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Cultural Competency and the Rollout of the Affordable Care Act

A note for our readers: the views reflected by the authors do not reflect the views of ASPA.

By Laura Caccioppoli

Cultural competency within health care is extremely important because, in many cases, it is a matter of life or death. Every day people from various ethnic, religious and socioeconomic cultures obtain the use of health care services. Not having access to translated materials or interpreters both limits the resources a person has to make important medical decisions and jeopardizes the well-being of the patient. Moreover, understanding and respecting religious and cultural traditions can dramatically increase the quality of care an individual receives. A quick glance at the recent Census will show that our country is only getting more diverse, and that these challenges are here to stay.

caccioppoliThe recent rollout of the Affordable Care Act (ACA), has shown how culturally competent policies and practices are mission critical to service delivery, and should be considered a case study for public administrators on the importance of culturally competent service delivery. Consider the Latino community, who before the implementation and rollout of the ACA, registered among the bill’s highest supporters. According to a Pew Research poll, in September 2013, 61 percent of Latinos supported the bill as compared with 42 percent of the public. By March 2014, the public’s support for the law dropped to 41 percent, but the Latino community’s support plummeted to 47 percent. Not only is the Latino community’s support for the ACA dropping, they are also not signing up for the law. In fact, Latinos have only seen a 0.8 percent decline in the number of uninsured.

These data beg the question, why did the group that registered with the highest support of the health care law have the lowest enrollment rates? It seems that a major contributing factor could be the lack of culturally competent advertising and enrollment strategies.

Many of the ACA’s early advertisements targeting the Latino community were not produced with cultural competency in mind. For example, the advertisements assumed that Latinos would want to shop on the online marketplaces for insurance. Instead, many Latinos prefer to do their shopping in person or over the phone. However, these advertisements included only a web address and no phone number or a physical address where people could go to receive help navigating the marketplace. In addition, for low-income families without computer access, an advertisement with only a URL may not be helpful for the enrollment process. Indeed, computer access is not solely a challenge for the Latino community, but without a phone number of physical address, those without computer faced added challenges to the enrollment process.

For those Latinos who speak Spanish and have a computer, there were still barriers to enrollment. First, Spanish advertisements linked to the English version of the website, which was probably confusing. There were also instances where links on the Spanish site would redirect users to the English site, which would make it difficult for Spanish speaking users to navigate the website effectively. Moreover, there were complaints about poor translation of the English website into Spanish. One of the examples, this Washington Post article cites, was the use of the translated word for “prima” for “premium.” The trouble is that this word also refers to a female cousin in Spanish. While the Obama administration pointed to the fact that the Spanish television network, Univision, used the word “prima” to describe premiums; the overall rollout neglects the fact that the Latino community, which constituted high rates of the uninsured population, may not have the health literacy to understand what a prima/premium, copay or deductible even is. Even if Latinos were able to find a phone number, there has been a shortage of Spanish speaking counselors to help them.

Due to a lack of educational promotion of the ACA in the Latino community, there has also been a lot of confusion surrounding ACA enrollment and the potential for deportation. For many in this community, there is a fear that their family members may be deported if they enroll in the exchanges. Currently, only legal immigrants are eligible for coverage. However, it is not uncommon for Latinos to have a mix of immigration statuses in their families. Although information obtained regarding immigration status is only used for determining eligibility and is not turned over to the Department of Homeland Security, this information has not been clearly communicated to the Latino community. Certainly, the threat of a family member’s deportation is enough to make most people hesitant to enroll.

It would certainly be misleading to present the rollout of the Affordable Care Act to be entirely lacking in cultural competency. In fact, the Obama administration did make a few attempts to be culturally competent, albeit, not enough. Most importantly, the administration created a website for Spanish speakers, CuidadoDeSalud.gov. Although there were bugs in the website – which involved the abovementioned translation issues and redirects to the English version of the site – the administration should receive credit for attempting to reach out to the Latino community. There is also evidence that the administration moved swiftly to correct errors on the website. In fact, the CuidadoDeSalud.gov website did not initially allow users to compare plans; the website would just redirect users to the English version of plan comparisons. However, the administration quickly rectified the issue after listening to complaints.

Indeed, it is clear that in terms of creating a culturally appropriate advertisement and enrollment campaign, the ACA rollout was unsuccessful. The reason why this is so very important, especially when it comes to the Latino population is twofold. First, the Latino population is on average healthier and younger than other uninsured populations. In fact, the median age of Latinos is 27 years old as compared to 37 years old, which is the public’s median age. These are the types of people needed to enroll, young adults, who can help offset the cost of the elderly who consume more medical services.

In contrast to the Latino population that is 31 percent uninsured, 21 percent of African-Americans and 13 percent of white people are uninsured. Because there are so many uninsured Latinos, and because the Latino population is on average younger and healthier than the public, their enrollment will help offset the cost of providing insurance to groups, such as the elderly, who use more health care services. The Latino population is therefore a crucial group to be enrolled if the Affordable Care Act is to succeed.

Public administrators should be using the rollout of the ACA as a case study. Considering that the 2010 Census data show us that the Latino population is growing at a fast rate, it is important that public administrators, who are often the ones in charge of providing service delivery, keep in mind the demographics of the people they are serving. The lack of appropriate cultural awareness in the rollout of the ACA contributed to both the lack of Latinos enrolling in the exchanges and ineffective service delivery.

All persons need access to quality health care. Having quality care means going beyond treating a symptom, it means treating the whole person while respecting their culture. The first step is enrolling people in health insurance and public administrators are in the unique position to be able to help facilitate culturally competent service delivery through the ACA.


Laura Caccioppoli is pursuing her masters in political science and a certificate in nonprofit management at Villanova University. [email protected].

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