Picture Story on Accessing Health Care through Affordable Care Act

Hi, all.

I'm happy to have below  a Jpeg of the latest picture story by Adult ESL Practitioner/Health Care Specialist Kate Singleton.

In 6 small panels she provides content to use with adult learners at any level, but especially at the beginning level.  This is an addition to her earlier picture stories, which you can find at http://www.cal.org/caela/esl_resources/Health/healthindex.html

Certainly timely! I'd love to hear how  you use these materials and questions you have about Health Literacy.


Uploaded image from Miriamb3





Instructions & background for "New Insurance, New Doctor"

Hi everyone, 

Below please find instructions and background information to go with the new ESOL picture story "New Insurance, New Doctor" posted here earlier this week.  I am working on finding a web home for the picture story and instructions, but for now this is probably the best way to make it available.  Please share it with colleagues!  Unfortunately I can't add an attachment on this list, so I am pasting the instructions from a Word document --- hopefully the format won't get too crazy in the conversion.

Kate Singleton




Picture Story: “New Insurance, New Doctor” --- Instructions and Background

This health literacy picture story was created in 2/2014 to help English for Speakers of Other Languages (ESOL) teachers explain basic information to adult English language learners about:

  • the Affordable Care Act and how it applies to learners.
  • how to use insurance if you are not experienced with it; insurance terminology.
  • what non-clinical communication tasks to expect when seeing a US doctor or other healthcare provider for the first time. 
  • strategies to improve communication in a doctor’s visit.

The story may also be helpful in other educational and healthcare settings to raise awareness of patients and providers alike to issues of communication, information, culture, and overall mutual understanding that are likely to intensify with current healthcare system changes.


The Basic Story:

Frame 1: Ana applies for new insurance on www.healthcare.gov.  It’s her first time getting insurance.

Frame 2:  Ana receives her new insurance card about a month later.  She is ready to make an appointment for a check-up.

Frame 3: Ana goes to her appointment and presents her new insurance card at the front desk (reception).  She has many questions about how to use the card and what she needs to do now that she is at the doctor’s office.

Frame 4: The receptionist says a lot of things that Ana doesn’t understand.   Ana feels more confused.

Frame 5: The receptionist gives Ana many forms to fill out.  Ana feels even more confused.

Frame 6: Ana is now very confused.  She says, “I’m so confused! Please explain!”


Introducing the story:  

Tell learners they will be working on a story called “New Insurance, New Doctor.” Say that many things are changing about going to the doctor and paying for health care in the US, and the story will help them talk about this.  Ask them what they have done in the past in their native country or in the US to get health care or to pay for health care.  Where did they go?  What did they have to do to get to see a doctor or other healthcare provider?  How did they pay for it?  Ask them if they have had experience with medical forms, insurance, and making medical appointments in the past.  Let them share experiences if they’d like to and their English is up to it.


Vocab to Preteach:

  • www.healthcare.gov
  • Affordable Care Act / Obamacare
  • Insurance
  • Insurance card
  • Payment, premium
  • Appointment
  • Receptionist
  • Co-pay
  • Deductible
  • HIPAA (Health Insurance Portability and Accountability Act) --- full name is WAAAY too much info for ESOL learners.  Best to keep your explanation very basic if you go into it at all and stick to info about privacy of medical information. Seehttp://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html for more info.
  • Medical history
  • Forms (you can download examples of doctor office forms and, if your learners are up to it, insurance forms like Explanation of Benefits)
  • Confused
  • Explain
  • Interpreter




Possible Question Prompts and Issues to Discuss for Each Frame:

NOTE --- Because of the complexity of US health care today, discussion of any one of these frames can get complicated quickly!  Please look through the suggested question prompts and issues below and gauge how much info and detail your learners can realistically handle in one class.  For many classes it is advisable to stick to only the most basic questions and issues.

Frame 1: Ana applies for new insurance on www.healthcare.gov.  It’s her first time getting insurance.

            Question Prompts to Elicit Story from Learners:

  • This is Ana. 
  • What is Ana doing? 
  • What website is she looking at? 
  • What does she do on this website?

