Issues around language and communication significantly affect a growing proportion of California’s population in general, and the Medicare population in particular. According to data from the U.S. Census, a California Health Care Foundation (CHCF) report, and a report from the University of California Office of Health Affairs, the number of Californians aged 65 and over is already greater than any other state in the nation, and this number is expected to grow at more than twice the rate of the state’s total population between now and 2020.
By 2030, California’s elderly population, those 65 years of age or older, is expected to increase 130%. The number of beneficiaries younger than 65 with a disability is also increasing steadily, with a 16 percent increase between 2000 and 2004. In addition, 2000 Census data reveal that close to 40% of Californians speak a language other than English at home and 20% of this population (6-7 million people) has limited English proficiency (LEP). In four California counties (Imperial, Los Angeles, Monterey and San Francisco) between one-quarter and one third of the population has LEP. California’s foreign-born population has also grown by 37% between 1990 and 2000, and immigrants now constitute over 26% of the state’s population, or almost 9 million people.
Meeting the health care, social service and advocacy needs of this growing aging population requires ensuring diversity among health care and service providers, placing a greater emphasis on cultural competency and cultural humility training and practice, and providing access to strong interpretation services for people with limited English proficiency. This article focuses on the last item, language access services. It provides a brief overview of the need for interpreters, some key federal laws that support this need, and concludes with a list of resources containing websites, articles, and helpful information regarding interpretation services.
Need for language access services
Even for native English speakers, finding, accessing, and understanding the health care one receives can be overwhelming. The process of accessing this care involves: understanding what insurance plan one has and how it works, finding a good doctor, securing an appointment, traveling to the health care provider, meeting and communicating with the provider, paying for care, and accessing and paying for medication. For people with limited English proficiency (LEP), the barriers and challenges this process entails are magnified several fold.
A recent study by the Discrimination Research Center offers a glimpse of these barriers through examining the language services of hospital emergency departments throughout Alameda County. In this study, “Unequal Access to Health Care: A Test of Language Services at Alameda County Hospitals,” callers speaking English, Vietnamese, Cantonese, Tagalog or Spanish conducted 551 tests at 12 Alameda County hospitals. More than half of the callers not speaking English were disconnected or a hospital employee hung up on them. Some details from the study include:
- 62% of calls in Vietnamese resulted in a hang-up or disconnection;
- About 50% of Vietnamese-speaking callers were not connected to a Vietnamese speaker;
- 63% of calls in Cantonese resulted in a hang-up;
- About 55% of calls made in Tagalog were transferred to someone who spoke that language;
- 62% of calls in Spanish were transferred to a Spanish speaker;
- None of the calls in English resulted in a hang-up; and
- English-speaking callers were never put on hold longer than 10 minutes.
While this is just a snapshot of one specific area of health care in one county, its findings of differential access to care and treatment due to a lack of language services are mirrored in a wealth of research, literature, articles, and thousands of individual stories (see The California Endowment’s annotated bibliography, “Language Barriers in Health Care Settings” With the beginning of Medicare Part D’s prescription drug benefit, the language barriers met at pharmacies, plan services hotlines, doctors’ offices, and plan and subsidy information sent in the mail are also just beginning to be documented. As advocates and Medicare beneficiaries who speak English struggle to understand and access this benefit (through comparing plans, enrolling, and then navigating through the fish nets of utilization management techniques such as prior authorization, step therapy, and drug quantity limits to eventually access the medications they need), the struggle faced by people with LEP is again magnified several fold.
Brief overview of federal laws and policies
Health programs and services are required to provide culturally and linguistically competent care under numerous statutory, regulatory, contract and accreditation authorities. While many of these requirements have been in effect for years, other requirements have arisen more recently due to the growing diversity in the U.S. and California populations. Below is a brief review of the key federal law and subsequent policies governing language access issues, followed by some links to other resources and publications for more complete information on both the federal and state laws and policies.
Title VI:
The most important federal law governing language accessibility in health care is Title VI of the Civil Rights Act of 1964. Title VI states that: “No person in the United States shall, on grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.” Throughout the years, federal court decisions, Department of Justice regulations, and decisions and guidance issued by the Office of Civil Rights (OCR) of the U.S. Department of Health and Human Services (HHS) have consistently interpreted Title VI protections to extend to people with limited English proficiency, requiring the provision of translation and interpreter services from federally funded recipients. This requirement applies to nearly all health care providers, as federal funding of health care is almost universal. Federal financial assistance for health care includes Medicare, Medicaid, SCHIP and block grants to health and welfare agencies, among other sources.
The OCR is responsible for monitoring and enforcing compliance with Title VI mandates for all federally funded health care programs and services, as well as providing technical assistance in making programs accessible to LEP persons. In attempting to clarify the standards for LEP services consistent with Title VI, the OCR issued a key guidance memorandum on January 29, 1998. This guidance clearly explains that any federal financial recipients, including hospitals, managed care organizations and clinics, as well as social service agencies, whether they receive financial assistance directly or through contractual or other arrangements from HHS, are prohibited from adopting and implementing policies and procedures that exclude or have the effect of excluding or limiting participation of beneficiaries in its programs, benefits or activities on the basis of national origin. Although it stressed flexibility, particularly for small providers, in choosing methods to meet their responsibilities to LEP persons, the guidance made it clear that recipients should take reasonable steps to provide services and information in appropriate languages other than English in order to ensure that LEP persons are effectively informed and can effectively participate in and benefit from its programs.
