

But now the real new challenge related to the ACA is immigration status. It will be the single greatest social determinant of whether or not you are covered by health insurance moving forward.

January 1, 2014, represents a permanent shift in the health care environment, where there will now be access to the private insurance marketplace in a way that has never been there before. And in those states that have chosen to expand their Medicaid coverage, for the first time childless adults will have access to public insurance.

But all of those expansions have different barriers for those with different immigration status. Whether it's for those undocumented, who are completely left out of the ACA, or for legally permanent residents (green card holders here for less than 5 years) who are still facing challenges in accessing or affording private health insurance or Medicaid. This question of immigration status will really become one of the biggest challenges as we not only try to enroll people, but also try to get them into care.

That's a really important issue which I’m not sure has been very well covered in the mainstream media and through educational programs being distributed around ACA.

I assume, Jeff, with the on-boarding of potentially hundreds or thousands of new patients who are going become eligible under the ACA, that there will be potentially some stressors on the clinics to be able to accommodate the language and cultural needs of the newly enrolled. Are there new or different barriers that surface for these communities as they are preparing to enroll in a health plan, many potentially for the first time?

There are a number of questions here that I can respond to, Tessie. In the midst of this great opportunity to enroll people for the first time, there are tremendous challenges currently being faced. In particular, lack of appropriate funding for full implementation of the ACA represents a challenge for some of the programs that are working to ensure we have diversified workforces to address the needs of the diverse patients coming on for the first time.

Many of the pipeline and workforce programs that have been supported by federal dollars have been either eliminated or reduced to such diminished proportions that they’re no longer reaching our communities. 

What about you Kathy, are you working with other partners around the specific issues of immigrant status, language and cultural behaviors in this opportunity to enroll in the Marketplaces?

It's wonderful to be on this interview with Jeff from APCHO. We are partnering, as we have been for over two decades, to lead a national strategy. This national ACA implementation strategy across 15 states works with community-based organizations and community health centers to do the outreach, education, and particularly enrollment, and do so in language that's culturally accessible, and sensitive to the immigration status challenges that many AAPI families face.

And we're also working with the Asian American Advancing Justice Network, which has 4 affiliates across the country. In particular the LA Affiliate is leading the work in California, and working with the state-based marketplace, Covered California. Their affiliate in DC is working with us around making sure that civil rights provisions are really mapped well as people are trying to access health insurance. 

The Role of Technology

I don't think I've heard of another collaboration quite like this that focuses on a particular population target with the kind of the breadth and robustness that you describe.

Because we're ZeroDivide, we obviously have an interest in the role that technology can play around the provision of cultural linguistic competent health care services, and in the coming enrollment efforts. I'm wondering if both of you have had an opportunity to think about how meaningful use standards are really going to play out once people become enrolled and begin to engage with their health plan and providers. Do you see a role for eHealth tools, or technology in general, in these efforts?

Absolutely, eHealth tools offer new ways to get information out to our community quickly and effectively. For example, using collaboration tools to assist in doing translation of materials. You could have somebody in Boston working with somebody in San Francisco on the same document, sharing in the work and decreasing the speed the time to finish those materials. 

Another thing could be through using SMS as an outreach strategy. Certainly new media and social media are ways to promote the enrollment opportunities and to do more education.

Also, using electronic health platforms to gather data. We are trying, along with our partners at the National Health Law Program and Community Catalyst, to look at how we can track in real time how the enrollment process is going. Since this is an historic moment, how do we really get the information from the Navigators and In-Person Assisters who are helping people enroll?

How can we get them to report back on a timely basis and then get those reports back to the Centers for Medicaid and Medicare Services, or to the state-based exchanges so that there can be improvements in real time.

I have this vision of eHealth tools being a conduit for expanding the continuity of care, management capacity and prevention capacity that health centers currently have. It's a vision that I've shared with you in the past, Tessie, but it's a challenge for AAPCHO to implement.

Many of our people in our network have their expertise in either providing health, or and caring for underserved populations. We have a rapidly growing technology component, particularly with the integration of ehealth records in many of our member centers, but it's still a very limited group of people that we can call upon to help us better leverage our opportunities with eHealth.

Our partnership with ZeroDivide has been incredibly important for an organization like AAPCHO, in helping a network of safety net providers to be better able to understand and leverage opportunities. [ed. note: ZeroDivide submited a Pacific Asian Health Mapping tool to the Knight News Challenge on behalf of our partnership with AAPCHO and APIAHF].  

But the specific examples that I have in my vision are for our many patients who are managing multiple conditions. For example in Hawaii, many of our patients are obese, and currently seeing a nutritionist or behaviorist to help them manage their obesity, diabetes, and/or cardiovascular issues. eHeath tools can be an extension of nutritionists, if we are able to appropriately harness them.

I'm envisioning etools that patients can use, for example, to take pictures of the meals that they eat, and then sharing those pictures with the nutritionist to better assess whether they are improving their diet. Or tools that record their workouts better, so that their physical therapist or behaviorist can help them track ways to be better motivated, or ways to improve.

There are many opportunities and we have very limited access to technology people who can help us brainstorm and develop innovations. Our partnership with ZeroDivide is very timely and instrumental for us as a network.

We’re very excited to be involved in this work as well.

Thanks again to both of you for your participation in this series, we’re really looking forward to opportunities to partner with you and others around the issue of cultural linguistic access to health care and the role that technology can play. Thank you both for joining us! 

Thank you, it's been great! 

Thank you Tessie, and thank you ZeroDivide.


Full Interview

eHealth Equity, cultural competency, ACA, Obamacare