Giving Immigrants a Hand in Navigating the Health Care System
(From NCSL's State Health Notes, volume 23, number 381, October 7, 2002)
Elba Quiles, a former high school principal from San Juan, Puerto Rico, runs a free English language instruction program at a community college in her adopted hometown of Georgetown, Delaware. A few years back, Quiles added a Spanish class for local Anglos who work with the area's sizeable population of Hispanic migrants, most of whom have jobs in its half-dozen poultry and food processing plants. Now, she and another instructor teach six such classes to a diverse group of students, among them radiologists, therapists, nurses and social workers.
The situation in Georgetown is no longer unique. During the 1990s, the number of foreign-born U.S. residents rose to 31 million, or 11 percent of the population, and according to 2000 Census data, 21.3 million of the newcomers speak English "less than very well," up from 13.9 million in 1990. All told, the number of other languages spoken here tops 300, from the more-common (Chinese, Russian and Spanish) to the more-obscure (Croatian, Somali and Urdu).
In medical settings, the language gap can interfere with physician-patient communications, resulting in care that's based on incomplete or inaccurate information as clinic and hospital workers turn to unqualified interpreters-including minor children-to translate a patient's symptoms as well as to delays or outright denials of service. In addition, the U.S. Department of Health and Human Services (DHHS) notes, people with limited English proficiency often cannot understand the basics of how to apply for programs for which they and their families may be eligible, including Medicaid, the Title XXI State Children's Health Insurance Program and an array of social service and welfare programs.
As Quiles puts it, health care professionals in doctors' offices and hospitals that treat large numbers of non-English speakers "need to know the vocabulary" of other languages, but as important, they also need to know "the culture" in order to understand and respond to the patient as a person, not simply a case. Minnesota's experience with Hmong refugees-who've settled in the state in large numbers-illustrates the point. In the Hmong language, there is no word for cancer, or even a concept of it, and in trying to explain radiation, inexperienced interpreters have described it as "we're going to put a fire in you"-an obvious deterrent to treatment.
Federal Guidance: A Civil Rights Approach
Now, the federal government is taking steps to address the problem via a "guidance" that reiterates the need for agencies to avoid discrimination against people with limited English proficiency on grounds of national origin. In the health care field, the guidance applies to all entities receiving federal funds, including state, county and local health and welfare agencies; hospitals and clinics; managed care organizations; nursing homes and senior centers; mental health centers; Head Start programs; and contractors. What that means in practical terms is that providers must offer all non-English speaking patients free language assistance that will assure "meaningful access" to their services-a daunting task, even for facilities in big cities that have a pool of potential translators at their disposal.
To state and local governments and the provider community, cost concerns loom large. In a report issued in March, the Office of Management and Budget (OMB) put the annual cost of interpretation services to patients with limited English proficiency as high as $267.6 million, covering 66.1 million emergency room, inpatient, outpatient and dental visits. At the same time, OMB said that greater access can "substantially improve" the health and quality of life of many immigrants and their families and that language assistance may "measurably increase the effectiveness of public health and safety programs."
Help with compliance, financial and otherwise, is available. In an Aug. 31, 2000 letter to state Medicaid directors, for example, DHHS clarified that federal Medicaid and Title XXI matching funds are obtainable for expenditures on oral and written translation services, whether for staff or contract interpreters or telephone services. In addition, the department's Office of Civil Rights (OCR) is offering technical assistance to states for a variety of promising practices aimed at helping newcomers navigate the health and social service systems, including
community language banks; state-supported language offices; simultaneous interpretation using off-site technology; multicultural projects using community outreach workers; translated print and on-line documents; telephone information lines with frequently spoken languages on recorded messages; signage; and outreach.
The move to assure language access began on Aug. 11, 2000, when President Clinton issued an executive order directing all federal agencies that fund nonfederal entities to publish written policies on how both they and the recipients of the funds can ensure "meaningful access" to people with limited English proficiency. The order, which sought to reinforce Title VI of the 1964 Civil Rights Act barring discrimination on the basis of race, color or national origin under any program that receives federal financial assistance, gave the Department of Justice (DOJ) responsibility for issuing the guidance to other agencies and ensuring cross-agency consistency as well as for monitoring and enforcing compliance.
In its final guidance, issued on June 18, DOJ asked all federal agencies to use its model in creating their access plans and reiterated four factors to be considered in their individualized assessments of the obligation: the number of people eligible for a program; the frequency with which they use it; the nature and importance of the program's services to people's lives; and the resources available to program and its costs.
The process slowed a bit last fall, when DOJ required federal agencies to seek additional public comment on their guidances and Congress asked OMB for its cost-benefit analysis, but it appears to be back on track. At DHHS, for example, the Office of Civil Rights issued its policy guidance on Aug. 30, 2000, providing "additional clarification of existing responsibilities" under Title VI. On Feb. 1 of this year, it republished the guidance and is now reviewing those comments. Specifically, it sought input on cost-effective ways to provide services, suggestions for technical assistance and descriptions of the costs of translation, interpretation or other language services. A final document is due out later this year; meantime, the Aug-ust 2000 guidance remains in effect.
In its document, DHHS defines "meaningful access" as language assistance that results in accurate, effective communications between provider and client, at no cost to the client. Typically, effective programs are presumed to have four elements-an evaluation of the language needs of the population being served, a written policy on language access, staff training and monitoring-although OCR will assess compliance on a case-by-case basis. If efforts at voluntary compliance fail, the office is authorized to terminate federal funds if the provider, after being given the opportunity for an administrative hearing or a referral to DOJ for injunctive relief, still falls short of the goal.
