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Research Article

Disability

Communication Access In Mental Health And Substance Use Treatment Facilities For Deaf American Sign Language Users

Affiliations
  1. Tyler G. James ([email protected]), University of Michigan, Ann Arbor, Michigan.
  2. Michael S. Argenyi, Wake Forest University, Winston-Salem, North Carolina.
  3. Donna L. Guardino, University of Rochester, Rochester, New York.
  4. Michael M. McKee, University of Michigan.
  5. Jaime A. B. Wilson, Wilson Clinical Services, Tacoma, Washington.
  6. Meagan K. Sullivan, Gainesville, Florida.
  7. Eiryn Griest Schwartzman, Baltimore, Maryland.
  8. Melissa L. Anderson, University of Massachusetts, Worcester, Massachusetts.
PUBLISHED:Open Accesshttps://doi.org/10.1377/hlthaff.2022.00408

Abstract

Deaf and hard of hearing (DHH) American Sign Language users experience significant mental health–related disparities compared with non-DHH English speakers. Yet there is little empirical evidence documenting this priority population’s communication access in mental health and substance use treatment facilities. This study measured mental health and substance use treatment facilities’ noncompliance to Section 1557 of the Affordable Care Act (ACA), which requires health care facilities receiving government funds to provide effective communication access, such as a sign language interpreter, to DHH patients. Using nationally representative data from the Substance Abuse and Mental Health Services Administration, we found that 41 percent of mental health facilities and 59 percent of substance use treatment facilities receiving public funds reported not providing services in sign language in 2019 and were thus noncompliant with the ACA’s mandate to provide accessible communication to DHH patients. We mapped these data to display state-level noncompliance, and we make detailed recommendations at the policy, facility, and provider levels. These include monitoring noncompliance among government-funded facilities, expanding state-by-state mental health licensure reciprocity and telehealth policies to improve access to American Sign Language–fluent mental health professionals and addiction counselors, establishing systematic processes to collect information on disability-related accommodation needs, and increasing the workforce of DHH American Sign Language–fluent providers.

TOPICS

Deaf and hard-of-hearing (DHH) American Sign Language users are a sociolinguistic minority group within the United States, consisting of at least 500,000 people.1 This population experiences widespread deleterious social determinants of health, including higher rates of under- and unemployment, being publicly insured or underinsured, and lower educational attainment,25 which are attributable to the oppressive system of audism and associated with worse health outcomes. Audism is a system of power that privileges people who are not DHH. Compared with non-DHH people, DHH American Sign Language users experience higher rates of interpersonal violence and suicide, along with a two- to threefold higher risk for mood and anxiety disorders, lifetime trauma exposure, and substance use.4,612 Addressing these disparities is prioritized by organizations that serve DHH American Sign Language users, DHH community members, and mental health service providers who are providing care to DHH patients.4,13,14

Background And Context

Language Deprivation

DHH American Sign Language users with congenital or early onset of hearing loss have a high risk for adverse childhood communication experiences, such as poor caregiver communication and language deprivation.15,16 Difficulty communicating with family members is common among DHH people who have hearing parents,17,18 which included 92 percent of DHH children in a study published in 2004.19 Prior research has found that hearing parents often do not gain American Sign Language proficiency,20 and only around one-fourth used American Sign Language regularly at home as of 2014.21 Without exposure to an accessible language from birth, DHH children are at high risk for language deprivation.17

The social inequities that DHH American Sign Language users face can be partially attributed to language deprivation.22,23 Language deprivation is linked to difficulty learning and poor emotional regulation, including unregulated externalization of emotions.15 Studies have found that as a consequence, large numbers of DHH patients in inpatient and outpatient mental health facilities have shown some degree of language deprivation.8,15 Language deprivation is, therefore, an important factor when considering the etiology and prevalence of mental health conditions among DHH American Sign Language users. Ensuring that mental health care communication is accessible is a precursor to appropriate diagnosis and treatment.

