When Biak Sung escaped from Myanmar in 2011, there was no health insurance for people like her.
So it's not surprising that months after buying a plan on the Affordable Care Act marketplace, Sung, 27, a mother of two and a political refugee - whose English consists of "hello" and "thank you" - doesn't know how to use her family's policy.
Last week, Sung, whose husband works full time, went to the Southeast Asian Mutual Assistance Association Coalition (SEAMAAC) in South Philadelphia to learn about her new policy, an Independence Blue Cross silver-tier Keystone HMO Proactive plan.
"She doesn't know what steps to do next and she is concerned," said Zing Thluai, a SEAMAAC worker who speaks one of three Burmese dialects.
For 30 years, SEAMAAC has been addressing the concerns of Asian immigrants in this region. In the fall, it realized the ACA enabled many of the city's 23,000 uninsured Asian Americans to buy coverage.
Amy Jones, SEAMAAC's health director, developed a program that ultimately got 451 families covered. For that, Jones was among 11 people recently awarded the White House Champions of Change for ACA outreach to Asian Americans and Pacific Islanders.
The task was tougher than expected, said Michael Donnelly, SEAMAAC's health coordinator, because most clients don't speak English and need help with basics like paying bills. Add to that an innate fear and distrust of authority.
Backed by 11 bi- and multilingual staffers and seven volunteers trained as certified application counselors, Donnelly and Jones fanned out to discuss premium payments, deductibles, co-pays, coinsurance, and preexisting conditions.
They even tried explaining the tiers and networks embedded in the silver-tier Keystone HMO Proactive plan. Members can pay no deductible at certain hospitals and as much as $3,000 at others.
"Just try explaining the tier concept," Donnelly said. "If you speak perfect English and lived in this country 20 years, you are going to have trouble" grasping it.
The group also confronted political concerns. People opposing the ACA were telling others that signing up meant they would forfeit next year's income-tax refund.
When Sung learned that her Proactive plan would cost 27 cents a month, she was worried because others she knew were paying a $35 monthly premium. She asked her navigator to make her premium $30 a month to preserve their tax refund.
"This was [an] organized and coordinated effort to throw false information out there to scare people," said Thoai Nguyen, SEAMAAC's chuief executive officer.
When the marketplace closed last month, the SEAMAAC staff sighed with relief. And then they realized their real work had begun. Many clients finally had a plan, but most didn't know the basics of how or when to use it.
So the staff started calling clients, asking whether they had paid their premiums or needed assistance. It wasn't unusual to hear people say they had received a bill but didn't know what to do with it because they weren't sick. Staffers had to explain that the bill must be paid every month, sick or not.
Clients also said they were still using free clinics rather than a private doctor. The group has now begun teaching people how to find a physician and make appointments. And, no, members tell clients, you don't have to be near death to see a doctor.
"Preventative medicine is a tough concept for most people in developing nations," said Nguyen. "The idea of going for an annual checkup when you're not sick is strange to them. You only go [to a doctor] when it is possibly a matter of life and death."
Seeking care for issues like depression and alcoholism is also foreign to many Asian immigrants and refugees.
"Mental health or behavioral health is a foreign concept to most people," Nguygen said. "You're crazy or you're not crazy. But there is no working up to crazy."