The Financing Angle
In its cost-benefit analysis of the guidance as it affects the health care arena, OMB suggested a host of advantages to providing language assistance, among them better communication between patients with limited English proficiency and English-speaking providers; greater patient satisfaction; more confidentiality and truer "informed consent" in medical procedures; fewer misdiagnoses and medical errors; cost savings through fewer emergency room visits; less staff time in dealing with non-English speaking patients; and fewer eligibility and payment errors.
As the agency's multi-million dollar price tag suggests, however, those improvements come at a cost and states are struggling to figure out how they pay for compliance. According to OMB, the federal government could do two things to help out: first, create uniformity among the dispensers and the recipients of federal funds, although taking care to build in flexibility to address local circumstances; and second, improve the availability of telephone interpretation services and access to them. It suggested, for example, that bulk purchases of language services could improve efficiency and achieve economies of scale, particularly for languages encountered with less frequency.
For their part, states have already developed a number of methods for providing language services, including salary premiums for bilingual medical staff; language classes for medical staff specific to a medical setting; nonprofit language banks that recruit, train and schedule interpreters; volunteer interpreter services; and remote simultaneous interpretation. Hourly rates for the services range from $25-$60 for staff interpreters and language banks to $130 or more for telephone language lines.
To help offset the cost of interpreter services-either direct or under contract with providers or health plans-states can draw down the federal match under both Medicaid and Title XXI in one of two ways: They can bill for language assistance as part of another medical service, raising the base rate accordingly, or they can bill for it as an administrative expense. (The administrative match rate for Medicaid is 50 percent; for Title XXI, it is capped at 10 percent.).
Making it Work
Despite a lack of written federal guidelines on how to apply for the match, at least five states (Hawaii, Maine, Minnesota, Utah and Washington) are receiving the funds and putting them to work. Here are snapshots of what three of the five have done.
> In Minnesota, languages spoken now include Amharic, Arabic, Cambodian, Chinese, Croatian, Hmong, Korean, Lao, Liberian, Oromo, Russian, Somali, Spanish, Sudanese and Vietnamese-a reflection of the estimated 225,000 immigrants and refugees who have settled there over the past 20 years. Over the last few years, the Department of Health over the last few years has developed a wealth of information to enhance language access, including a spoken language resource guide; professional standards for interpreters; contact information for interpreter services and payment rates; a translation protocol for written materials; and examples of new software to aid in translation.
Last year, the Legislature approved a two-year, $4.3 million initiative (including $1.9 million in federal matching funds) to improve access to medical services by adding interpreter services to limited English proficiency clients in the state's Medicaid program.
> Like many other states, Washington has been sued under Title VI, and as part of a consent degree issued more than 10 years ago to assure effective communication between patients and health providers, it established language support services and launched certification of interpreters (now available in seven languages). No civil suits have been filed since the programs began. Washington was also the first state to use the Medicaid match to help support the costs of interpretation services. Starting in 1992, the state established two contracting structures under Medicaid. For public hospitals and health departments, it enters into "interlocal agreements," reimbursing 50 percent of the cost of hiring interpreters, offset by its 50 percent federal administrative match ($3 million in 2000), with no state money involved. For private physicians, clinics and outpatient services at hospitals, it pays interpreter agencies directly, to the tune of $10 million a year in federal and state Medicaid dollars. The funds support services to the estimated 160,000 Medicaid recipients with limited English-speaking skills.
To ensure better quality control, accountability and efficiency in the private contracts, the state will soon move to a "brokerage system," using intermediaries between providers and interpreter agencies to improve scheduling and payment processes. The change is expected to save up to $2.6 million in federal and state funds between January and June of next year. According to Tom Gray, section manager for transportation and interpreter services in the Medical Assistance Administration, the move won't supplant a provider's responsibility to assure language access. If the broker can't make an interpreter available, it's up to the provider to adhere to the spirit and letter of the law by finding someone else to do the job.
> In Maine, interest in adding sign language as a reimbursable service under Medicaid paved the way for adding foreign language interpreters. After convening public hearings and inviting public comment, the agency revised its program manual to add interpreters for sign language and foreign language as covered services and in January 2001, began reimbursing providers for part of the cost they incur in hiring interpreters (up to $30 an hour, or approximately half the going rate.) Hospitals cannot bill separately for interpreter services but the costs are allowable as part of their Medicaid reimbursement rates.
While the system isn't perfect, Meryl Troop, director of multicultural services in the Department of Behavioral and Developmental Services, said providers in general "are less reluctant" to make interpretive services available than in the past. And while some resent having to pay the difference between Medicaid rates and the cost of the interpreters, many acknowledge they would now be liable for the full cost and are grateful for the help.
Other states have stepped forward as well. In Massachusetts, for instance, an emergency room interpreter bill was enacted in April 2000; in April 2001, New Jersey decided to develop cultural and language competency courses and improved outreach; and in August 2001, Oregon created a 25-member council on health care interpreters to address testing, certification and funding issues.
While it's too soon to assess the effectiveness of any one approach or the full benefits and costs of compliance, state officials agree that access to the federal match for interpreter services is a great beginning. In tough budget times, however, many challenges remain to finding the right prescription for language access.
by Ann Morse, Program Director, NCSL's Immigrant Policy Project
(For a clearinghouse of information, tools and technical assistance on limited English proficiency and language services, visit http://www.lep.gov)