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MELISSA BLOCK, HOST:

This is ALL THINGS CONSIDERED from NPR News. I'm Melissa Block.

AUDIE CORNISH, HOST:

And I'm Audie Cornish.

We're going to focus now on big challenge for California's health insurance marketplace: reaching the state's many ethnic communities. Nowhere is that more true than in San Francisco. Less than a century ago, Chinese immigrants were barred from many of the city's hospitals so they created their own health care system. And Sarah Varney reports it's now thriving as Chinese-Americans adapt to the Affordable Care Act.

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SARAH VARNEY, BYLINE: San Francisco's Chinatown is a city within a city. Built by Chinese immigrants in the latter half of the 19th century, Chinatown was a refuge from the era's vicious prejudice. But it was also somewhat of a prison. Chinese residents weren't allowed to leave the area after dark. They were barred from local schools, and when it came to medical care, they were on their own.

LARRY LOO: Chinese Hospital Association really formed back in 1899, back in the days when really a lot of the residents in Chinatown really didn't have access to modern health care.

VARNEY: Larry Loo was born in Chinatown at Chinese Hospital. In its early days, it was called the Tung Wah Dispensary, the only medical facility inside the Chinatown gates offering Western medicine. It was rebuilt in 1925. And even after Chinese-Americans and other Asian immigrants were welcomed elsewhere in San Francisco, loyalty for the hospital endured.

LOO: I'll tell you, great thing about the hospital here is the staff can speak multiple languages. The doctors speak multiple languages. Your pharmacy speaks multiple languages. And the food, it's actually very good Chinese food. I have to tell you that.

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VARNEY: The hospital now runs its own health insurance company called Chinese Community Health Plan. And it's competing against well-known brands, like Anthem Blue Cross, in California's health insurance marketplace. The Chinese plan is tiny by industry standards with just 15,000 members. It has long sold health coverage to Medicare beneficiaries and local businesses. But it's finding success with a new group of customers: young, uninsured Chinese immigrants who work in the city's restaurants, laundries, and produce shops.

Irene Louie manages the health plan's busy walk-in center in the heart of Chinatown.

IRENE LOUIE: We have 93 percent of our membership that their primary language is Chinese or Cantonese, Mandarin.

VARNEY: But that language barrier hasn't stopped word from spreading that residents now face federal tax penalties for failing to have health insurance. At a nearby insurance enrollment center in Chinatown, there is a steady line of people waiting to buy coverage.

Erika Zhou is here. She's 20 years old, young and healthy and without health insurance. She emigrated from China to the U.S. 18 months ago and got her Green Card. And she's since found a steady waitressing job.

SAM HO: (Foreign language spoken)

ERIKA ZHOU: (Foreign language spoken)

VARNEY: Sam Ho, an enrollment specialist, shows Erika her options on a computer screen: The Chinese Community Health Plan appears in Chinese characters. Erika earns too much to qualify for a subsidy and she picks the Chinese plan, since it's the lowest price by far and she doesn't expect to use it much.

ZHOU: I didn't go anywhere to see a doctor. I didn't get sick for whole year.

VARNEY: Although Erika knows some English, she says she wants to speak to her doctor in Cantonese if something were to happen. Language access is critical to Chinese-Americans. Among the many immigrant groups in the U.S., they are among the least likely to speak English. Although Asian-Americans make up 5.6 percent of the U.S. population, here in San Francisco, one out of three residents is Asian, the vast majority Chinese.

That could explain the Chinese health plans' remarkable success selling policies on California's competitive exchange: the company has already surpassed its sign up goal for the entire year, and it's only January. Irene Louie says her walk-in center caters to Chinese sensibilities.

LOUIE: We like to talk to people in person. Face-to-face, just get it over with it. You know, have the question and, you know, resolved.

VARNEY: There are other cultural distinctions. When customers do call in, it's impolite to ask their first name or other personal details at the beginning of a conversation. And don't expect sterling customer reviews. Even though the service - and the hospital's famed rice porridge - might be excellent, Louie says Chinese-Americans are tough customers.

LOUIE: We tell them 1-to-10, how do you like the service? They will say: Oh, I give you a seven. And then we ask why? Can you give us higher score than seven? They say: Oh, no, no, no. I think seven is very good. They are afraid if I give you the highest score then you won't make any improvement.

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VARNEY: Any bitterness among Chinese-Americans over the years of exclusion from San Francisco's hospitals has long since subsided, says Larry Loo. In fact, he hopes to attract non-Chinese customers to the health plan.

LOO: Even though the delivery system has a very strong mission to ensure that Chinese community is taken care of, that it's also here to serve everyone else.

VARNEY: Still, Chinatown is investing in its own once again. A new, more modern Chinese Hospital is under construction.

For NPR News, I'm Sarah Varney.

CORNISH: Sarah Varney comes to us from our partner Kaiser Health News, a nonprofit news service.

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