Hispanics and effective health care communication in the United States

Health care reform and immigration reform are heated subjects in the United States of America. The main research question of this paper links the two by analyzing the effectiveness of government communication about the Affordable Care Act (ACA) towards Hispanics. The expansion of health insurance does not necessarily ensure access to care for all members of this minority group. Apart from questions of eligibility, immigrants face other obstacles, such as language, cultural differences, and perceptions about health care. These realities should be taken into consideration when vangehuchten & willems: hispanics 281 communicating with Latinos, but was this the case for ACA? This paper presents the results of a corpus-based research of six government sources and six sources from nonprofit organizations on ACA. An analysis of effective communication using 11 parameters was performed on this corpus and showed that undeniable communicative flaws, together with the too frequent lack of linguistic accuracy in Spanish, point out the need for experts when it comes to communicate publically with ethnic minorities.


Introduction
In 2012, The United States of America had approximately 48 million uninsured citizens.
Consequently, health care reform is currently one of the most controversial political issues of the country. After taking office in 2008, President Obama transformed the proposals for reform into a law, known as 'The Patient Protection and Affordable Care Act' (ACA) which is also known as Obamacare. The most important consequence of Obamacare is that all legal citizens are now entitled to health insurance, without the fear of being rejected by private insurance companies.
Universal Health Care has been something unknown to most citizens of The United States. Even though the U.S. is the highest spender on health care per capita in the world, these services are not available to everyone (Mauk & Oakland 2009). In 2010, about 16 percent of the total inhabitants in the U.S. did not have health Insurance (Tate clac 63/2015(Tate clac 63/ , 280-314 vangehuchten & willems: hispanics 283 2013. The United States was ranked 37 out of 191 by the World Health Organization for the performance of their health care system (Murray & Frenk 2010). The main reasons for this outcome are the lack of universal care and poor access to health care (Mauk & Oakland 2009).
There are basically three possibilities for health insurance in the U.S., one being private and the two others public. Most Americans are insured in the private sector through Health-Maintenance Organizations (HMOs). The poor are insured publicly through a program called Medicaid. This program provides federal grants to states to treat the poor and needy under 65. A second public health program is called Medicare, which covers much of the care of the elderly and disabled people. This program is sponsored by the contributions made to the social-security fund. However, there is a major group that falls through the cracks of the current system. These are the people that do not fit into one of the groups mentioned above. The working poor, for example, might not qualify for Medicaid, and if their employer does not offer insurance they are probably unable to afford to buy private insurance. Fifty million Americans remain uninsured.
The Patient Protection and Affordable Care Act (ACA) was a top priority of president Obama when he took office in 2008 to resolve this problem. During his first term, he created a background for the ACA which consisted of determining minimally acceptable insurance benefits, employer responsibilities, clarifying the individual mandate (Fontenot 2014). This individual mandate is new and implies a health insurance plan for all citizens. If people abstain, they will be penalized.
Given the compulsory character of the ACA, effective communication towards the persons that should subscribe the insurance is essential, since people either think it is unnecessary or they cannot afford it (Tate 2013). The following section explains why it is important in this context to focus on the specific situation of the Hispanic immigrants.

