Chan, a Chinese immigrant in her early 30s, walked out of a clinic with a scarf wrapped around her nose Thursday as snow fell in Sunset Park, Brooklyn’s Chinatown. “I just had a procedure on my nose for a sinus infection,” said Chan, who declined to provide her full name. “I just arrived from Hubei, China, only a few days ago, and now I’m sick.” Chan paid for the procedure in cash because she didn’t have health insurance. “Thankfully, the cost was not too bad, but I’m definitely interested in getting insurance, since I plan on staying and getting a job here,” she said.

Chan, similar to many Asian immigrants in the United States, is part of a key demographic targeted by health care activists working to sign up millions of new applicants before Sunday's deadline to enroll for coverage this year under President Barack Obama’s Affordable Care Act. The push comes amid soaring immigration rates in recent years from Asian countries to the U.S. But the ongoing efforts to sell health insurance to Asians have been impeded by many obstacles, including the lack of understanding about why health insurance is so important, concerns about whether the cost of coverage is worth it and the various misconceptions about how the federal health care law works.

“When we first started, we realized even before we can start doing ACA outreach, we have to do health education first,” Regina Lee, chief development officer at Charles B. Wang Community Health Center in New York City, said. The clinic serves mainly Asians, and roughly 26 percent of its clients in 2014, or about 12,000 patients, did not have health insurance. “A lot of people don’t understand the U.S. health system,” Lee said.

Chinese Immigrants And Health Insurance Coverage

Nonwhites make up roughly 40 percent of the United States’ population, of which Asians comprise 5 percent. But minority groups collectively account for more than half the country’s uninsured. Health care activists have launched similar efforts to recruit Hispanics, blacks, low-income mothers and other groups to sign up for the federal health care law. But in many ways, Asian immigrants represent a unique challenge. Many have a poor proficiency in English or don't speak or understand the language at all. They can also be unfamiliar with Western customs, including how the U.S. government works.

Asian-Americans include many different ethnic groups. Of the 16 million Asians living in the United States in 2013, according to Census estimates, 3.6 million were Chinese. Approximately 12 million Asians were foreign-born. They are mostly legal immigrants.

Immigration from China remains strong, with those immigrants recently surpassing Hispanic arrivals in 2012, according to the Pew Research Center. That puts Chinese immigrants as the second-largest immigrant group after Mexicans at 11.6 million. Immigrants from India, with 2 million people, were previously in second place.

About 41 million individuals were uninsured prior to the start of the ACA in 2013, according to data from the Kaiser Family Foundation, a nonprofit health care foundation. The number of uninsured Asian-Americans stands at 15 percent, just slightly below the national average of 16 percent. As of Jan. 16, 7.1 million people have signed up on the federal marketplace, and another 2.4 million were estimated to have obtained health insurance through the 14 states that have established their own marketplace, according to An ethnic breakdown of the numbers was not available.

Large U.S. metropolitan cities such as New York City and San Francisco tend to have the highest concentration of Asians. San Francisco’s population is 33 percent Asian, and New York City's is about 13 percent. Most Chinese immigrants in New York City and San Francisco are legal immigrants who qualify for private insurance.

Flora Ferng, director of programs at Asian Americans for Equality (AAFE), said that 60 percent of AAFE’s clients, of which over 56 percent are Mandarin-speaking and 24 percent Cantonese-speaking, are premium-paying, and 36 percent are on Medicaid. Undocumented immigrants do not qualify for state-assisted health insurance, but San Francisco and New York City have systems that provide health care for those without insurance, with some clinics charging these immigrants based on their ability to pay.

Closing The Coverage Gap

The U.S. Department of Health and Human Services has recognized the coverage gap among ethnic minorities. “The health care law is working to address long standing disparities in access to health care that have affected minority communities,” Kathleen Sebelius, HHS secretary, said in a press release, adding that 1.9 million uninsured Asian-Americans, or eight in every 10 Asian-Americans, now have new options for quality health care under Obamacare. About 68,000 New Yorkers who speak Chinese, Korean and Hindi will gain health insurance coverage upon full implementation of the ACA, according to a 2013 report from the Urban Institute, a D.C.-based think tank that evaluates economic and social policies.