More recently, the OCR has given additional guidance on elements common to programs or services that comply with Title VI, and encourages other programs to use these elements as a model. Some of these include:
- Developing a written plan for providing LEP services;
- Designating a staff person to coordinate Title VI compliance;
- Providing information and training to staff on these policies;
- Posting translated notices regarding the availability of no cost interpreters;
- Providing translation of important forms and documents; and
- Collecting, analyzing and maintaining data to determine if interpreter services are adequately provided.
The OCR has also advised federally funded recipients to use four factors for assessing whether they are taking the actions necessary to ensure that LEP persons have meaningful access to their programs and services. These four factors include:
- the number or proportion of LEP individuals served, likely to be served, or encountered by the program;
- the frequency with which LEP individuals have or should have contact with the program, activities or service;
- the nature and importance of the program or serve to people’s lives; and
- the resources available to fund recipient and costs.
As the OCR is charged with providing technical assistance, programs and services wanting additional assistance/guidance in making their programs accessible to LEP individuals can contact the OCR office in their region. Of the OCR’s ten regional offices around the country, the Region IX office covering California is located in San Francisco.
National Standards on Culturally and Linguistically Appropriate Services in Health Care (CLAS Standards):
In December 2002, the HHS Office of Minority Health (OMH) issued the National Standards on Culturally and Linguistically Appropriate Services in Health Care (CLAS Standards). These standards serve to ensure that all people entering the health care system receive “equitable and effective treatment in a culturally and linguistically appropriate manner.” Of the three areas covered in these standards, (culturally competent care (standards 1-3); language access services (standards 4-7); and organizational supports for cultural competence (standards 8-14)), only those for language access services are considered legal mandates, based on Title VI reviewed above. These four standards are listed below.
- Health care organizations must offer and provide Language Assistance Services, including bilingual staff and interpreter services, at no cost to each patient/consumer with Limited English Proficiency at all points of contact, in a timely manner during all hours of operation.
- Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive Language Assistance Services.
- Health care organizations must assure the competence of language assistance provided to Limited English Proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer).
- Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.
For a complete list, review and commentary on the CLAS Standards as well as a discussion on the importance of cultural competence in healthcare, view the CLAS executive summary report on the U.S. Department of Health and Human Services, Office of Minority Health website.
Resources on other federal and state laws and policies:
While Title VI of the Civil Rights Act provides the legal foundation for the right to language services and the mandate for federally funded health care programs to provide them, numerous other federal and state laws and policies build on and strengthen this foundation. For more information, view the links below.
- Appendix C of “Straight Talk: Model Hospital Policies and Procedures on Language Access,” a publication of the California Health Care Safety Net Institute. Provides a brief overview and explanation of both federal and state laws and policies pertaining to language access services.
- Ensuring Linguistic Access in Health Care Settings: Legal Rights and Responsibilities (August 2003), a publication of the National Health Law Program (NHeLP), offers a more comprehensive review of the laws and policies governing culturally and linguistically competent health care.
- ‘Summary of State Law Requirements Addressing Language Needs in Health Care’ provides an updated chart with citations to, and a short description of, each state’s laws regarding services to LEP persons in health care settings. This chart updates and replaces the listing of state laws first published in NHeLP’s 2003 language access manual mentioned above.
- California Standards for Healthcare Interpreters: Ethical Principles, Protocols, and Guidance on Roles and Intervention (California Healthcare Interpreting Association)
- California State Legal Codes (i.e. Health and Safety Code, Welfare and Institutions Code, etc.)
- Title VI of the Civil Rights Act of 1964
Conclusion and resource list for language access services
As California’s Medicare population grows in number and diversity, health and social services organizations and providers must continue to ensure their services are linguistically and culturally accessible to the populations they serve. With the beginning of Medicare Part D and the complexity and challenges of accessing this benefit, having information and assistance accessible to LEP individuals is particularly critical. Below are some links to websites, reports and guides on successful practices in language accessibility, as well as some resources of organizations/agencies offering language services.
- NAPCA National Toll-free Multilingual Helpline Center – The National Asian Pacific Center on Aging (NAPCA) offers the only national helpline that Asian and Pacific Islander (API) elders can call to obtain direct bilingual enrollment assistance and access to translated information on Medicare Part D without having to first navigate through English voicemails, phone menus and operators. Below are the toll-free helpline numbers:
- Chinese (Cantonese & Mandarin) 1-800-582-4218
- Korean 1-800-582-4259
- Vietnamese 1-800-582-4336
- English 1-800-336-2722
- National Alliance for Hispanic Health’s bilingual hotline – In addition to 1-800-Medicare, the National Alliance for Hispanic Health has a bilingual hotline to assist Spanish speaking individuals. The hotline is available Monday – Friday from 5:00 AM – 3:00 PM Pacific Time at 1-866-783-2645.
- Language Access section of the National Health Law Program’s website – This section contains a wealth of information and links to articles on language access issues, promising practices, and federal and state legislation. NHeLP’s Language Services Action Kit also provides a good review of federal laws and policies regarding language access, ways to receive federal funding to cover language services costs, and advice on advocacy efforts around this issue.
- Language Access Services section of the Medicare Quality Improvement Community (MedQIC) website – This site is divided into three areas with information on tools, literature, and links for language services.
- Let Everyone Participate website (www.lep.gov) – This site is an excellent resource for federal agencies, recipients of federal funds, and community-based organizations and individuals. It provides guidance on federal laws and policies concerning language access, and also acts as a clearinghouse, linking to information, tools, and technical assistance regarding Limited English Proficiency and language services.
- Health Information Translations – Originally created as a collaborative initiative in Central Ohio to improve health education for limited English proficiency patients, this site provides numerous translated materials on a wide variety of health topics. All materials are available in eleven languages, with more languages to be added in the coming year.
- Below are links to three agencies/organizations offering language services:
