For over 40 years, civil rights laws have prohibited federally funded entities from discriminating on the basis of national origin, race, and ethnicity. Changing demographics, however, as well as heightened federal and state policies, have increased the need for effective and efficient models of providing language services to individuals who are limited English proficient (LEP).
Medicaid and the State Children's Health Insurance Program (SCHIP) provide health insurance to many low-income individuals, including those who are LEP. State and local benefits offices ("benefits offices") that administer these programs are responsible for activities such as outreach, enrollment, retention, and communication with applicants/enrollees ("clients"). These benefits offices must be able to communicate effectively with their LEP clients. Communication can, in fact, be the deciding factor in whether a LEP individual actually enrolls in a program and receives benefits. Benefits offices that have implemented effective communication strategies help ensure that LEP individuals receive timely information, in languages other than English, that helps them understand how the program operates and how to access services and retain eligibility.
In contrast, communication barriers can preclude LEP individuals from applying for or retaining eligibility in these programs or from receiving full benefits. Offices' lack of resources and knowledge, or those placing a low priority on providing language services can create barriers for LEP clients. Resource constraints may include a shortage of bilingual staff and trained professional interpreters and translators. The lack of knowledge in benefit offices about LEP populations is also significant. According to a New York City survey, benefits office workers did not offer language services to 87 percent of LEP clients. These clients reported being turned away from Medicaid offices; made to wait excessive amounts of time before being served; required to bring an "informal" interpreter or rely on a non-confidential interpreter; and required to make repeated visits before receiving benefits.
Summary of Findings
Through surveys and site visits, the National Health Law Program (NHeLP) assessed language service programs and activities under way in state and local agencies and benefits offices that help people apply for and retain eligibility for Medicaid, SCHIP, and other publicly funded health programs. Some states have implemented or are developing department-wide language service plans. In others, the language service plan or policy applies to a specific subset of the department, such as the Medicaid agency within the Department of Health. Administrative subdivisions, such as Los Angeles County, have in some instances developed their own language services plans. Converting these plans from paper to practice can be a major challenge for benefits offices.
This study identified a number of innovative and replicable activities:
Designated staff. To assure accountability and performance, almost all the benefits offices interviewed for this project have designated one or more staff members to coordinate language service activities.
Community involvement. Benefits offices are beginning to recognize that providing language services requires broad community acceptance and participation. They are formalizing community involvement through advisory boards that offer suggestions, identify issues, and assist with planning and implementation or services.
Language access planning. Benefits offices are creating written language plans, as suggested by the Department of Health and Human Services Office for Civil Rights (OCR). Language plans identify language needs and describe the office's strategy to meet the need.
Determining language needs at first points of contact. Benefits offices are taking steps to introduce language access at the first points of client contact. For example, "I Speak" posters and cards that identify clients' language needs as soon as they walk through the door are used by front-desk staff.
Language services throughout the client encounter. Because LEP clients experience language barriers throughout the health care encounter, benefits offices are using bilingual staff and interpreters to assist their clients throughout intake, clinical encounter, and follow-up.
Bilingual caseworkers. Some agencies are assessing bilingual staff hired as caseworkers to determine if they can interpret for clients or staff.
Dual role bilingual staff. Many benefits offices are hiring bilingual staff to perform multiple roles, including specific language assistance tasks. For example, in addition to other job responsibilities, individuals with conversational proficiency in a second language may provide limited telephone assistance at the front desk while those with greater proficiency may interpret during intake interviews.
Contract interpreters. Some benefits offices are partnering with other state and local agencies to share interpreters and translators while others are using interpreters and translators who work on a contract basis. Offices interviewed for this report are finding such interpreters through state or local agencies, colleges and universities, refugee resettlement sites, community-based organizations, and commercial entities.
Community resources. Benefits offices can work with entities in their community to improve language services available. Many are working with local advocates, legal aid organizations, community-based organizations, refugee resettlement organizations, and community colleges.
Interpreter competency. Benefits offices are working to improve the competency of bilingual staff who provide services in languages other than English. Some offices have developed specific assessment or qualification testing.
Telephone language lines. Benefits offices are using telephone language lines (i.e., services that offer interpreters via telephone), but only as a last resort for frequently encountered languages. They use them more often for less frequently encountered languages. The offices often verify the competency of the telephone language lines.
Written translations. Some benefits offices are translating vital documents in-house, using bilingual staff, or through contracts with outside translators. They notify LEP clients of the availability of these documents through brochures, coloring books, kitchen magnets, and fotonovella (picture stories). When entire documents cannot be translated because of limited resources, benefits offices often use language notification flyers and taglines on documents to inform clients that an interpreter is available to translate the document orally.
Data collection. Many offices collect client-level data on applications while others collect information on special language designation forms. Some offices use the data to help evaluate services and identify additional needs. Office staff may soon have language services easily available through databases currently being developed.
Staff training. Staff training is essential to ensure that available language services are appropriately utilized in benefits offices. Some offices are engaging in on-site, staff-wide training and testing, while others are using online training and information dissemination.
Client satisfaction. Benefits offices are monitoring client satisfaction as they continue to evaluate and expand their language services. This may be as simple as client-charting notations or may entail formal client surveys.
The results here represent one step toward identifying and evaluating the various models of providing linguistic access and cultural competency in health care. The activities described in this report clearly demonstrate that one size does not fit all when it comes to providing language services. Rather, the nature, scope and delivery approach will vary from state to state, community to community, and from one local benefits office to another. However, by borrowing and adapting from the activities already under way, benefits offices can make great strides toward improving health care access. Benefits offices that are developing language services should follow this eight-step process:
Step 1—Designate responsibility.
Step 2—Conduct ongoing analysis of language needs.
Step 3—Identify and work with resources in the community.
Step 4—Determine what language services to provide.
Step 5—Determine response to LEP individuals.
Step 6—Train staff.
Step 7—Notify LEP clients of available language services.
Step 8—Update activities after periodic review.
While determining appropriate language services depends on individual circumstances, benefits offices have an array of options that can be tailored to the needs of their LEP clients and the office's setting, size, and location. Offices may hire bilingual staff and contract interpreters, use in-person or telephone interpreters, or partner with other agencies and offices to share resources and costs.