Health Care in Monolingual Community-Finding Peace in Chaos

EDITOR’S NOTE: This article was originally published in Chinese and has been translated into English and edited for clarity.

52-year-old Ah Shan immigrated to America and now resides in San Francisco. With rheumatoid arthritis, she needs to take medicine regularly. Speaking in Cantonese with a rural accent, she sighed and said that once their children are older than 18 years old, it’s hard for low-income adults to apply for Medi-Cal.

Under the current system, low-income adults under 65 who have children between 0-18 can be eligible. Even though Shan cannot get Medi-Cal because her children already have grown up, she can apply for health care through disability criteria, but she is worried for her husband, who couldn’t qualify.

Once the Medi-Cal expansion takes effect next January, people with income at 138 percent or below poverty level and younger than 65 years old can qualify. There will be approximately 1.42 million Californians who will be newly eligible under the expansion.

According to the California Pan-Ethnic Health Network (CPEHN),  many groups currently ineligible for Medi-Cal are now all going to be covered, including childless adults, as a result of  the Affordable Care Act. 

In California, ethnic minorities make up 60 percent of the population. Of the 1.42 million who are newly eligible for Medi-Cal, 2/3 are from minority communities, and 35 percent have Limited English Proficiency (LEP).

Although minorities and LEP make up a big part of Medi-Cal expansion, translation error, miscommunications are all problems that people with LEP face during medical treatment.

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May, a 40-something-year-old woman, remembered vividly her unpleasant experience with health care.

A few years ago, she was diagnosed with a tumor next to her breast and received a letter asking her to go to SF General Hospital. Due to her limited English proficiency, she couldn’t understand the letter clearly and thought she had no other choice except SFGH. She said the doctor there removed an “acne” right next to the tumor, instead of her finger-sized tumor, which she found out only after the surgery. She said the doctor even got a translator to explain himself. She didn’t have to pay for the surgery.

May hopes that the insurance she buys in the future will provide her not only with basic health care, but also good quality health care with comprehensive translation services and paperwork.

Legislators are paying more attention to the plight of people with limited English proficiency.  Assembly member Phil Ting has just recently held a hearing and urged everyone to support a bill, AB 1263, in the hope of getting $20 million in federal funding to hire 7,000 interpreters to help with Medi-Cal enrollment.

Even though the health care plans chosen to participate in California's Health Care Exchange -- including Chinese Community Health Plan (CCHP), Blue Shield, and Kaiser Permanente -- all provide quality service, once ACA rolls out, there are still concerns about whether there will be a lack of doctors, medical personnel and interpreters services.

North East Medical Service CEO Eddie Chan said that the demand for health care in San Francisco will not necessarily be higher after ACA is implemented, since most of the city’s uninsured already have health care through Healthy San Francisco. In a sense, health care providers in San Francisco are greatly benefiting from ACA, because they never got any funding under Healthy San Francisco anyway. “The only compensations we got are the few dollars  patients pay each visit,” Chan said.  

“In San Francisco, we are in a better place. Because we already have a record for all those uninsured, they are getting health care under Healthy SF, and we already know who they are,” Chan said. “Compared to other places, who are actually just going to have a flush of new patients, we are actually having it pretty easy.”  

For SF General Hospital, administrators are trying hard to show the public that it is a world-class hospital with excellent service. “Because there will be more choice, people might leave SFGH for others, that’s why we really want to show our patients that the care they are receiving is really good,” Rachael Kagan from SFGH said.

For example, under the ACA, SFGH has done many initiatives to improve health care, such as lowering patients’ wait times and adding more video interpreter machines (VMI). 

As much as VMIs help, Nora Goodfriend-Koven, director of San Francisco City College's Health Care Interpreter Certificate program, would like to stress that VMIs are not the same as in-person interpreting. “There is a place for VMI, and there are places where it should not be used, but now many medical providers are not distinguishing between them,” she said.

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Jenny, a 54-year-old middle class woman, has been working for 20 years. Since last February, when she got the flu, she has had insomnia. In the past few months, she either couldn’t sleep a wink at all, or only got a few hours of sleep. She grew very weary, but because she believed that she could only get insurance through work, she had to keep working despite poor health conditions.