            Issues to discuss (choose depth of questioning according to learner level and ability):

  • What is ACA/Obamacare? 
  • What is insurance? 
  • How can you apply for insurance through www.healthcare.gov
  • Where can you get help in your community if you don’t understand how to apply for insurance, or if you can get insurance (if you qualify)? (Where are ACA navigators and certified application assistants located?  How can you contact them?) NOTE: For this issue you will need to do a little research to find contact information for the resources that exist in your area.  A good place to start is the search tool at https://localhelp.healthcare.gov/. You don’t need to know all the ins and outs of applying for insurance, but you will need to be prepared with information to connect learners to people who do.
  • Initial open enrollment for Health Insurance Marketplace closes March 31, 2014.

Frame 2:  Ana receives her new insurance card about a month later.  She is ready to make an appointment for a check-up.

Question Prompts:

  • What is in Ana’s hand? 
  • What can she do now that she has an insurance card? 
  • How long did it take to get her insurance card?
  • What did she need to do between picture 1 and 2 to get her insurance card? (pay premium)
  • How does she make an appointment for her check-up?


  • You need to pay a premium before you get your insurance card.
  • How do you choose a doctor in your area?
  • What kinds of info are on an insurance card? (you can do a Google Images search to find clear examples of insurance cards to show learners)
  • What do you do with an insurance card?
  • How do you make an appointment with your new doctor?  How long might it take to get an appt.?

Frame 3: Ana goes to her appointment and presents her new insurance card at the front desk (reception).  She has many questions about how to use the card and what she needs to do now that she is at the doctor’s office.

Question Prompts:

  • Where is Ana now? 
  • It’s her first time at this doctor’s office.  It’s the first time she goes to a doctor in the United States.  How do you think she feels?  Is she nervous?  Is she confused? 
  • What questions is she thinking about? 
  • Who is she giving her insurance card to? 


  • What happens at the doctor’s office before you get to see the doctor?
  • What is the clipboard on the counter for? (signing in)
  • Who is a receptionist?  What does a receptionist ask you to do?
  • What does the receptionist do with your insurance card?  Do you have to show any other cards?  Do you have to pay before you see the doctor or after?  How much might you pay if you have insurance?
  • How long do you have to wait in the lobby before you see your doctor?

Frame 4: The receptionist says a lot of things that Ana doesn’t understand.   Ana feels more confused.

            Question Prompts:

  • Now who is talking?  Does Ana understand the receptionist?  What does Ana hear?  What are some of the new words Ana doesn’t understand?
  • Normalize for learners that many people who are native speakers of English have trouble understanding insurance terms, and have trouble understanding people who work in doctor’s offices who are busy and rushing.  Talk about ways you can ask a person to repeat things more slowly or explain things more clearly. 


Frame 5: The receptionist gives Ana many forms to fill out.  Ana feels even more confused.

Question prompts:

  • Now what is the receptionist doing? 
  • What does she say to Ana? 
  • What does she give Ana? 
  • Does it look like a lot of forms? 
  • What kinds of forms do doctors’ offices give?
  • What language do you think the forms are in?


  • Learner comfort level with filling out forms in English
  • Strategies to help with forms:
    • ask for forms before the appt. so you can work on them at home
    • you might be able to get forms online before appt.
    • have a friend or family member with stronger English come to appt. to help with forms
    • ask if any office staff can help you fill out forms
    • ask if interpreter and/or social worker is available to help with forms

Frame 6: Ana is now very confused.  She says, “I’m so confused! Please explain!”