Mental Health Care Access

DHH American Sign Language users face several barriers to seeking mental health care, including scheduling and affording care.24,25 Because of language deprivation and lack of communication access, DHH American Sign Language users frequently enter mental health care with limited health literacy and health care navigation skills.5,23,26

Most health care providers, including mental health providers, are inadequately prepared to meet the needs of DHH American Sign Language users. They lack knowledge of DHH people’s culture and language, including their values and social norms, as well as the systems of oppression that DHH people face.18,2730 This disconnect between many clinicians and DHH clients contributes to mistrust that can weaken a patient’s ability to seek help and stay in treatment and can reduce the overall efficacy of treatment.31 Repeated encounters with these barriers justifiably fuel negative perceptions and avoidance of the mental health care system,32 frequently resulting in delayed treatment, misdiagnoses, inappropriate treatment, exacerbation of mental health problems, and increased length-of-stay.25,3335

As a result of language dysfluency caused by language deprivation, psychiatric assessment of DHH American Sign Language users is complex.36 Mental health providers must understand the trauma that is frequently associated with communication barriers such as past refusals to accommodate communication needs; given this and other concerns, the providers need to invest a considerable amount of resources in the assessment process. This requires effective health care communication between DHH American Sign Language–using patients and their care team.

Accessible Health Care Communication

Federal regulations define what constitutes effective communication access and describe requirements to provide auxiliary aids as a form of accommodation to DHH American Sign Language users. Auxiliary aids may include on-site American Sign Language interpreters, Deaf interpreters, web-based interpreting services (for example, video remote interpreting), Cued Speech transliterators, real-time captioning services, or alternative document formats. An American Sign Language interpreter is a person who is hearing and provides sign language interpretation, whereas a Deaf interpreter is a fluent DHH American Sign Language user who is trained in interpreting while incorporating the unique cultural and linguistic needs of the DHH person.15 Cued Speech is a systematic method of communication to provide sounds of spoken language in visual form.37 Real-time captioning services provide spoken English in a written format, similar to subtitles on a television screen. Federal law does not mandate the certification or licensure of communication service providers, although some states have licensure requirements that may require credentialing by the Registry of Interpreters for the Deaf, a national professional organization that credentials American Sign Language interpreters.

The Americans with Disabilities Act (ADA) of 1990 and Section 1557 of the Affordable Care Act (ACA) regulate DHH American Sign Language users’ health care communication access. The goal of these regulations is to ensure that such patients receive effective communication access, which may be through a sign language interpreter. However, these regulations differ in how facilities are permitted to respond to patients’ requests for accommodations.

ADA Titles II (28 CFR Part 35) and III (28 CFR Part 36), which cover state and local governments and places of public accommodation (for example, hospitals), respectively, both require that effective communication be provided. Title II stipulates that the person with a disability must be provided primary consideration of the type of accommodation they would like. The public entity must honor the choice of the requestor, with certain exceptions granted by regulation. Title III permits places of public accommodation to make the determination of what accommodations are provided.

Most health care organizations, including mental health and substance use treatment facilities, are regulated as places of public accommodation under ADA Title III. Therefore, if a DHH American Sign Language user requested an on-site interpreter in a private or nonprofit hospital, under ADA Title III the hospital could provide another modality, such as web-based video remote interpreting, if it demonstrates that this modality is effective. Section 1557 of the ACA covers any health care entity (for example, hospitals and health insurance providers) that receives federal funding, including funds from the Department of Health and Human Services or any executive agency. ACA Section 1557 has the same requirements for effective communication as Title II of the ADA—that is, primary consideration, as stated in 42 U.S. Code Section 18116(a).

Despite and because of these policies, DHH American Sign Language users are often not provided effective communication access, such as commonly requested on-site American Sign Language interpreters, in health care settings. Under such circumstances, video remote interpreting is often provided, despite DHH American Sign Language users often reporting that this service is ineffective and interferes with patient-provider communication because of a lack of staff training and technical difficulties.38,39 Similarly, qualitative studies focused on health care communication access before and after implementation of ACA Section 1557 indicate poor communication experiences among DHH American Sign Language users.38,40 Such experiences have also surfaced in multiple federal lawsuits alleging that health care organizations fail to provide accessible communication to DHH American Sign Language users.4144 Lack of effective communication access increases patient stress, diminishes patient-centered care, and leads to health care–associated trauma.38,40

Few studies have examined DHH American Sign Language users’ access to effective communication specifically within mental health care or substance use treatment settings.35 However, we are aware of multiple cases in which DHH American Sign Language users have been denied effective communication while in mental health and substance use treatment facilities. Similar experiences are reflected in a 2018 lawsuit in Florida, where a DHH American Sign Language user who was involuntarily admitted to an inpatient psychiatric facility after attempting suicide was denied access to an interpreter.44 The patient, diagnosed with depression and anxiety disorders, was forced to communicate with providers through writing, underwent treatment and evaluation without an interpreter, and finally received an interpreter only when being made ready for discharge. In his case documents, the patient reported that he was unable to share pertinent experiences during a psychiatric mental status exam and that he did not understand his diagnosis, medication, or treatment options.

