Lilian Saldana turned down Obamacare coverage once, and she might do it again.
With sign-ups set to resume Saturday, the 23-year-old Covina resident and her younger sister are hesitant to enroll because their parents are immigrants who are not citizens and therefore ineligible for benefits under the Affordable Care Act.
Saldana, an after-school tutor, admits she could put the insurance to good use for a checkup, but she worries about putting her parents at risk or creating a rift at home.
"We've always done things together as a family," she said.
The Saldana sisters are among roughly 600,000 Latinos in California who remain uninsured — despite qualifying for subsidized coverage under the federal health law. Latinos outnumber whites and Asians among the 1.3 million Californians who are eligible for federal aid and lack private health coverage.
California officials, sensing continued reluctance from people such as the Saldanas, are tackling the immigration fears directly for the first time in new TV ads. One commercial shows documents flying into a vault as a Latino man tells viewers their information is "confidential and private."
This is part of $95 million the Covered California exchange will be spending on marketing and outreach in the months ahead. California accounted for 15% of enrollment nationwide during the initial launch, and the Obama administration is counting on the Golden State to deliver another big turnout.
Open enrollment runs from Saturday to Feb. 15.
But it will be a hard sell to many Latino families of mixed immigration status.
People living in the U.S. illegally are not eligible for health-law coverage. For that reason, some residents are nervous about answering detailed questions about family members who aren't applying, and they worry that turning over this information could lead to deportation for spouses, siblings or other relatives.
Those fears were heightened this year when a wave of Central American children crossing the border illegally sparked angry protests and President Obama backed off immigration reform in the fall amid stiff opposition.
Despite repeated government assurances that no information is shared with immigration authorities, some Latinos are willing to gamble with their health rather than risk having their family torn apart.
"This is a very big deal in California," said Catherine Teare, senior program officer for health reform at the California HealthCare Foundation. "It's really hard for Covered California or anybody to make those concerns go away."
Compounding the problem, the state has often fumbled its outreach to this crucial demographic. Covered California opened last fall with no application in Spanish, bland advertising and a shortage of enrollment counselors in Latino neighborhoods.
State officials say they learned from their mistakes and expect to build on a late surge of Latino enrollment last March and April. There's little margin for error because the upcoming open enrollment lasts three months, half the time before.
"We have to address this issue of immigration status head on," said Peter Lee, executive director of Covered California. "We need trusted voices saying it's safe."
Overall, about 3.4 million Californians have gained health insurance in the last year through private insurance or an expansion of Medi-Cal, the state's low-income health plan. The percentage of Californians who are uninsured was cut in half to 11% by June, according to the Commonwealth Fund, a private foundation that studies health policy.
By mid-February, Covered California wants to sign up 500,000 more people to private health plans, in addition to the 1.2 million who did so during the first open enrollment.
Statewide, 62% of those who remain without insurance are Latino, according to a survey by the Kaiser Family Foundation.
About half of those people aren't U.S. citizens or legal residents, so they can't get insurance through the exchange or Medi-Cal. Among those who are eligible, 37% said they were at least somewhat worried that signing up for health insurance would draw attention to their family members' immigration status.
Hugo Ramirez, who manages Covered California outreach for nonprofit group Vision y Compromiso, remembers a man who called a radio talk show that Ramirez was appearing on last year. The caller said he was a U.S. citizen but his wife was not.
"I'm afraid that if I give this information it'll be used against her," Ramirez recalls the man saying.
A Latina in Bakersfield, in a recent consumer survey, told the California HealthCare Foundation she felt Obamacare might be a trick to get undocumented immigrants to apply and identify themselves.
In March, President Obama went on the Spanish-language TV network Univision to assure Latinos that information would not be turned over to immigration officials. The federal government has deported more than 2 million people since Obama took office.
During the first open enrollment, the exchange urged outreach workers to carry a letter from U.S. Immigration and Customs Enforcement echoing Obama's promise. But that agency letterhead merely made some people more nervous, Lee said.
This time, Lee said he's drafting letters on immigration bearing the names of Covered California and immigrant-rights groups that are well respected in the Latino community.
Covered California had already altered its advertising to promote in-person assistance at local clinics and churches because Latinos weren't always comfortable discussing immigration issues over the phone or online.
The exchange credited that shift in marketing for a boost in enrollment. The exchange had signed up 75,000 Latinos by the end of December, drawing criticism from state lawmakers and other health-law supporters. The state's total grew to 367,000 by mid-April.
Bigger penalties for the uninsured might also be a motivating factor in the months ahead. The fine for going without coverage increases next year to $325 per adult or 2% of household income, whichever is greater.
Another challenge is enrolling Californians who have grown accustomed to living without health insurance. They may pay cash at local clinics or travel to Mexico for care.
Nearly half of the remaining uninsured in California have been without coverage for two years or more, according to the Kaiser Family Foundation.
The Saldana family has learned to cope without insurance, said Lilian Saldana, and she recently took her mother to a neighborhood clinic for a physical. But she worries about what will happen if either of her parents suffers a serious illness.
"My family's being held back whether I apply for it or not," she said. "There's nothing I can do about it."