Covered California is set to solve problems like Jenny’s. Currently, 86 percent of Americans get insurance through employers, but for the other people who do not, they can get affordable healthcare through Covered CA.

Currently, Covered CA’s main goal is to get people informed through outreach and education. According to California Simulation of Insurance Markets (CalSIM), even though there are statewide outreach efforts, it estimated that only be 55 percent of those eligible -- about 780,000 Californians -- will apply in 2014.

Seeing this situation, many Chinese nonprofit organizations and other health care providers are stepping up to do comprehensive outreach to the Chinese speaking community. For instance, Chinese Progressive Association (CPA), NICOS Chinese Health Coalition, Chinese Community Health Plan (CCHP) and North East Medical Services (NEMS) are all doing outreach and education on their own and collectively.

Susan Fang, CPA health care policy fellow, said that CPA recently did a small survey among its members and found that most are in a household of two and have income below 138 percent poverty line, thus making them eligible for Medi-Cal under the expansion. According to The Urban Institute, when the health status of an employee rose from fair or poor to good or excellent, the employer’s profit will also increased from 15 percent to 20 percent. 

However, Kent Woo, NICOS' CEO, speculates that the problem right now is that even with the mandate and punishment, many people who are eligible for federal subsidies for Covered CA are still not prepared to apply due to cost. Compared to getting very cheap health care under Healthy SF, coverage purchased through Covered CA, though affordable through federal subsidy, is still quite costly.

Even with a federal subsidy, an individual still has to pay premiums, whereas now they get care under Healthy SF with a minimal cost. Therefore, in spite of the fact that Healthy SF is not comprehensive health care and people can only use it when they are injured or ill within San Francisco, many still think Healthy SF is adequate for them.

“In the next two to three years, people will still stick to what they know, and not apply for Covered CA and buy coverage, until the punishment penalties are increased later on,” NEMS CEO, Eddie Chan, said.

NEMS got $411,000  from the federal government to do outreach. In August and through September, they will host many informative talks and will set up workshops to educate especially Cantonese speaking and Mandarin speaking consumers about ACA and enrollment in Covered CA and Medi-Cal.

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The cost of health care is high and health care spending alone takes up 17 percent of the U.S.’s GDP. In the long run, it will take up 20 percent of GDP, and it is definitely not sustainable. The Affordable Care Act aims to solve this problem. Even though in the short term, the changes might lead premiums to increase, in the long run, the purpose of ACA is to stop health care waste and transform the American health care model from a volume-based model to a quality-based model.

Under the volume-based model, hospitals might be prone to prescribe more medicines, more MRI scans, and more readmissions, because they will get higher compensation and profits.

“Since the beginning of last summer, we already get reimbursed based on the survey results regarding patients’ satisfaction in certain categories. It is aimed to make the hospital pay more attention to patients’ satisfaction, but not volume. Also, in certain cases, if patients need to be readmitted after a treatment, the hospital needs to pay a penalty,” Rachael Kagan, spokesperson for SFGH, said.

In fact, before the ACA, San Francisco already established the Universal Healthcare Council in 2008, and from this Healthy SF was born. Supervisors also passed the Healthcare Security Ordinance, which mandated that employers with over 20 full-time employees have to provide health care for workers or submit a certain fees to fund Healthy SF.

To make the transition of ACA, and the intersections of ACA and local policy more smoothly, San Francisco Mayor Ed Lee has already announced that the city will reconstitute the Universal Healthcare Council.

“Healthy SF serves around 60,000 San Franciscans per year,” Department of Public Health Director Barbara Garcia said. Even after the ACA is in place, she said, “We estimate that there will still be 20,000 making use of Healthy SF.”

Susan Fang, a fellow at CPA, stresses that while the ACA is providing health care for many more people, it’s still leaving out the undocumented. While CPA supports ACA, it will continue strive to fight for health care for all, including those who are undocumented.

The road to universal and affordable health care for all is not easy. But  people like Ah Shan, May, and Jenny, are willing to pay for health care, not only to have security for their health, but also to give them and their family a peace of mind.

“Nothing matters more than a healthy body and healthy mind,” Jenny said.

* Some names have been changed due to the interviewees’ request to remain anonymous.