Study Objective

Given DHH American Sign Language users’ mental health and substance use disparities and the lack of research on treatment facility accessibility, the objective of the current study was to assess the provision of accessibility services, such as services in sign language through an interpreter or fluent provider, in US mental health and substance use treatment facilities covered under ACA Section 1557—that is, health care facilities that receive federal funds. We applied legal epidemiology methods, including the transformative paradigm and framework of public health law research,45,46 to categorize mental health and substance use treatment facilities as “covered entities” or not and then examined geographic distribution by state of covered entities’ reports of not providing services in sign language to DHH patients. To our knowledge, at the time of publication, this was the first study to assess Section 1557 noncompliance among US mental health and substance use treatment facilities at the national level.

Study Data And Methods

Data

This study was a secondary analysis of data from the 2019 National Mental Health Services Survey (N-MHSS) and the 2019 National Survey of Substance Abuse Treatment Services (N-SSATS), administered by the Substance Abuse and Mental Health Services Administration (SAMHSA). The two surveys represent a census of all known facilities in the US that provide mental health treatment and substance use treatment, respectively.47,48 A few exclusion criteria apply: Department of Defense treatment facilities, individual or small group practices not licensed as a clinic, and jails or prisons were excluded from the N-MHSS.47 Data for both surveys were collected via web-based questionnaires, paper-and-pencil surveys, and telephone interviews.47,48 Response rates were 91 percent for both surveys in 2019.47,48 Therefore, these data are representative of mental health and substance use treatment facilities in the US in 2019. Of note, we chose to analyze data from 2019, as the COVID-19 pandemic has likely confounded the data on compliance in 2020 and 2021.

Measuring Noncompliance

Facility characteristics, including administrative and funding questions, were collected in both surveys.47,48 These characteristics were used to identify status as a covered entity under Section 1557, defined as a facility operated by or receiving funding from an executive-branch agency. For example, nonprofit facilities that received monies from the Department of Health and Human Services or SAMHSA Community Mental Health Services Block Grants were deemed covered entities.

Facilities’ provision of services in sign language was measured in N-MHSS and N-SSATS using the following item: “Does this facility provide [mental health or substance use] treatment services in sign language at this location for the deaf and hard of hearing (for example, American Sign Language, Signed English, or Cued Speech)?” (emphasis in original).47,48 Responding facilities were directed to mark “yes” if staff or an on-call interpreter agency provided this service. Section 1557 noncompliance was measured on the basis of covered entity status and the answer to the previous question. A covered entity indicating an answer of “no” was considered noncompliant.

Analysis

We conducted data analyses using SAS, version 9.4 (see online appendix exhibit A1).49 We began our analysis by calculating frequencies and percentages to describe the characteristics of mental health and substance use treatment facilities. Using chi-square analysis, we assessed the association between providing services in sign language (for example, through an interpreter) and being a covered entity (see the appendix for analysis details).49 The proportion of noncompliant covered entities was then mapped using the website Datawrapper. Because of the descriptive nature of the data and limitations in the spatial granularity of the data set (that is, the inability to map lower than the state level), we did not conduct more in-depth spatial analysis.

Limitations

The primary limitations of this study are related to the design of the two SAMHSA surveys. The single question used to identify whether facilities provide accessible services for DHH American Sign Language–using patients includes multiple, qualitatively different auxiliary aids (that is, American Sign Language, Signed English, and Cued Speech), including American Sign Language–proficient providers. Although many qualified interpreters are trained in both American Sign Language (a natural language) and Signed English (signs that follow English grammar), Cued Speech is a method of communication in which mouth movements are combined with a system of hand movements to provide information on sounds of spoken language.37 Because multiple modalities were measured in this question, it was not possible to differentiate among services provided.

Our analytic strategy assumed compliance to Section 1557 without regard to the fluency of the provider or interpreter, which is an important legal and practical issue that the data could not address. Further, a facility responding that it had or provided the service did not necessarily indicate that communication access was provided across the course of treatment. For example, a facility may have indicated that it provided the service (for example, if it used an agency), but the facility would be noncompliant if an interpreter was not called, available, or provided. Therefore, we used the term noncompliant, indicating that the facility did not provide the service, versus compliant, which would require more information to assess and would vary from patient to patient.

