The United States continues to be a magnet for immigrants from around the world. Data from the most recent Current Population Survey show that more than 28 million Americans are foreign-born, up from 9.6 million in 1970, and that over 44 million Americans speak a language other than English at home. In all, over 300 different languages are spoken in this country. While many immigrants have traditionally settled in major urban areas, a substantial number now also live in suburban and rural areas throughout the country.
Many recent immigrants have limited proficiency in English, which presents challenges for health care provision around the nation. Numerous studies have found that inadequate language services can negatively affect access to and quality of health care and may lead to serious health consequences. Not surprisingly, the recent influx of immigrants has brought with it a growing demand for appropriate and effective language services. A number of factors hinder such services, however, including an increase in the number of languages spoken, costs associated with providing such services, lack of knowledge on the part of heath care providers of legal requirements for providing language services, and lax enforcement of federal and state laws, which has allowed many health care providers to neglect the issue.
The issue of access to language services has increasingly garnered national attention. Reiterating longstanding provisions of Title VI of the Civil Rights Act of 1964, President Clinton issued Executive Order 13166 in August 2000, ìImproving Access to Services for Persons with Limited English Proficiency.î This executive order recommits the federal government to improving the accessibility of government-funded services to individuals with limited English proficiency (LEP). It requires each federal agency to develop and implement guidance to ensure meaningful access for these individuals without unduly burdening the fundamental nature of each department or program.1 Subsequently, the Department of Health and Human Services (HHS) Office for Civil Rights issued its own guidance.2
While general recognition exists that ensuring access to language services improves the quality of health care provided to individuals with LEP, recipients of federal funds, such as state and local Medicaid agencies, hospitals, and managed care organizations, expressed concern about EO 13166 and HHS guidance, citing that they would be responsible for providing interpreters yet not receive reimbursement. A recent report from the Office of Management and Budget, however, estimates that language services would only add an extra 0.5 percent to the cost of the average health care visit.3 Moreover, the Centers for Medicare and Medicaid Services (CMS) have informed states that federal reimbursement for language services is available for Medicaid and State Childrenís Health Insurance Program (SCHIP) enrollees.4
These facts notwithstanding, health care providers have raised legitimate concerns about providing language services for patients with LEP. To address some of these concerns, the National Health Law Program, with funding from The Commonwealth Fund, undertook an assessment of programs under way to improve access to interpreter services in health care settings. It examined several different methods of providing oral interpretation, including using bilingual providers/staff, hiring staff interpreters, contracting with qualified interpreters, and creating interpreter pools. Because of time and cost limitations, this report does not address translation of written materials, interpretation in government offices, or other promising practices regarding, for example, cultural competency or ensuring language concordance between providers and patients.
The National Health Law Program developed a short survey instrument and distributed it to interested organizations nationwide during the fall of 2001 and winter of 2002. From the completed surveys, 14 programs and projects were selected for more indepth assessment. Programs were selected to reflect a range of interpreter services in different health care settings, funding sources, and costs of implementation. Programs profiled in this report include those sponsored by state and local governments, managed
care organizations, hospitals, community-based organizations, and educators. Examples include:
? Statewide Medicaid/SCHIP reimbursement. The agencies that administer Medicaid in Hawaii, Maine, Minnesota, Utah, and Washington obtain federal matching payments for language interpretation services provided to Medicaid and SCHIP enrollees. The report profiles programs in Minnesota and Washington.
? State and local government initiatives. The Commonwealth of Massachusetts has implemented an emergency room interpreter law that requires general hospitals and acute psychiatric hospitals to offer no-cost interpreters to persons using their emergency rooms and inpatient psychiatric facilities. In Minnesota, the Hennepin County Office of Multi-Cultural Services is engaged in a number of activities to provide interpreters to clients, including at appointments with health care providers.
? Managed care organizations. In addition to paying for trained medical interpreters, the Alameda Alliance for Health in Alameda, California, has instituted a stipend policy to encourage physicians and physician extenders (such as physician assistants and registered nurses) to use professional medical interpreters. The L.A. Care Health Plan has developed a Health Care Interpreter Pilot Program, which offers training and certification to L.A. Care Health Plan providers and staff.
? Hospitals. The New York City Health and Hospitals Corporation and the Center for Immigrant Health of the New York University School of Medicine is operating a remote simultaneous medical interpreting program in conjunction with the cityís Gouverneur Hospital. Maine Medical Center in Portland has worked with the HHS Office for Civil Rights to develop a tailored plan for providing language access that reflects the suggestions made by the Office for Civil Rights in its LEP guidance. And eight health care facilities in Dane County, Wisconsin, are operating a collaborative enterprise to develop standardized interpreter policies and assess individualsí abilities to provide competent interpretation services for the collaborating facilities.
? Community-based organizations. Community-based organizations are working with hospitals and health care providers to make qualified interpreters available to them. The language banks of the New York Multicultural Association of Medical Interpreters and the Northern Virginia Area Health Education Center are described.
? Educational models. Entities are focusing on making educational modules and courses available in order to increase the number of competent interpreters. This report highlights the ìBridging the Gapî curriculum developed by the Cross Cultural Health Care Program in Seattle, which is being used nationwide, and three programs that are benefiting local communities: a home-study certification program operated out of the HealthReach Community Care Clinic in Waukegan,Illinois, and for-credit courses in medical interpreting being offered by colleges in Massachusetts and South Carolina.
With this report, the National Health Law Program has attempted to identify and describe promising programs and practices that can be adapted or replicated elsewhere. Recognizing that improving access to language interpretation services will involve increased spending, the report also identifies some of the current funding sources for such services.
Recommendations
The findings presented here demonstrate the need for a range of approaches tailored to the needs of specific communities and patient populations, and they show that such approaches are meeting with success. Some programs identify ways to develop reliable funding sources to pay for interpreters. Others document ways to increase the quantity of interpreters and the quality of the service they provide. In most instances, these efforts represent partnerships between government, providers, and communities, and they hold
great potential to be replicated elsewhere.
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