Question Prompts:

  • Now how does Ana feel?
  • What does she ask the receptionist to do?  Is it easy or difficult to ask this?
  • Let’s list/review all the ideas we can think of for how Ana and the receptionist can have better communication at the doctor’s office


  • Doctor’s office could provide an interpreter for the appt.  Many should for free by law if they receive any federal funding like Medicare payments.  Learner can ask them if they will provide an interpreter free of charge.  Ask them when you call to make an appointment.
  • Learner can bring an adult family member or friend to appt. who speaks more English to help with communication.
  • Ask for staff to explain things, like Ana does. 
  • Ask staff to write down any terms you don’t know so you can get more information on them later from friends, family, teachers, and Internet.
  • Ask friends/family who have insurance to explain insurance terms to you before you go to the doctor.
  • Audio record your appointment on a smartphone or other audio recorder so you can listen and understand more later.
  • Ask for forms before the appt. so you can work on them at home
  • You might be able to get forms online before appt.
  • Have a friend or family member with stronger English come to appt. to help with forms
  • Ask if any office staff can help you fill out forms
  • Ask if an interpreter and/or social worker is available to help with forms or communication


No unique issues are listed for this frame as it can be used to summarize discussion of previous frames.



Thank you so much, Kate, for posting your detailed lesson plan to the community.  I have a question for you. Have you, or anyone you know tried out the lesson plan? I would really like to hear how it went, and so on.

Also, do you think it is a good idea to fill out generic forms in the classrrom as a practice? Has anyone tried that?

Thanks again, Kate.

Everyone: I'm sure we would all benefit from feedback on using this picture story and the lesson plan - so what do you think?




Hi Miriam,

Great question.  The story and lesson are hot off the presses, created in the past week in response to comments from local ESOL teachers and public health folks who are quite concerned about what many people with LEP who are new to health insurance and US healthcare are experiencing or soon to experience as they begin to use their new coverage (if they qualify for it).  I will be teaching with the story for the first time in about 2 weeks and will post about how it goes.  I'd love to hear from others who use it how their experience goes.  I would ask that people share their comments here rather than contacting me directly because I think there is so much value in an open discussion to flesh out how to address these complex health care topics for the ESOL field.  We are all in this together!  I think key considerations with this story will be knowing in advance what community resources are available to help learners with the marketplace, having that contact info available for the class, and deciding in advance of the class how much or how little detail your class can handle, then sticking to your plan and not getting sidetracked or in too deep.

When I pilot this story later in the month I will be co-teaching what we are calling an ESOL health literacy mini-course in my county's adult ESOL program (in Fairfax Co., VA).  It will be a 3 session course (2 hrs. per class) focusing on accessing care, affordable care resources in the community, using health insurance, and communicating with healthcare providers.  The course will use the picture stories "Emergency;" "New Insurance, New Doctor;" and "A Doctor's Appointment" to introduce language and information for the topics brought up in these stories.  We are very excited to see how it goes.  We are offering the class as a free elective to lower level students who are already enrolled in ESOL classes on other nights of the week.  I've just learned that at the first site where we are offering it there are already 47 students signed up for it!  That is a huge level of interest considering these students are already coming to school the other nights.  One other thing we are excited about --- on the night we are presenting "New Insurance, New Doctor," the local organization funded to provide application assistance to the public for the insurance marketplace has agreed to send certified application counselors to speak with learners in the class.  The folks at this organization have been wonderful to work with so far, providing us with terrific information and resources that have helped us in planning the class, and they are very interested in making sure what they present to the learners is clear and useful without being overwhelming.  Sorry for digressing from your question about using the plan, but as you can tell I am pretty excited about this class model and wanted to share!



This looks fascinating.  I saw a link to other picture stories to health care topics too!  I think this will be a great help to one of my ESL students in particular.  She is a personal care attendent, but her long time patient recently died.  She is now trying to get her CNA license, but does not have the proper vocabulary.  Her former patients wife is trying to help her - and I think this is a great way to provide vocabulary for what she wants to do!  Thanks for sharing!

Hi Miriam and others,

As promised I’m reporting back on using the new ACA-related picture story “New Insurance, New Doctor” with an ESOL health literacy class in the last week.  The class I used the story with was multilevel but very much in the intermediate range.  They related well to the story and were engaged in discussion about it the whole time we were using it.  I’ll describe what we did in the lesson and then tell you our big takeaway at the end. 