The Affordable Care Act, commonly known as “Obamacare,” was passed by Congress and then signed into law by Obama in 2010. Under the ACA, states can set up a health insurance exchange, or marketplace, where people can shop and compare plans. People with existing health conditions can no longer be denied health care coverage. All of the insurance plans in the exchange had to fulfill certain requirements.

But many Asians don't see the appeal of the health care law. “I give you money, and what do I get in return? Nothing,” Youngsoo Cho, marketing director for San Francisco-based insurance provider Chinese Community Health Plan (CCHP), said, of how some Asian clients perceive health care insurance. “Then there are some who see it through the lens of auto insurance: If I have an accident, I’m covered. But that’s not exactly how insurance works.”

High Costs

A lot of Chinese immigrants have also been reluctant to buy insurance because it’s expensive, said Lee from Charles B. Wang. “But we have to convince them, ‘No, it is to protect your health and also to protect your financial security,’” Lee said.

Many Asians in New York or San Francisco are either self-employed or working in small businesses that are not likely to offer health benefits, according to the Coalition for Asian-American Children and Families (CACF). Many of them work in cash-based industries for low pay, and some 28 percent reported a time last year when they skipped seeking medical attention because they could not afford it, according to the CACF.

“If I fall sick, I’ll just go to the pharmacy and get over-the-counter medication,” said one roadside florist in her 40s who only gave her last name as Tan. She said she was from the Fujian province in China and had been working in Sunset Park, Brooklyn, for “many years.” When asked what would happen if she were to fall gravely ill, she said that had never happened before and she didn’t see the need to apply for health insurance.

Even those who can afford it are not necessarily pleased with the costs. “I have insurance, but every time I go to see a doctor, I have to make a co-pay of $70 on top of my premiums,” said the owner of a hair salon in Manhattan’s Chinatown who only gave her last name, Yu. “For those who are uninsured, the clinics only charge them $50. It’s so unfair! The way I see it, it’s better to be uninsured.”

Ferng, from AAFE, said that such claims were common misconceptions among the Chinese community.

Selling Obamacare To Asians

Many Asians are also unsure about how to apply for and use Obamacare. “When I heard about Obamacare, my insurance provider was telling me that it will be more expensive,” said Yu, the salon owner who had insurance for many years. When asked if she had looked on the state’s marketplace to see if it would be cheaper, she said she hadn’t. “But, if it’s cheaper, I'll definitely switch for sure!” she said. She wasn't aware of Sunday's deadline.

Confusing media reports can scare off prospective health insurance consumers, Ferng said. “When you open a big newspaper, the first thing you see is ‘ACA could be very expensive’ or ‘ACA could be gone,’” she said. Those kind of reports can shake clients’ confidence in the federally designed program.

Health care activists said they have spent years trying to convince Asians that the federal care law could help improve their access to health care. Enrollment centers where people can ask questions in person have helped such efforts. “A physical location where Chinese folks can walk up helps a lot,” Cho, from the CCHP, said. “This is helpful when you’re more accustomed to dealing with someone of your own ethnicity.”

Tie-ins with ethnic media have also been very important. “When ACA first rolled out, local papers realized their importance in spreading the word,” said Lee from Charles B. Wang. “We did a special insert with the Sing Tao Daily to promote the ACA. We also participated in a forum sponsored by [Chinese daily] World Journal.” Lee said that of its 47,000 patients and 258,000 visits last year, about 90 percent of patients were served in a language other than English, and 86 percent have incomes below 200 percent of the poverty level, or about $40,000 yearly household income in a family of four.

“I heard about AAFE and Obamacare from an event that was held at the Fei Long Supermarket" in Brooklyn, said Hua, 37, a Fuzhou native who has been in the United States for more than 10 years and has applied for insurance through AAFE. She had sporadic insurance coverage for the past three years, only occasionally renewing it, but has decided to settle on a stable plan now. “I’m glad that I will be covered now, because even though I’m still relatively young and healthy, you never know when accidents will happen,” she said.