Health Affairs ForefrontHealth Equity
HHS Must Improve Language Access To Make Meaningful Access A Reality
Across the country, as health care navigators continue their critical work to help enroll people in health coverage, the experience of multilingual assisters illustrates how one’s voice can be a lifeline for those facing critical barriers to accessing health coverage and services. Rumina Lakmis of Springdale, Arkansas, is one example. As a navigator at the non-profit Arkansas Coalition of Marshallese (ACOM), she is a resource for a sizeable Marshallese community in the state, which includes many limited-English speakers who rely on her for language support or for assistance understanding their insurance options or eligibility they cannot access elsewhere.
Nationally, about one-third of Asian Americans (AA) and 14 percent of Native Hawaiians and Pacific Islanders (NHPI), which includes people from the Marshall Islands, do not read, speak, write, or understand English well. Without help in their own languages, essential services and resources are inaccessible to them. Even enrolling in health insurance or using coverage to see a doctor or fill a prescription is very difficult because of the lack of assistance for limited-English speakers.
Breaking Down Barriers
Language barriers present especially difficult challenges when it comes to navigating new coverage options under the Affordable Care Act (ACA). In the absence of robust language access efforts from the federal government, multilingual advocates like Lakmis have had to take the lead to ensure that people who do not speak English well or at all are able to get and understand their health insurance.
ACOM is one of more than 70 community-based organizations and health centers in the national AA and NHPI health advocacy network, Action for Health Justice (AHJ). In the first three ACA Open Enrollment periods, AHJ groups reached out to, educated, and helped enroll nearly 1 million AAs and NHPIs in 24 states and in 56 languages. Through this work, navigators have seen first-hand the challenges their clients face and the inadequacies of the current system for assisting non-English speakers. In communications with staff at the Asian & Pacific Islander American Health Forum, one of AHJ’s co-founding organizations, Lakmis recounted some of the experiences she has had helping limited-English speakers obtain health insurance. She said she is used to contacting the Marketplace call center for an interpreter and getting an automatic response that assistance can only be provided in Spanish. When she clarifies that her clients don’t speak Spanish, but Marshallese, the response is, “Where is that?”
Federal law is designed to prevent people from encountering this type of barrier to obtaining basic insurance coverage and health services. Title VI of the Civil Rights Act of 1964 requires that people with limited-English proficiency have “meaningful access” to federally funded programs and activities. The ACA also contains a strong civil rights provision, known as Section 1557, that incorporates many civil rights laws and prohibits discrimination on the basis of national origin, which protects limited-English proficient (LEP) persons.
Section 1557’s protections apply to the U.S. Department of Health and Human Services (HHS), the federal and state Marketplaces, and the qualified health plans offered in those Marketplaces. In May 2016, HHS’ Office for Civil Rights issued its final rule to implement Section 1557, clarifying when covered entities must provide language assistance services, including in-language information and resources. Section 1557 makes clear that language should not be a barrier to accessing health coverage or services.
And yet, consumers continue to struggle. The first clients Lakmis worked with were a pastor, his wife, and a friend from De Queen, Arkansas. All three are diabetic and came to her office to get enrolled in health coverage so that they could finally get the basic health care that they were unable to afford before the ACA. With Lakmis’ help, they got covered. However, as is often the case with LEP community members, their need for language assistance did not end there. They continue to contact Lakmis regularly to interpret for them and translate Marketplace and insurance documents.
Empowering LEP Consumers
Unfortunately, too few consumers have the sense of security that comes with having in-language and culturally competent assistance. For many individuals, language barriers can have serious financial, legal, and health implications. For example, the Marketplace sends vital notices pertaining to a consumer’s legal rights, including what kind of coverage a person is eligible for and what types of documents one must send to prove eligibility and get financial help.
But the notices come in only two languages: English and Spanish. This leaves out the millions who speak some of the most commonly spoken languages nationwide, including Chinese, Vietnamese, and Korean, to name a few. If a legal notice is not sent in their language, consumers have no idea about its importance, or the appropriate response. Failure to reply to such a notice can lead to substantially reduced tax credits or terminated coverage.
Federal civil rights protections, including Section 1557, are intended to reduce these types of barriers, but meaningful access to enrollment and post-enrollment assistance is still a distant reality. In order to ensure these protections, HHS needs to work diligently to enforce and implement them within the Department and its programs, including the federal Marketplace. Although HHS has taken important steps over the past few years to help inform consumers of their rights, there is far more that must be done.
For example, HHS should fully translate the most critical Marketplace notices into the most commonly spoken AA and NHPI languages, such as Chinese, Gujarati, Hindi, Korean, Tagalog, and Vietnamese. HHS should prioritize the translation of those notices that ask consumers to submit additional documents, that inform them that their coverage is about to be terminated, or that affect the consumer’s legal rights in any way.
While notices have in-language taglines, or short statements, that are supposed to inform people of the urgency of the document and that help is available, the taglines are insufficient because they come at the end of lengthy documents and consumers often miss them. In addition, the text still is not specific enough to adequately inform consumers of the nature of the document and what they must do. HHS can readily make these taglines more conspicuous, such as putting them at the beginning of the notices as contemplated by the final Section 1557 rule and as the District of Columbia’s Marketplace does.
Call center services also serve a vital function whose quality must be improved, as Lakmis’ regular experience illustrates. Even when consumers know that the federal language line can provide help in their language, they might not receive appropriate interpretation services. In Lakmis’ case, the call center staff sometimes do not understand the need to connect her clients to the Marshallese interpreter, despite Marshallese being one of the languages for which help is available. Without accurate interpretations and competent services provided by the telephone language line, many people face confusion and wasted time, especially if they are misinformed or misdirected. HHS has improved the call center and language line, but it must routinely monitor and track call center quality to ensure services are both accurate and timely.
Of course, all of the improvements needed to ensure compliance with language access requirements rely upon data--especially disaggregated data for smaller racial, ethnic, and language populations--to identify need and to measure progress. HHS should use best practices to encourage consumers to supply optional, but critical information such as their race, ethnicity, and primary language and then analyze and publicly release the data to ensure efforts meet the needs of all consumers.
Where language access measures fall short, advocates like Lakmis help close the gaps. But the federal government is obligated and better positioned to meet the needs of LEP consumers. With clearer language access directives under Section 1557 and the approaching Open Enrollment period in November, HHS must use the time to vigorously tackle language barriers and to deliver on the ACA’s promise of truly embracing all communities.