Health care and Hispanics in the States
According to the US census Bureau, in 2012 there were 52.4 million Hispanics living in the United States. This means that roughly speaking, 1 out of 6 people are Hispanic.
Hispanics can be divided into three different groups, according to their legal status.
These groups include legal citizens and unauthorized immigrants. The third group is called Lawful Permanent Residents (LPRs), who have been living in the U.S. for less than five years legally (Capps & Roseblum 2009). In 2009 there were 4.2 million LPRs in the United States, and most of them did not get insurance through their work, since the 1996 Welfare Reform Law required a five year waiting period during which LPRs were unable to enroll into Medicaid (Capps & Roseblum 2009). During the enactment of the ACA, lawmakers were conflicted whether to include LPRs in the health care reform. In 2009, Obama signed the Immigrant's children Health Improvement Act (ICHIA), hereby giving States the option to expand medical care to LPR children and pregnant women (Ku & Jewers 2013). Most states immediately participated in the program, and some are still considering doing so. Even though most children and pregnant women received coverage ever since, adult LPRs were initially left out of the Medicaid program (Ku & Jewers 2013). Finally it was decided that LPRs with income levels below 400 percent of the poverty level (which is the vast majority) will qualify for either Medicaid or for subsidies when buying insurance through the insurance exchanges.
In all, nearly two out of three Hispanics are now eligible for health insurance, which accounts for 31.5 million people. According to Ku and Jewers (2013), this means that overall insurance coverage has improved in the recent years for immigrant families.
However, 'Insurance coverage does not, in and of itself, ensure access to care' (Ku & Jewers, 2013: 11). Apart from questions of eligibility, immigrants face other obstacles.
Barriers to enter are language, cultural differences, and perceptions about health care.
With respect to their linguistic situation, according to the U.S Census (2009) (n.d.). At this respect, it is important to be aware of the fact that 38 percent of the Hispanics are considered adolescents, and that the average age of Hispanics is 27.5 while the total population has an average age of 36.9 years.
Given the specificity of the Hispanic target audience, it is the purpose of this study to assess the existing public communication on ACA regarding its effectiveness. With this aim, we elaborated an assessment tool that was applied on a corpus of 12 communication initiatives on ACA towards Hispanics. In the next section, we will present this tool.
3. Effective government communication: a tool for assessment Horsley, Liu and Levenshus (2010) define professional government communication 1 as serving the informational needs of citizens and helping people to make informed decisions. However, according to these authors, there has been minimal theory-driven research in the field of government communication, as the prevailing research studied this topic within the scope of corporate or organizational communication theory. On these lines, Horsley, Liu and Levenshus (2010: 292) offer a summary of communication theories and models that have been applied to government communication. Of the five models they discuss, the Contingency Theory of Accomodation model (Cancel, Cameron, Sallot & Mitrook 1997) seems the most appropriate one for our purpose, as it explains how the practice of public relations is contingent on factors that vary across time, environment, situation and publics, which makes it different from the more traditional models of public relations communication. It is the basic principle of the Contingency Theory of Accomodation model that there is no one-size-fits-all approach, and that each specific public communication goal requires specific communication strategies. Therefore, we decided to take this model for organizational communication as a starting point, and to apply its basic principle to the traditional components that are clac 63/2015, 280-314 1 In this paper, 'government communication' is used as a hyponym of 'institutional communication '. vangehuchten & willems: hispanics 286 present in any communicative process, namely context, code, sender, message, media channel, receiver and feedback (cf. Jakobson 1960). This way, the consideration of various specific aspects of public communication that enhance its effectiveness allowed us to distinguish 11 relevant parameters for assessment, as shown in Figure 1 below. The components 'code' and 'context' were split over various parameters, as will be discussed in greater detail in 3. A first variable that needs to be controlled by the sender is the visibility. Each sender of official institutional communication should have a corporate identity. This can be achieved by using official government symbols. In this way, the public will recognize the sender straight away.

The media channel
Government communication is mostly directed towards the media, which act as an intervening variable between political entities and citizens (Sanders, Canel Crespo & Holz-Bacha 2011). With regard to different media types, digital media are on the rise.
Digital communications include social media, email, intranets, websites and interactive TV (Jobber & Chadwick 2012). According to Azyan (2010), governments are facing several challenges when dealing with digital media. The digital generation is in need of a two-way dialogue with the government, hereby no longer wanting to be plain citizens but rather 'consumers' (Azyan 2010). However, the social media hype has caused for governments wanting to engage with citizens, with often achieving the opposite results.
Usability tests have shown that government websites are often organization-centric, confusing and complicated, which makes it complicated for citizens to find the relevant information.
On the other hand, there are also a lot of benefits to using digital media. Digital media are often low in costs, they allow for easy global reach, it is easy to measure the number of visitors to a website and they allow for interactivity or feedback (Jobber & Chadwick 2012).
Apart from digital media there are also other channels such as broadcast (radio and TV) and print (newspapers, magazines, brochures), outdoor (such as billboards) and indoor (indoor posters, shelf-displays). Distribution across different media channels is very important. In this way the government reaches more people and because of the competition with other news outlets, it may increase the likelihood of accurate and fair media coverage (Liu, Horsley & Yang 2012).
As a consequence, government communication should take into account that the distribution is to be made through multiple media channels in an integrated or interconnected manner.

Therefore, it is important that recipients experience an open line of communication,
which is best established by forming a dialogue. In this respect public feedback is crucial. People should be able to reach the government for feedback or questions. Also, recipients should perceive the news as meaningful. But what is meaningful to some might not be relevant to others. As a result, the audience should be segmented. At this respect, the above cited Plain Language Act underscores the importance of addressing 'separate audiences separately' (PLA 2010). Therefore, it seems logical that a target audience of Hispanics should be approached in Spanish. Furthermore, they should be segmented according to their legal status, as well as to their age (e.g., Hispanic adolescents should also be approached separately).
By summarizing the above cited parameters, we composed the following checklist for effective government informative communication that takes into account all of the parameters as well as the context of each of them:

Illinois Coalition for Immigrants and Refugee Rights-Brochure
The Illinois Coalition for Immigrants and Refugee Rights (ICIRR), is a non-profit organization that promotes 'the rights of immigrants and refugees to full and equal participation in the civic, cultural, social, and political life of our diverse society'. The brochure 'Información sobre las opciones de atención médica para inmigrantes en Illinois Guía de recursos comunitarios' will be the source of analysis. There was no date on the brochure. This source was chosen because it acts locally, on the one hand, and it uses a different media channel, on the other.

