In the Literature
Research has demonstrated that U.S. residents with limited English proficiency (LEP) have a harder time accessing health care. Furthermore, even when LEP patients do receive care, language barriers can reduce the quality of that care or increase the risk of miscommunication between patients and clinicians. Substantial research has shown that the use of trained interpreters can improve access to and quality of care, as well as patient satisfaction.
There has been relatively little research, however, documenting the health-related language barriers facing older adults. In "Language Barriers to Health Care Access Among Medicare Beneficiaries" (Inquiry, Spring 2006), Ninez Ponce, Ph.D., M.P.P., of the UCLA School of Public Health, Leighton Ku, Ph.D., M.P.H., of the Center on Budget and Policy Priorities, and colleagues report that Medicare beneficiaries with LEP are less likely than those who are proficient in English to have access to a consistent source of care and less likely to receive important preventive care, including cancer screening tests.
LEP seniors covered by Medicaid as well as Medicare fared better, perhaps because federal civil rights policies require Medicaid health care providers to offer language assistance. Physicians serving only Medicare patients are not bound by such requirements.
As the U.S. population ages and immigration continues at its current pace, the need for policy remedies is likely to grow. "Language barriers could affect many Medicare beneficiaries," Ponce and colleagues say in this Commonwealth Fund–supported study. "Data from the 2000 census reveal that about 2.3 million people 65 or older do not speak English or do not speak it very well."
The researchers analyzed data from the 2001 and 2003 California Health Interview Survey. Study subjects—totaling about 19,000 adults aged 65 or older who reported Medicare coverage—were divided into three language categories: LEP, bilingual, and English-speaking only. For each, the researchers assessed three measures of health care access: having a usual source of care, receipt of a mammogram in the past two years (women only), and receipt of a screening for colorectal cancer.
Because older adults who are dually eligible for both Medicaid and Medicare may have better access to interpreting services available under Medicaid, the researchers also examined health care access by coverage type: Medicare and Medicaid, Medicare with private supplemental coverage, and Medicare only.
Overall, adults with Medicare coverage only nearly always had a usual source of care (97%) and relatively high mammogram rates (79%), but had low rates of receiving a colorectal cancer screening (25%). Dual eligibles and Medicare beneficiaries with supplementary coverage had better health care access than those with Medicare only.
One-quarter of dual-eligibles—or approximately 92,000 of people in California—reported not speaking English well. The percentage of non–dual eligibles (i.e., Medicare only or Medicare plus supplementary coverage) who were LEP was much smaller, but this group still numbered about 49,000. LEP older adults were overwhelmingly Latino or Asian.
After controlling for other demographic and other health status variables, the researchers found that LEP seniors were less likely to have a usual source of health care than those who spoke only English. For female, non-dual-eligible Medicare beneficiaries, LEP status had a significant negative effect on the probability of having had a mammogram within the past two years. Medicare beneficiaries with LEP status were also substantially less likely to have gotten a colorectal cancer screening.
Dual-eligible LEP seniors were more likely to have good access than were those covered only by Medicare. This group, in fact, had comparable health care access even to those LEP seniors with some form of private supplementary coverage—and a better chance of having had a recent mammogram. LEP seniors with no public or private supplemental coverage (i.e., covered by Medicare only) were found to fare the worst on every access measure.
Language barriers can impede access to care even when patients have insurance coverage. But type of coverage can have an impact as well. Dual-eligible LEP seniors fared better on all measures of health care access, compared with those with Medicare-only coverage. These differences are attributable to a number of factors, the researchers say.
First, the Medicaid program in California, the state where this study took place, requires that language services be made available to its patients, while Medicare and private insurers do not have such requirements. California Medicaid managed care plans are required to offer interpretation services and are monitored in their efforts. Second, Medicaid beneficiaries are more likely to use community health centers and safety-net hospitals that traditionally serve low-income patients. These sites may provide more comprehensive services and serve a higher volume of LEP patients compared with individual doctors' offices.
Funding issues may be at the heart of problem, say the authors. "[T]he federal government could improve
access for LEP Medicare beneficiaries by providing Medicare payments for interpretation services or increasing provider payments when patients are LEP," they state. Such policies could have repercussions
beyond Medicare, since other private insurers often adopt Medicare payment methods. "Medicare payment policies should come into concordance with our civil rights policies," the authors conclude, to ensure that all patients gain access to good quality care.
Facts and Figures
- An estimated 8 percent of Medicare beneficiaries, ages 65 and older, in California reported not speaking English well.
- Medicare-only beneficiaries are at risk for lacking comprehensive health care coverage because their incomes are too high to qualify for Medicaid—but not high enough to purchase supplementary policies.
- While federal civil rights policy requires
most health care providers to make interpretation services available to LEP patients, lack of reimbursement has been a stumbling block to implementation, particularly in private physicians' offices.