Determinations of whether a facility is a covered entity under Section 1557 are made through a legal process during litigation, when patients seek remedy under the ACA for inaccessible facilities. To minimize misclassifying facilities, we attempted to be conservative in how we defined a covered entity. For example, we did not include private health insurance plans under our definition, even though many such plans are administered by organizations that receive federal funds (for example, ACA exchange plans). Last, more microlevel detail, such as geographic coordinates of the facilities, would have allowed us to use a more robust analytic framework and identify specific areas that are more or less accessible to DHH American Sign Language users.

Because of these limitations, it is likely that our findings underestimated the number of facilities that were noncompliant with ACA Section 1557 during the study period. Despite these limitations, this study offers the first examination of Section 1557 compliance for DHH American Sign Language users, using data representing the universe of mental health and substance use treatment facilities in the US in 2019.

Study Results

Facility Characteristics

Exhibit 1 and appendix exhibit A2 show characteristics of mental health and substance use treatment facilities included in the study, by covered entity status.49 A majority of mental health (96 percent) and substance use (78 percent) facilities were classified as covered entities. Covered entities were primarily operated by private nonprofit organizations (62 percent and 55 percent for mental health and substance use treatment facilities, respectively). The majority of mental health and substance use treatment facilities that were covered entities qualified as accepting Medicaid (92 percent and 87 percent, respectively) or Medicare (71 percent and 48 percent, respectively). Most mental health facilities that were covered entities were accredited by the state mental health authority (72 percent) or the Centers for Medicare and Medicaid Services (CMS; 53 percent); substance use treatment facilities were predominantly accredited by state substance abuse agencies (79 percent) (appendix exibit A2).49 Appendix exhibit A3 provides state-level prevalence of noncompliance for all facilities.49

Exhibit 1 Characteristics of mental health and substance use treatment facilities in the US, by covered entity status under Affordable Care Act Section 1557, 2019

Mental health facilities (N = 12,472)
Substance use treatment facilities (N = 15,961)
CharacteristicsCovered entitiesa (n = 11,942)Not covered entities (n = 530)Covered entitiesa (n = 12,474)Not covered entities (n = 3,487)
Facility operated by:
 Private organization
  For-profit19.2%41.9%33.9%60.1%
  Nonprofit61.650.054.635.5
 Government
  State (such as state mental health authority, department of health)6.96.22.01.6
  Local, county, municipal, or regional7.51.95.02.0
  Tribal0.20.01.80.8
  Federal (such as Department of Veterans Affairs, Department of Defense, IHS)b4.60.02.70.0
 Other0.10.0cc
Insurance and fundingd
 Free servicecc0.212.6
 Cash or self-payment84.472.292.286.0
 Private health insurance81.750.581.944.4
 Medicareb70.60.047.70.0
 Medicaidb91.60.087.30.0
 State-financed plan other than Medicaid60.360.359.69.9
 State mental health agency (or equivalent) funds57.524.3cc
 State welfare or child and family services agency funds42.818.3cc
 State education agency funds30.99.1cc
 State corrections or juvenile justice funds17.210.4cc
 Other state government funds36.816.8cc
 County or local government funds47.723.5cc
 Community Services Block Grantsb22.80.0cc
 Community Mental Health Block Grantsb33.10.0cc
 Federal military insurance (such as TRICARE)b52.10.048.20.0
 Department of Veterans Affairs fundsb25.00.0cc
 IHS, tribal, or urban fundsb8.90.014.80.0
 Other1.12.3cc
 Federal, state, or local government grants or fundsecc59.832.6
Provides services in sign language for DHH patientsf
 No41.277.359.285.4
 Yes58.822.740.814.6

SOURCE Authors’ analysis of data from the 2019 National Mental Health Services Survey (N-MHSS) and the 2019 National Survey of Substance Abuse Treatment Services (N-SSATS) administered by the Substance Abuse and Mental Health Services Administration. NOTES IHS is Indian Health Service. DHH is Deaf and hard of hearing.

aCovered entities for Section 1557 of the Affordable Care Act (ACA) (per 42 U.S. Code, Section 18116) are “any health program or activity, any part of which is receiving federal financial assistance…or under any program or activity that is administered by an Executive Agency.”

bIndicator used to identify covered entity status.

cNot reported.

dSome cases missing. N-MHSS excludes 28 cases on these items; N-SSATS excludes fewer than 99.

eSome cases are missing. N-SSATS is missing 620 responses.

fBased on responses to the question, “Does this facility provide [mental health or substance abuse] treatment services in sign language at this location for the deaf and hard of hearing (for example, American Sign Language, Signed English, or Cued Speech)?” (emphasis in original).

