Federal laws (Affordable Care Act and Title VI of the 1964 Civil Rights Act, for example) mandating spoken language access and prohibiting language-based discrimination have been with us for many years. They inform the importance of providing equivalent access to federally subsidized services for everyone, regardless of language proficiency.
Using health care as an example, myriad studies document how better patient care, fewer incidents of medical negligence and malpractice, and improved patient and community health are inextricably connected to meaningful, effective language assistance.
However, as the American Public Health Association (APHA) reported in October, 2023, health care language access and legal compliance continue to be significant problems for America’s health care system.
As stated in the APHA’s The Nation’s Health:
“Language barriers are common across sectors, but their consequences can be especially severe in health care. More than 25 million U.S. people — nearly two-thirds of them Spanish speakers — have limited English proficiency, and research shows they often experience poorer health than their English-proficient peers, such as worse cancer outcomes, higher hospital readmission and more medical errors. They are also more likely to be uninsured and lack access to care.
Many health providers offer language assistance, but a considerable number of others do not, even when patients have a legal right to it…. A 2014 study found only 64% of hospitals offered any language services.
Federal civil rights law requires hospitals and other health providers that take federal funds, such as Medicare and Medicaid payments, to provide “meaningful access” to patients with limited English proficiency.
Data on compliance is limited, but show significant room for improvement. For example, a 2013 Medscape survey of more than 4,700 health providers in the U.S. found that less than one-third asked about language at intake, less than a quarter contracted with interpreter services, and almost 40% relied on patients’ families to interpret, which language-access experts caution against…
Federal guidelines on the issue — the National Standards for Culturally and Linguistically Appropriate Services in Health Care, or CLAS standards — were released in 2000. But a 2010 study found few hospitals, just 13%, were following all of the language-related standards.
Lisa Diamond, MD, MPH, co-author of the 2010 study, said she suspects little progress has been made since, considering the standards are an unfunded mandate.
“In an ideal world, it would be policy to reimburse (language services) like we do for other medical procedures,” said Diamond, an associate attending physician at Memorial Sloan Kettering Cancer Center…
But the reality is that many health providers do not fully understand their legal obligations, she said. They may also lack funding to effectively comply or underappreciate the expertise that trained interpreters bring…
Not all insurers — including Medicare and most state Medicaid programs — reimburse for interpreter services, despite research showing interpreters improve health outcomes and are more effective than relying on ad hoc interpreters, such as family and friends. For example, a 2015 study that included Spanish-speaking patients at a public hospital clinic found that using trained medical interpreters cut the medical error rate in half, far below the error rate associated with ad hoc interpreters.”
Multiple efforts are still needed to ensure legal compliance, patient safety, and language-based health care equity, such as:
- Having ALL medical schools provide education about language access requirements and their relationship to malpractice, provider education;
- Having continuing medical education courses that focus on language access and the perils of not making sure providers and patients speak the same language ;
- Conducting effective in-house provider education to explain the legal, business, and patient care rationales for language access, including discussions of how medical malpractice insurance does not pay for money damages ordered by a court or federal agency for civil rights violations and language-based discrimination; and
- Employing more effective lobbying with insurers, Congress, state legislatures, and federal agencies especially as the U.S. population continues diversifying and language assistance needs grow concomitantly.
The Nation’s Health coverage also includes poignant language access narratives, such as:
“Adriana Ochoa, language services supervisor at Arkansas Children’s Hospital in Springdale, talks with a family. Medical interpreters play a vital role for people who do not speak English, but their services are not reimbursed by many insurers.
Adriana Ochoa remembers the stress of interpreting for her Spanish-speaking parents at doctor’s visits when she was young, worried she had missed a key word or misunderstood another. “It’s a lot of responsibility for a child,” said Ochoa, the language services supervisor at Arkansas Children’s Hospital in Springdale, a small city in the state’s northwest corner. “And it’s not the best way to communicate with patients.”
A certified medical interpreter, Ochoa spends most of her time on the hospital floor, helping Spanish-speaking patients with limited English proficiency communicate with providers and navigate the facility’s systems. The hospital has an on-site staff of interpreters in Spanish and Marshallese — Springdale has one of the largest Marshallese communities in the U.S. — available around the clock, starting when a patient checks in.
Requests for language assistance come in all day, every day, Ochoa said. She carries a walkie-talkie with her so she can dispatch an interpreter seconds after getting a call, their skills crucial in emergencies.
“We make sure conversations are clearly interpreted,” she told The Nation’s Health. “But we also act as a bridge for cultural understanding.”
There are many examples of grass roots programs to organize around language access imperatives and to educate limited English proficient people, recent immigrants, and their communities. One such effort, as reported by The Nation’s Health is happening in Chicago.
“New work in Chicago highlights the long way many health systems have to go in providing equitable care to patients with limited English.
Last year, the local Asian Health Coalition launched its Health Equity Through Access to Language Strategy, or HEALS program. The first phase was an assessment that surveyed more than 400 residents and two health systems that serve Asian communities, said Alia Southworth, MPH, senior program director for health promotion at the coalition.
Among its findings: 42% did not know they had a right to an interpreter, 60% used a professional medical interpreter in the prior year, and 26% used family or friends as interpreters. Problems began even before some sat down with a clinician: Sixty-two percent of patients said they had trouble making an appointment, as language services may not kick in until the actual visit.
On the medical side, providers lamented the high financial burden. For example, one clinic was spending $50,000 a month on language services — all of it unbillable.”
Such programs and commitments can help alleviate current language access deficiencies. Education, training, and genuine commitments to health equity all must coalesce to provide equitable health care access, regardless of language.
© Bruce L. Adelson 2023. 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.