A sign from a recent health care rally (seiuhealthcare775nw/Flickr)

Health disparities in the state are stark.

“Diabetes affects 13 percent of Native Americans in the state, 11 percent of Latinos, 10 percent of African Americans,” says Ellen Wu, the executive director of the California Pan-Ethnic Health Network (CPEHN). “That’s compared to five percent of the white population.”

Wu says there’s a gap in access to care too. That’s why the Supreme Court decision upholding the Affordable Care Act is such a watershed moment for her.

She says of the three million Californians who will now be eligible for coverage through the state’s health benefit exchange in 2014, two-thirds come from communities of color.

“For example with diabetes … they’ll be able to get screened earlier and prevent it. And when they do have onset they’ll be able to manage their care better and stay healthier,” said Wu.

The same goes for asthma, she said. “We know that for communities of color, they can show up in the emergency room for an asthma attack at higher rates than whites so the free preventive care under the Affordable Care Act (ACA) is really, really critical to keeping our communities healthy.”

The news of the decision was especially welcomed among the state’s Indian tribes. It turns out that folded into the ACA was a provision updating and making permanent a 1976 law on health care for American Indians and Alaska Natives.

Indians leaders had been working for fourteen years to get the law – called the Indian Health Care Improvement Act – reauthorized, and some people wanted it approved as a stand alone legislation.

Some of the updated provisions include giving authorization for hospice and assisted living care and establishing comprehensive behavioral health prevention, and treatment.

In response to the decision James Crouch, the executive director of the California Rural Indian Health Board, said it gives them confidence in their “efforts to establish a Low Income Health Program for our tribal communities and ensure successful implementation of some of the key improvements to the Indian Health Care Improvement Act.”

For many advocates, today was decades in the making.

Remember Health Reform efforts, Act I? Ellen Wu says CPEHN was founded in the 1990′s back when the Clinton administration was working on the issue.

“To see it 20 years later be able to… to come to fruition, is really an amazing experience.”

Wu got choked up. “It’s the biggest thing that happened since the 60s, with Medicaid and Medicare and we get to be a part of it. it’s really exciting.”

For people who don't speak English well, most health care terms are not as easily understandable as this sign. (Elliott Brown: Flickr)

As policy makers work toward setting up the California Health Benefit Exchange–the marketplace where individuals and small businesses will be able to buy health insurance–they’re grappling with questions on two fronts: what benefits the policies will offer and how to ensure that people enroll. According to a new report, 2.6 million adults under age 65 will be eligible for federal tax credits to buy insurance in this new marketplace. Of those people, 67 percent will be people of color, and 40 percent (or just over one million adults) will speak English less than very well. This lack of English proficiency could be a barrier to these people enrolling in the exchange, according to the report [PDF].

Ellen Wu is Executive Director of the California Pan-Ethnic Health Network, one of the sponsors of the report. “Language poses a barrier when people try to enroll in coverage programs,” she said in an interview. “We know that it’s just confusing for those of us who DO speak English well, and for those who have a different language other than English, it’s even more difficult to first find the materials in their language and second to understand the terminology.”

The report draws on a model created by the UCLA Center for Health Policy Research and the UC Berkeley Labor Center. It found that people with limited English skills were expected to enroll in the Exchange at lower rates than those with solid English skills. Of those million people with limited English skills who will receive subsidies, 53 percent are expected to enroll by 2019 “if language is not a barrier,” says the report. But if there is not “appropriate and effective multilingual outreach and education,” enrollment will fall to 42 percent, meaning 110,000 people will not enroll due to a language barrier.

Wu says she was not surprised by the study’s findings. “We hear from our communities, it is very difficult for people to find information in a language they understand,” she said. “This is an estimate and a model, just one piece of information of how critically important it is to not do the same things we’ve been doing before. … The population of the newly insured under the Affordable Care Act is different, and we have to DO things differently to make sure that they’re all included.”

Wu explained that the people eligible for the subsidies are people who have been chronically uninsured for much of their lives, that they are majority people of color and 40 percent don’t speak English well “which looks very, very different from our currently insured population.”

In an email, Peter Lee, Executive Director of the California Health Benefit Exchange had taken note of the study’s findings. “This study affirms the focus of the Exchange on developing strategies to reach out to diverse California communities to maximize enrollment in expanded health coverage beginning in 2014. The California Health Benefit Exchange is committed to offering a consumer-friendly experience that is accessible to all Californians, recognizing the diverse cultural and language needs of those we serve.”

The report included several recommendations to ensure that all eligible Californians are enrolled in the appropriate insurance program. Not surprisingly, the first recommendation is to make information available in multiple languages–a minimum of 13 which is the same number of languages the Medi-Cal Managed Care program uses. Wu also speaks of a “no wrong door approach, so that no matter where a newly eligible person goes, if it’s in person, over the phone or online that immediately they get help in the language that they need.”

The report also details the need for culturally and linguistically appropriate outreach. This is where the state must turn to community advocates, Wu says. “We feel that it’s very important for state agencies, particularly the Health Benefit Exchange to partner with community organizations who have long served communities of color and people who don’t speak English very well and are trusted resources to do outreach and enrollment.”