Next Great Immigration Hurdle -- The Right to a Medical Interpreter

New America Media, Investigative Report, Hilary Abramson, Posted: May 30, 2006

Editor's Note: Today, millions of U.S. citizens and non-citizens who speak limited English have the legal right to free medical interpreting. But tomorrow could tell a different story. The Senate immigration bill sent to the congressional conference committee last week included one amendment that would uphold the right and another that could kill the right by making English the official language of the land. The conference committee -- expected to act by the end of the summer -- can only choose one version or delete both. At a time when health policy experts around the country are trying to make the law more effective, the health of as many as 50 million people, whose primary language is not English, may be at stake. Hilary Abramson, a contributing editor of New America Media, has been researching language access in U.S. health care with a grant from the Fund for Investigative Journalism.

SAN FRANCISCO--The two out of five Los Angeles residents who speak Spanish at home would find it easier to buy a can of paint at Lowe's than explain to a public hospital emergency room doctor where it hurts.

The home improvement store offers foreign language interpreting in less than a minute over a special telephone line at the customer service desk. But there is only one fulltime, trained, Spanish-speaking medical interpreter in L.A.'s five public hospitals and clinics; and the health department is investigating why a desk clerk at the L.A. County/USC Medical Center emergency room recently failed to know the access code to its Spanish language line.

Thousands of miles away, the regional trauma center in Savannah, Ga., boasts of having improved its medical interpreting for a burgeoning limited-English-speaking community. But that was only after a young, Spanish-speaking woman, whose boyfriend acted as her interpreter, died during her second visit to its emergency room.

Across urban and rural America, policymakers are grappling with the reality that more than 20 million U.S. residents -- 1 in 12 -- speak one or more of hundreds of languages, but may not speak English well or at all. By law, they are entitled to free interpreting when they seek medical attention.

The issue of medical interpreting for immigrants is poised as the next challenge to every polarized bone in America's body politic. In the Senate immigration bill -- to be considered by the congressional conference committee during the summer -- is an amendment by Sen. Jim Inhofe (R-Okla.) to make English the official language of the land. Some lawmakers and civil rights experts believe it could lead to the death of interpreting as a right. To counter it, Sen. Ken Salazar (D-Colo.), included in the same bill an amendment that supports language access. The conference committee will have to choose one or the other, or delete both.

“While the Inhofe amendment in itself can be seen as largely symbolic, I am concerned about what could happen in the bill’s reconciliation process, because it is exclusively controlled by one party,” says Cindy Roat, who designed the most widely used training for medical interpreters in the country. “Mastering any language well enough to describe your symptoms to a doctor takes years, and the same federal government that wants immigrants to learn English and to assimilate is doing little or nothing to support either process.”

The senatorial mixed message comes just when the issue of medical interpreting is showing up on the national radar. Debate begins with the lack of consensus over what a medical interpreter is, how many are working in the country and what constitutes professional training. It dead-ends at how much professional medical interpreting costs and who should pay for it. Language access researchers, lawyers, policy specialists and advocates estimate it will take at least five more years to agree on solutions. Even with current law on their side, many health care experts wonder if they can beat a brewing health crisis within a health care system they consider dysfunctional.

The issue is fraught with danger. The total number of patients dying annually in the United States due to medical error is roughly equivalent to a full 747 jetliner crashing and killing all passengers every other day. According to the Institute of Medicine, which recently studied medical error, language plays a part in many preventable deaths.

Sidebar: From Sickbed to Jail, for Lack of Medical Interpreting

Horror stories abound. There are reports of lost limbs due to lack of informed consent ensured by professional interpreting. Young children commonly experience psychological trauma from being expected to play interpreter and inform mom or dad of their terminal disease; children who speak English as a second language often misinform adults about how to take their drugs. Patients withhold vital information from physicians for fear that relatives or neighbors acting as interpreters will know their private business. Doctors rely on their high school language skills and bilingual staff members are pulled away from full-time jobs, often misinterpreting for lack of training and medical vocabulary.

Two decades ago, Miami paramedics defined "intoxicado" as "high on drugs" instead of "nauseous." This led to a series of emergency room miscommunications and a malpractice settlement that could amount to $71 million over the lifetime of a former high school athlete. William Ramirez was 18 and able-bodied before he collapsed; when he awakened, he was quadriplegic. More than 36 hours reportedly passed without treatment for what really ailed him -- an acute subdural hematoma and other brain injuries.