Mental Health Facility Noncompliance

There was a significant association between covered entity status and providing services in sign language (chi-square = 264.05; p<0.0001; Cramer’s phi = 0.15). Exhibit 1 shows that 41 percent of mental health facilities classified as covered entities were noncompliant; the proportion was larger among facilities that were not classified as covered entities (77 percent).

Exhibit 2 displays the state-level prevalence of noncompliance with providing sign language interpreters among mental health facilities that were covered entities. In total, seventeen states had 50 percent or more of mental health facilities in noncompliance. South Carolina had the lowest prevalence of facilities in noncompliance (16 percent), whereas Wyoming had the highest prevalence (64 percent). See appendix exhibit A3 for state-by-state prevalence rates.49

Exhibit 2 Prevalence of mental health facilities in the US that are covered entities under Section 1557 of the Affordable Care Act but do not provide services in sign language to Deaf and hard-of-hearing patients, 2019

Exhibit 2
SOURCE Authors’ analysis of survey data from the 2019 National Mental Health Services Survey administered by the Substance Abuse and Mental Health Services Administration. NOTES Puerto Rico not shown because of mapping constraints; its noncompliance level was 39 percent. Map developed using the website Datawrapper.

Substance Use Treatment Facility Noncompliance

There was a significant association between substance use facility covered entity status and providing services in sign language (chi-square = 816.60; p<0.0001; Cramer’s phi = 0.23). As shown in exhibit 1, a majority of substance use treatment facilities that were classified as covered entities were noncompliant (59 percent); this rose to 85 percent among noncovered entities.

Exhibit 3 displays the state-level prevalence of noncompliance with providing sign language interpreters among substance use treatment facilities that were covered entities. In total, thirty-five states had 50 percent or more of their substance use treatment facilities in noncompliance. Missouri had the lowest rate of noncompliance, with only 23 percent of Section 1557–covered treatment centers noncompliant. Idaho was the state with the highest prevalence of noncompliance, with 88 percent of facilities noncompliant. See appendix exhibit A3 for state-by-state prevalence rates.49

Exhibit 3 Prevalence of substance use treatment facilities in the US that are covered entities under Section 1557 of the Affordable Care Act but do not provide services in sign language to Deaf and hard-of-hearing patients, 2019

Exhibit 3
SOURCE Authors’ analysis of survey data from the 2019 National Survey of Substance Abuse Treatment Services administered by the Substance Abuse and Mental Health Services Administration. NOTES Puerto Rico not shown because of mapping constraints; its noncompliance level was 67 percent. Map developed using the website Datawrapper.

Discussion

This study represents the first known inquiry into mental health and substance use treatment facilities’ noncompliance with Section 1557 of the ACA, requiring the provision of sign language interpreting for Deaf and hard-of-hearing patients. Previous studies of DHH American Sign Language users have indicated inequities in receiving effective communication in health care environments4,24,38,50 and significant consequences for mental health treatment and diagnosis when communication access is not provided.35 We found that 41 percent of mental health facilities and 59 percent of substance use treatment facilities receiving public funds self-reported noncompliance in 2019, despite being mandated by Section 1557 to provide services in sign language to DHH American Sign Language users on request.

Substance use treatment facilities had a higher prevalence of noncompliance than mental health facilities. Interestingly, states that had relatively low rates of noncompliance among mental health facilities typically had higher prevalence of noncompliant substance use treatment facilities. For example, South Carolina had the lowest prevalence of noncompliant mental health facilities (16 percent) but the fourth-lowest prevalence of substance use treatment facility noncompliance (37 percent). This pattern of more noncompliant substance use facilities than mental health facilities within states occurred across all states except Hawaii (equal prevalence of noncompliance), Missouri, and West Virginia. The inconsistent prevalence of noncompliance across mental health and substance use facilities within states makes it difficult for patients and patient coordinators to identify facilities that are accessible to DHH patients.