Our basic plan for the 2 hour class (which had quite a full agenda) was as follows:

  1. Very brief look at healthcare.gov.  Talked about what it is and March 31 deadline.  This literally took 3 minutes just to focus people on using the site to apply for insurance. 
  2. Picture Story.  Whole group discussion of story, using the questions in the proposed lesson plan for the story.  Intro’d pertinent vocab before discussion and reviewed it as we went thru the story.    Gave learners handouts with an enlarged copy of insurance card and an explanation of benefits to look at when those terms came up in our discussion of the story.  Went through a handout with a write-up of story.  Elicited strategies and sample questions Ana can use to make communication as clear as possible at the new dr's. office.  We divided those into things she can do before the appt., and things she can do at the appt.
  3. Insurance vocab list handout.  We discussed and compared insurance terms.  We presented  them in categories like: documents the insurance company gives you (e.g., policy, explanation of benefits), types of health insurance (e.g., HMO, PPO) things you pay (e.g., copay, deductible, premium), and things the insurance company pays (e.g., claim, covered expenses).  Students asked a whole lot of really sharp  questions.  The terms were clearly very challenging and very important to them.
  4. Matching sets for insurance vocab and definitions.  We were worried that the vocab was too confusing but learners did very well working in small groups to match the terms and definitions.
  5. Medical history forms and medication lists.  Because we had a guest speaker coming we didn’t have time to do these in class but we gave them out for learners to work on at home as examples of new patient paperwork.  We used these 2 simplified forms from the VA ESOL HL Toolkit:



We also used an online form from a local chain of primary care practices, for a real-life complex example.  We talked about how when forms are online, it’s possible to practice the forms at home before your appt.  Here’s the form:  http://www.inova.org/upload/docs/Inova%20Medical%20Group/Forms/IMG-adult-packet.pdf


6. Guest speaker.  We had a guest speaker from a local org which provides ACA application assistance.  

Our biggest takeaway from the lesson:  The most surprising aspect of the class for me and my co-teacher was that we noticed learners came into the class thinking that once one has obtained insurance, getting and paying for healthcare is smooth sailing; and they left with a much more realistic and sober view of the complexity of using health insurance.  Starting with the discussion of the picture story, but really noticeable in the discussion of insurance terms that followed, light bulbs were going off all over the room about how complex and not user-friendly health insurance is.  Learners gained awareness of:

  • the importance of keeping records of their insurance activity to make sure things get covered,
  • the importance of doing the math so that they get insurance they can afford that will best meet the needs of their families, and
  • the ongoing need to advocate for oneself with the doctor’s office and insurance company to make sure you get what you need and what your policy indicates. 

We were glad we had the picture story to ease learners into the discussion, and to start the class off with some levity before the mood got serious!  We are next using the story with a mixed beginner-low intermediate group so I’m in the process of simplifying the support materials for that lesson.  I'll let you know if there's more to report from that group.


Thank you, Kate, for sharing the detailed information on your lesson plan and how the class went. I found the comnments about the aha moments with your students particularly interesting.

I have a question about the second form  from VALRC,  where the students record in detail what medicines they take and what the medicines look like. This seems a great way to practice English colors and shapes and so on, as well as being a good way to keep records. I wonder, howver, about the value of describing the pills and medicines they take for certain generic medicines: I find that the generic prescription medicines I take may change shape, color, and size depending on the month!.same is true as to whether you are taking advil or Safeway's or CVS's generic ibuproferin.

Even that isn't foolproof, though. I'm thinking about the recent news story about the Kennedy who took Ambien instead of her allergy pill and crashed her car. She said aftewards that the pills are very similar. I guess the point is not to be casual about taking medicines and to read and doublecheck before taking. Very good vehicle for teaching English. Thanks again, Kate.

What activities do some of the rest of you use when teaching health?


SME, adult ELL CoP



Hi Miriam, 

Sorry it's taken me a few days to get back to you.  I see your point about the lack of visible differences between generic drugs.  We included the column about color and shape on that form in the Health Lit Toolkit since those are features experts in medication safety tend to emphasize to help patients keep their meds straight.  However, I think you are right that these days generics don't always resemble the brand name drugs they represent and do tend to look a lot more like other generics than they used to.  One nice feature of the Toolkit is that it includes Word versions of handouts in addition to PDFs so teachers can edit out a column that they don't want to cover or feel would be too complicated for learners.