Today, details of dramatic legal settlements from the lack of medical interpreting make health industry rounds, but untold numbers of lawsuits based on such interpreting errors settle out of court, away from public scrutiny. Most malpractice insurance companies report that they don't track claims based on linguistic errors and prefer to offer seminars on language access to insured health care providers rather than pressure them to offer medical interpreting.

The 1964 Civil Rights Act bans discrimination based on national origin. This requires any health care provider receiving federal funds -- practically all of them do -- to offer free interpreting to patients with limited English skills. Forty-three states have laws addressing language access in health care, but only New York's attorney general has made headlines by aggressively enforcing them. An executive order signed by former President Bill Clinton before he left office in 2000 requires all recipients of federal funds -- medical providers and government agencies -- to provide free verbal interpreting and written translating services for non-English speaking clients.

The enforcing federal agency -- the Office of Civil Rights (OCR) of the U.S. Department of Health and Human Services (HHS) -- is charged by Congress to obtain "voluntary" compliance. It waits for complaints to be filed, often works for years with the hospitals and health departments it investigates, and in 40 years has never imposed a fine or withheld funds for failure to comply. According to language access advocates, who usually pursue the complaints, once OCR obtains an agreement from a health provider to offer medical interpreting, its investigators rarely return and it's up to advocates to watchdog compliance over the years.

Hospitals subscribe almost universally to expensive telephonic language lines, which the OCR suggests are best used for unusual tongues encountered in a community. But telephonic interpreting is just about useless during childbirth, and because body language can transmit vital information to a doctor, in-person interpreting by a trained, medical interpreter is the gold standard. Citing high costs, most hospitals rely on untrained, bilingual employees and telephonic language lines.

In California -- known for the most progressive language access landscape in the country -- the subject is "barely on our radar," according to Jan Emerson, vice president of external affairs of the California Association of Hospitals and Health Systems. The first priority, she says, is costly hospital seismic retrofit, which has a two-year state deadline. "I don't think it (medical interpreting) is in our top-20 list of what's important. Our priority is to keep our doors open and give care. I don't even think it's a reality to have an interpreter or even the telephone access code ready 24/7." Proposed state regulations ensure that HMOs provide medical interpreting, but there are no "teeth" to guarantee enforcement.

Richard Coorsh, spokesman for the Federation of American Hospitals, whose 20 companies own more than 1,700 private, for-profit hospitals, calls studying the subject in their hospitals "a luxury we don't have."

Although Medicaid health coverage for the poor is supposed to cover medical interpreting, it is up to states to pay providers. Because Medicaid agencies reimburse providers for claims submitted after-the-fact -- at lower rates than professional interpreters charge -- most providers consider medical interpreting an "unfunded mandate" and refuse to pay for it up front.

There are physicians like Dr. Jane Orient, executive director of the Association of American Physicians and Surgeons, which sued last year to overturn former President Clinton's executive order on language access, which has been supported by the Bush administration. A federal judge ruled that the group's members hadn't been hurt by the law and had no standing to sue; the association filed an appeal that is pending in the 9th Circuit Court of Appeals.

"Some of us don't consider it a privilege to do this work with non-English-speaking patients when we're expected to pay for interpreting," Orient says.

And there are those who stand with Dr. Ann Myers, past president of the San Francisco Medical Society: "Family doctors can't afford to pay for interpreting, but it's still a privilege to serve this population. With the significant money insurance companies put in the hands of their executives and shareholders, they could cover medical interpreting. I'm just afraid they'd stop insuring these patients if they had to. Practically speaking, I believe that the feds should pay for medical interpreting."

It would cost about $268 million annually to pay for professional medical interpreting in the United States, according to an Office of Management and Budget report released six years ago. But even some national advocates believe that figure is understated. The best bet, they say, is to take the federal government up on its offer to pay states matching funds for medical interpreting through Medicaid and the State Children's Health Insurance Program (SCHIP). Only 11 states -- mostly with small, non-English-speaking populations -- have applied and received them. States with large numbers of non-English-speaking residents such as California, New York, Texas and Florida doubt they could come up with their half of the cash.

Pay now or pay later, warns Dr. Glenn Flores, a prominent researcher on the subject who is an associate professor at the Medical College of Wisconsin. "Almost 50 million U.S. residents do not speak English at home," he says. "They have more than the prevalence of common diseases most American have. In the end, they could overburden our emergency system. There could be a cascading domino effect on the health care system I don't think anyone wants to see.

"Pay a small amount up front for equitable, high-quality health care for all patients, or pay a lot more later on for unnecessary tests and procedures, preventable hospitalizations, medical errors and injuries and expensive lawsuits."

Photo by John Alden/J.A. Photo

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