Implications

The ACA was a monumental achievement but is an imperfect mechanism for protecting accommodations for DHH American Sign Language users.

The ACA was a monumental achievement but is an imperfect mechanism for protecting accommodations for DHH American Sign Language users. Primary limitations exist with the enforcement of the civil rights protections afforded by Section 1557. Government entities allocate few resources for enforcing disability civil rights law.51 Routes to enforcement, therefore, require the patient to file an internal grievance to the noncomplying facility’s Section 1557 coordinator, report to the Department of Health and Human Services or Department of Justice, or file a lawsuit in federal court. This places the onus on DHH patients to report accessibility issues and to participate in legal processes to enforce communication access. Linguistic barriers, lack of awareness of options, limited financial and advocacy resources, and a justifiable lack of trust in legal institutions may lead to a cycle in which DHH American Sign Language users forsake legal means of advocacy.

There are distinct challenges to obtaining needed services through litigation, including the length of time of litigation, lack of communication access when working with lawyers or courts, and the limited availability of qualified American Sign Language interpreters and Deaf interpeters working in legal settings. Even if a DHH American Sign Language user navigates these hurdles, the courts may deny legal standing if they believe that the patient is unlikely to use the facility in the future (for example, if there are multiple facilities in a geographic area) or the patient does not make a case that they would need to seek the same services at a noncompliant facility.

Given these challenges, we recommend that policy makers engage DHH advocacy organizations to redesign the Section 1557 grievance process and implement a proactive approach to monitoring compliance. For example, SAMHSA could randomly assess compliance among facilities receiving federal grants such as Community Mental Health Services Block Grants. Compliance could also be factored into CMS inspections and payments. In addition, accrediting bodies, such as the Joint Commission, should review facilities’ protocols and adherence to providing accommodations to patients in need.

We also recommend that mental health providers take an active approach to providing accommodations to DHH American Sign Language users. Health care professionals are gatekeepers to accommodations for DHH patients,38,41 despite a lack of knowledge of appropriate accommodations.52 Failure to provide adequate communication access leads to violations of the codes of ethics for all medical providers.5355 The linguistic power differential and lack of communication access compromises rights-based mental health care and can lead to a lack of informed consent and loss of opportunity for shared decision making, as well as coercion, misdiagnosis, neglect, abuse, and health care–associated trauma.35,44 Mental health providers should work with qualified interpreters, including Deaf interpreters, to ensure accurate assessment, diagnosis, and treatment planning. To further facilitate this accommodation, facilities should contract practively with American Sign Language interpreting agencies and ask patients about communication needs at intake, including the need for an interpreter.56,57

We also recommend the expansion of mental health and substance use treatment programs serving DHH American Sign Language users. When developing technical assistance and direct service programs, government officials should look at exemplar models, such as South Carolina’s or Alabama’s Department of Mental Health Deaf Services, as these states have robust services for DHH American Sign Language users, including American Sign Language–fluent mental health professionals. We unequivocally support the development of pipeline training programs to expand the workforce of DHH and American Sign Language–fluent mental health and substance use treatment providers and the adoption of national standards to credential interpreters working in these settings. In addition, given the scarcity of providers proficient in working with DHH patients,24 policy makers should support interstate mental health professional license reciprocity and telehealth reimbursement to increase service availability for DHH American Sign Language users seeking mental health or substance use treatment.

Conclusion

Although the Section 1557 of the ACA requires that health care organizations provide accessible services to Deaf or hard-of-hearing American Sign Language users, there are widespread geographic disparities in compliance at mental health and substance use treatment facilities. These inequities, paired with existing disparities in mental health conditions among this population, indicate an urgent need for facilities to remedy Section 1557 noncompliance and ensure that DHH American Sign Language users receive treatment in their preferred language modality when in publicly funded mental health and substance use treatment facilities. Future research should assess state variations in mental health policies and interpreter credentialing requirements and examine how the challenges presented during the COVID-19 pandemic may have further jeopardized communication access in health care settings.

ACKNOWLEDGMENTS

Content from this article was presented as a poster at the AcademyHealth Annual Research Meeting in Washington, D.C., June 4–7, 2022. The findings and conclusions of this study are those of the authors and do not necessarily reflect the views of the Substance Abuse and Mental Health Services Administration or the Department of Health and Human Services. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt, and build upon this work, for commercial use, provided the original work is properly cited. See https://creativecommons.org/licenses/by/4.0/.

NOTES

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