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Language Matters: Poor Communication Can Mean Poor Health Care

July 2009

Annette B. Ramírez de Arellano, DrPH

A woman reads the label on her prescription drug and thinks she understands it. It says “take once after breakfast.” But she is Spanish-speaking and “once” in Spanish means “eleven”; she therefore takes 11 pills after her café con leche.

An 8-year-old child accompanies his grandfather to the doctor. The elder gentleman does not speak English, so both he and the physician rely on the child to translate. The child speaks English but can neither fully understand nor convey what the health providers say. Yet everyone is lulled into thinking that information is being exchanged.

While much of the health care debate is being guided by how the arguments for or against reform are “framed,” policymakers are paying scant attention to a more basic linguistic issue: many persons are deprived of adequate care because they are unable to communicate with their providers. Language barriers are very real and affect how care is provided and received. At present, patients are more multilingual than practitioners. The most recent Census data show that, in the U.S., one in five persons speaks a language other than English at home. This proportion ranges from 42.6 percent in California to 2.3 percent in West Virginia.

The law, however, is clear: All persons in the United States have a right to language-assistance services when attempting to get access to health care services. This is part of Title VI of the 1964 Civil Rights Act, which states, “No person in the United States shall, on the ground 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.”

The Supreme Court has treated discrimination based on language as equivalent to national origin discrimination. The court has therefore interpreted Title VI to ban language discrimination. Similarly, the federal government treats language as a proxy for national origin: In federally funded programs and activities, those who speak a language other than English are entitled to treatment equal to that received by English speakers. And because the overwhelming number of hospitals and many ambulatory care clinics receive federal funds, they should be held to this standard.

But there is no way to monitor compliance with the legal requirement. Even major medical centers in cities such as New York and Washington, D.C. fail to provide services for so-called LEP (limited English proficiency) patients. In the absence of planning and resources, stopgaps reign. Non-health care employees or patients in the facility may be called upon to serve as translators, a makeshift arrangement that does not assure accuracy and violates patient privacy.

The Office for Civil Rights (OCR) of the federal Department of Health and Human Services (HHS) is charged with making sure that programs under its aegis are free of discrimination. And its purview is wide: It includes any organization or individual that receives monies through HHS. This encompasses health departments, health plans, social service agencies, nonprofits, hospitals, clinics, and practitioners.

But OCR has no way to exercise its oversight function preventively and systematically. Instead, it often reacts to complaints, initiating reviews and investigating cases brought to its attention. Major medical centers in Boston and San Francisco, among others, have been the target of OCR complaints on behalf of LEP patients. These cases have resulted in the launching of solid interpreter services to address the complaint.

In attempting to comply with the federal requirements, however, most states have enacted a hodgepodge of laws and guidelines. The result, as stated in an article in the Journal of General Internal Medicine, is “a haphazard patchwork of legal obligations which vary from state to state, from language to language, from condition to condition, and from institution to institution.” Not surprisingly, some initiatives reflect the political agendas of special interest groups. Their goal is therefore more to convey a political message than to meet patients’ health needs.

Some states are aware that language can affect care and lead to adverse effects and misuse of resources. They are therefore taking steps to remedy the situation. Some are requiring continuing education for health professionals to address issues of language access and/or cultural competency. Washington State has established a health care interpreter certification program to insure that those serving in that capacity meet given standards of competence and knowledge. And 12 states and the District of Columbia have indicated that language services are eligible for federal matching funds under their Medicaid/State Children’s Health Insurance Program. These efforts, while commendable, have not been incorporated into a “best practices” framework for other jurisdictions to replicate. They are therefore too hit-or-miss to affect large segments of the population.

The current debate on health care reform is focusing on expanding access, insuring quality, and controlling costs. Language is intrinsic to each of these goals. Without the ability to communicate, there is no access. And miscommunication is a major cause of medical errors and patient dissatisfaction, both obstacles to quality care. A national study carried by research from University of California-Irvine found that language barriers between patients and health care providers result in longer hospital stays and medical errors, both of which increase costs. Committing to universal health care means taking into account that language matters.

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