Analysis and results
The 12 sources are assessed by designating one point or half a point to each parameter.
There are 11 parameters, 9 that can earn up to a one point and 2  might not be completely covered by the source; in that case there will be a subtraction of -0.5. Some sources have extra properties which will count towards a 0.5 bonus point.
Each category (government and non-government sources) contains 6 sources. Each source can earn a total of 10 points. When added up, the 6 sources can earn a total of 60 points.   identity by not using an official symbol. Also, the reader does not know that the website is part of a federal program.

Government Communication
Furthermore, both Illinois and Kentucky scored low on the parameter 'Collaboration between entities'. This parameter underscores the idea that the most important stakeholders in the AC are connected to each other. These entities should refer the target audience to their peers, in order to help them get the right information from the right entity.
We will now discuss in greater detail the results of the indicators for the parameter 'Clarity', as represented in Table 4. The indicator that received the lowest score is 'Logical organization'. None of the government sources were able to logically structure their texts, mainly because of the length and complicated structure of the sentences, which prevents their readability.

Some examples:
A veces, a pesar de sus mejores esfuerzos, puede que encuentren retrasos causados por el volumen de visitantes a CuidadoDeSalud.gov y a nuestro centro de llamadas, periodos de mantenimiento, u otras situaciones especiales que les impiden terminar el proceso a tiempo. CuidadoDeSalud Facebook Page Las personas y familias que cumplan con ciertos requisitos de ingresos y que no tengan un seguro de salud económico ofrecido por un empleador o un programa clac 63/2015, 280-314 vangehuchten & willems: hispanics 302 del gobierno que cumpla con los requisitos mínimos de cobertura, podrán recibir créditos fiscales que reduzcan el costo de la cobertura. Covered California Website Nevertheless, most sources respected the inverted pyramid style and kept to one idea per paragraph. The source that failed to do so is Kynect Kentucky . Even though the sender uses short, telegram-style sentences, they do not comply with the rules of the PLA.
Overall, the sender does not start with a topic sentence on the beginning each paragraph.
As shown in the example below, the reader will assume that the first sentence will contain information about savings on their premiums, but this does not seem to be the case:
Also, with respect to the indicator 'Informative headings', we observed that the sender does not use question headings, but a combination of statement and topic headings.
According to the Plain Language Act, topic headings are often too vague. This turned out to be the case: the headings on this website are not helpful since they do not assist the reader to find the relevant information.    There are six different professional, non-government sources that score on average an 8 out of 10. They all score the maximum amount on the parameters 'Visibility', 'Collaboration with entities', 'Neutrality' and 'Integrated media platform'.
There is only one thing that stands out. Both the KFF website and the Brochure of the ICIRR score only half a point on the parameter 'Clarity'. This will be discussed more thoroughly when commenting on the results represented in Table 6.
All in all, the KFF video is the best practice of non-government sources. The good thing about this source is that it complies with all of the parameters. What stands out is that it appeals to everyone in the family, including adolescents, since it is an animated video with funny characters. These characters are able to get a serious message across. They do this in a very simple way by using every-day language and humor, which increases its persuasive character.
When comparing with the Government Communication sources, it is clear that the Nongovernment sources score considerably higher on the scale of effective communication. What both categories have in common is that all senders score low on the parameters 'Adolescents' and 'Legal status'. These indicators require very specific information, and especially the video sources fail to cover all important aspects of the ACA and at the same time focus on reaching adolescents and people with a different legal status in less than a few minutes. The KFF video is an exception, but this video is considerably longer.
We will now focus on the results for the parameter 'Clarity' and its indicators, as represented in Table 6:

Discussion and conclusion
The analysis of the corpus shows that non-government sources score considerably higher on the measurement scale than their government peers do. The average grade for a non-government source is 8/10 while the government received a 6.58/10 on average.
Overall, the parameters that received low(er) scores were 'Collaboration between entities', 'Complete information', 'Timing' and 'Clarity'. These observations allow to draw some important conclusions.
In order to reach the target audience with the right information from the right entity, the Also, the sender should offer complete information about the topic. Otherwise, the recipient might get confused or even frustrated for not being able to find the information relevant to them. The goal of the ACA campaign is that people will get informed and eventually sign up for health insurance. If they are misinformed or not informed well enough, the recipients may decide not to enroll. Regarding the recipients, it is unacceptable that the parameter 'Legal status' only scored 50 percent, knowing that Hispanics can have three different legal statuses which decide if they are eligible for health insurance through federal programs, health insurance exchanges or for none at all. Given the fact that a lot depends on one's legal status, the sender should offer specialized information for each of these groups of recipients. In a similar way, the group of adolescents should be given more importance, since it was only addressed 4 out of 12 times.