As a college-prep consultant, Marina Grijalva heard about the Affordable Care Act and how it would enable her to sign up for health insurance. But the enrollment campaigns — which the state poured tens of millions of dollars into — didn’t reach her sister or many other Latinos.

Had Grijalva not informed her sister of the new health law and walked her through the enrollment process, the 53-year-old woman may have remained uninsured this year.

She would not have been alone. About 52 percent of previously uninsured Latinos in California have gotten health coverage since last summer, according to a Kaiser Family Foundation survey released last week. However, signing up those who remain is likely to prove more difficult, the researchers said.

The survey found that of the 42 percent of Californians who remain uninsured, six in ten are Latinos and nearly half of that group is not eligible for coverage because of their immigration status. And most uninsured Latinos, including 37 percent of those eligible for coverage under the Affordable Care Act, responded that they are concerned that enrolling in coverage would bring unwanted attention to their family’s immigration status — a concern that federal agencies have repeatedly said is unfounded.

“People are confused,” said Grijalva, 37, who lives in Los Angeles.

“I also don’t think a lot of people in the Latino community know they have to sign up again for 2015 coverage.”

State officials are stepping up their enrollment efforts this month to prepare for open enrollment later this year. But some Latino advocates say Covered California, the state’s insurance marketplace, has a long way to go.

“Fact sheets in Spanish only became available this month, and events, such as bilingual information sessions, were often not well publicized,” said Sonya Vasquez, policy director of the Community Health Councils of Los Angeles.

Vasquez is concerned that despite the increased marketing budget, there still won’t be enough bilingual navigators to answer the questions of the millions of Latinos who need very basic information on health insurance just to become comfortable with the idea of applying.

Getting more Latinos to sign up faster this year is critical. The signup period is three months shorter than last year’s and will run from November 15 to February 15, 2015. Covered California has budgeted more than $100 million to try to encourage millions of Latinos to sign up for insurance or renew their coverage from last year.

Understanding cultural differences is key

Covered California has listened to complaints from Latino advocates about last year’s enrollment efforts and is making changes, said Dana Howard, deputy communications director for Covered California.

The agency was criticized last year for failing to translate materials accurately and for not understanding the way some Latinos think about health insurance or addressing their questions about it.

“Not everything translates culturally, generationally, or linguistically,” said Xavier Morales, executive director of the Latino Coalition for a Healthy California.

One example of poor translation last year was a frequently used tag line “a new state of health care” which Covered California translated into Spanish on ads, but which didn’t mean anything to most Latinos, Morales said.

A key problem was that Covered California often thought it could count on “one touch and done” for signing up Latinos, meaning a single contact such as an ad, a phone call or an email would prompt members of the Latino community to start and complete an application for health insurance, Morales said.

“The target [Latino] population does not trust the government system and as a result will need multiple contacts before they finally enroll,” Morales said. A good strategy would be to share stories of successful enrollments, he said.

“‘Seven touches and done’ should be the mantra for the next enrollment period,” Morales said, adding that contacts should include phone calls, in person conversations, emails, videos and mailings.

Morales and other advocates say Covered California also can’t overlook the fear that some mixed status families have that applying for health coverage could mean that undocumented family members might be deported.

“Examples of mixed status families successfully enrolling eligible members will go a long way to decrease [that] fear,” Morales said.

State learning from past mistakes

Covered California is planning to take advocates’ advice and produce videos that share successful enrollment stories, which will air this fall, Howard said.

Howard called the changes a “course enhancement” rather than a correction. He said alterations made early this year were effective in vastly increasing Latino enrollment by the time the general sign up period ended in March. The agency added phone numbers and physical addresses to flyers so that people could access information even if they didn’t have internet access.

Covered California plans to launch a new enrollment campaign targeted toward Latinos by early September.

“Reaching the Latino population remains one of Covered California’s top priorities,” said Covered California spokesman James Scullary. “We’re once again preparing a multi-prong approach to make sure we reach those communities.”

Covered California is also trying to increase the number of in-person and phone-based bilingual health insurance navigators, who can also go into the community to explain how to sign up and to be available for questions.

In June, for example, members of the Covered California staff, including executive director Peter Lee, attended the San Mateo County Fair. Bilingual staff members worked at a booth where fairgoers could ask questions and take materials about the upcoming sign up period.

But advocates wonder whether the state has made enough changes, particularly because enrolling the remaining uninsured Latinos is predicted to be more difficult.

“California is a prime example of how we can learn from our mistakes,” said Rachel Klein, director of organizational strategy at Families USA, a national health insurance advocacy group.

Enrollment predicted to be challenging