New Study Reveals Substantial Disparities In Health Care Spending And Usage Among Spanish-language Speakers

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Decades-old federal laws require interpreting and translation services for Limited English Proficient (LEP) people from federally subsidized hospitals and health care providers. However, despite these well-established statutes (such as Title VI of the Civil Rights Act of 1964) and court decisions (such as Lau v. Nichols, 414 U.S. 563 (1974)) language and national origin-based gaps in health care have not narrowed over at least the last 20 years.

Now, a new study documents that 25 million Spanish speakers receive about one-third less health care than other Americans. The new study published in the July 9, 2021 issue of Health Affairs and entitled “Health Care Spending And Use Among Hispanic Adults With And Without Limited English Proficiency, 1999–2018,” analyzes federal survey data from more than 120,000 adults. The analysis reveals that total use of health care as measured by spending was 35% to 42% lower among Spanish speakers compared to English speakers.

In addition, the study concludes that compared to Hispanic adults who were proficient in English, LEP Spanish speakers also had 37% fewer prescription medications. Spanish speakers are less likely to receive lifesaving services such as colon cancer screening than English speakers, the study reveals.

“Many hospitals and clinics have grossly inadequate interpretation and translation services”

Additional language-based explanations, according to UPI, include:

“Too few doctors or nurses speak Spanish, and many hospitals and clinics have grossly inadequate interpretation and translation services, despite federal mandates requiring them,” said senior study author Dr. Danny McCormick, an associate professor at Harvard Medical School and primary care physician at Cambridge Health Alliance.

“But most insurers won’t cover the costs of interpreters, and federal enforcement of the language mandates has been lax,” McCormick said.

The Health Affairs study highlights the difference in health care expenditures between Spanish speakers and English speaking, non-Hispanic adults. This spending difference has increased since 1999 by approximately $1,500.00 per person, $2,156 in 1999 to $3,608 in 2018 even after accounting for inflation.

Lead study author Dr. Jessica Himmelstein said the pandemic has magnified these language-based disparity problems. “..COVID-19 has taken a heavy toll in the Hispanic community, especially among people with limited English proficiency,” noted Himmelstein, a research fellow at Harvard Medical School and physician at Cambridge Health Alliance. “The pandemic has been a magnifier of the failure of our healthcare system to meet the needs of patients facing language barriers,” Himmelstein said, as reported by UPI.

COVID Pandemic Reveals Language Access Disparities

Indeed, the COVID-19 pandemic has laid bare myriad inequities and disparities in American society and the U.S. health care system. In a March 2020 publication, the Center for American Progress discussed this very point:

“Inequality is magnified in times of national hardship. Perhaps nowhere is this clearer than in communities of color, which have long endured inequalities across American economic, social, and civic systems. [S]tructural and environmental racism has produced extraordinarily high rates of serious chronic health conditions among people of color; and entrenched barriers in the health system continue to prevent people of color from obtaining the care they need…

While the U.S. health care system has made remarkable progress in dismantling structural barriers, too many people of color struggle to obtain the care they need due to cost, language access, and outright discrimination. Racial disparities in self-reported inability to afford care persist even after controlling for insurance coverage.

Language barriers prevent countless people of color from obtaining crucial information about disease treatment and prevention. More than 350 different languages are spoken in the United States. Millions of Americans—including 35 percent of Hispanic and Asian Americans and 14 percent of Native Hawaiian/Pacific Islander people—are also limited English proficient (LEP), meaning they speak English “less than very well.” LEP Americans have the legal right to access care in their preferred language. However, few hospitals require their medical residents to receive interpreter services training or offer medical staff formal assessments of their foreign language proficiency.”

The Health Affairs study raises multiple salient issues, such as the worsening of existing inequalities as a result of the pandemic. If one is to learn lessons from the deaths and loss resulting from language-based disparities and discrimination during the pandemic, we must closely examine health care shortcomings and the study’s conclusions. In addition, changes and reforms are necessary to reverse the troubling inequities revealed by the study. Such changes must include an organizational culture shift in health care so that people are not given different levels of care or access based on language or national origin. Such disparate treatment has been illegal in the United States for many years.

Changes Needed to Improve Health Care Language Access

“The gaps in care that we observed could be a result of several factors rooted in language-based inequities. Non-English speakers may be less likely to seek care for health concerns, anticipating that their needs might not be met. Patients with limited English proficiency, for example, may have had prior negative experiences with the health care system, including being made to feel unwelcome or discriminated against. Even when care is sought, the lack of language concordant clinical and administrative staff in many health care organizations may make navigating the health care system more difficult, impeding access to outpatient physician visits.

Inadequate communication with clinicians, who frequently fail to provide language-concordant care, could obstruct identification of medical conditions, leading to less treatment and follow-up. Last, language-based disparities in telehealth use may limit the access of people with limited English proficiency to needed care, particularly during the COVID-19 pandemic…

Addressing language-based access barriers will likely require changes in reimbursement models to ensure that medical interpreters are recognized and compensated as part of the health care team. At this time only fifteen states’ Medicaid programs or Children’s Health Insurance Programs reimburse providers for language services, and neither Medicare nor private insurers routinely pay for such services.

Ensuring adequate funding for interpreter services is essential if health system leaders are to prioritize language access and integrate it seamlessly into everyday workflows. In addition, policy makers should consider establishing and enforcing national benchmarks for the certification and training of qualified medical interpreters and qualified bilingual medical providers.

The culture of medicine and nursing should also change to recognize clinicians’ language skills as an important facilitator of high-quality, efficient care. When interpreters are needed, they should be incorporated as full members of the medical team and perhaps trained to expand their scope of practice to function as patient navigators. In parallel, medical schools and allied health professional training programs could promote language programs and the provision of medical language and terminology instruction for those who want to become bilingual clinicians and prioritize the recruitment of multilingual applicants.

Last, as care shifts to telemedicine and web portals, providers should commit to ensuring that appropriate language interpreter services such as the ones offered by Bromberg & Associates are available for patients with limited English proficiency.” 

© Bruce L. Adelson 2021. All Rights Reserved The material herein is educational and informational only.  No legal advice is intended or conveyed.

Bruce L. Adelson, Esq., is nationally recognized for his compliance expertise.  Mr. Adelson is a former U.S Department of Justice Civil Rights Division Senior Trial Attorney.  Mr. Adelson is a faculty member at the Georgetown University School of Medicine and University of Pittsburgh School of Law where he teaches organizational culture, implicit bias, cultural and civil rights awareness.

Mr. Adelson’s blogs are a Bromberg exclusive

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