By Rachel Showstack
Imagine that you recently moved to a country where almost everyone else speaks a language that you do not know well. You understand a few words here and there and you have learned to produce very simple sentences. When you talk, you sound like a foreigner. One day, you get a terrible headache, the worst in your life. The next thing you know, you are in the emergency department and doctors and nurses are talking to you, but you do not understand the questions they are asking, and you do not understand enough of what they are saying to know if they understand how bad and how unusual this headache is for you, or what they are planning to do to take care of you.
Being a patient in a hospital is scary, but for people who generally communicate in a language other than the dominant language (English in the U.S.), being a patient in a hospital without qualified interpreting services can be dangerous. A misinterpreted word can lead to very severe health outcomes, as in the case of Willie Ramirez, a young man who was taken to a hospital in Florida in a coma after suffering a cerebral hemorrhage (bleeding in the brain). The doctor diagnosed him with a drug overdose, in part because an untrained interpreter mistranslated the word “intoxicado” (poisoned, or ill from food) as “intoxicated” (drunk or drugged), and Mr. Ramirez did not receive the treatment he needed in time. He was left with quadriplegia, resulting in a malpractice settlement of 71 million dollars.
Many Kansas healthcare facilities have trouble consistently offering qualified interpreters for patients who prefer to speak a language other than English, and Alce su Voz has documented the stories of individuals who have suffered as a result of this problem. To understand the challenges of providing language services at Kansas health care institutions, our team spoke with health care leaders across the state and surveyed health care facilities. We then held meetings, beginning with a Language Access Policy Summit in 2023, with administrators of health care facilities, members of the Kansas Hospital Association, and state health care officials to share our findings and discuss possible solutions. After four years of research into these challenges, Alce su Voz has created recommendations to help the state of Kansas make sure its federally funded healthcare institutions follow federal language access rules and provide equitable care for linguistically diverse patients.
One of the major challenges encountered at health care facilities is the question of how to fund qualified interpreting services. Managed care organizations (MCOs), the companies that administer Medicaid coverage in Kansas (Healthy Blue, Sunflower Health Plan, and United Health Care), are required to offer interpreting services to their enrollees. However federal rules require health care agencies to provide qualified interpreting services to all patients with “limited English proficiency,” not just those with KanCare, which covers less than 30% of the population of Kansas. To do so, many health care agencies contract with a national interpreting agency and do not request the MCO services; patients covered under KanCare, for their part, are often unaware of the availability of interpreting services through the MCOs and therefore do not request them either. As a result of these and other situations, the interpreting services provided by the MCOs are not consistently being used as intended. Unlike many other states (such as the District of Columbia, Iowa, Idaho and others) where Medicaid directly reimburses providers for interpreting services, health care agencies in Kansas are currently not able to bill Medicaid to receive reimbursement for the interpreting services that they offer to Medicaid enrollees. As a result, Kansas health care agencies are losing a great deal of money to potentially reimbursable expenses.
Even when interpreting services are available, it can still be challenging to prepare all staff within a health care agency to offer the appropriate services when needed. Clinicians and non-clinical staff at health care agencies in Kansas require additional education on language access rules and the languages and cultures of communities in their region. For example, according to Section 1557 of the Affordable Care Act, health care entities are not allowed to have bilingual staff provide interpreting services unless those individuals are qualified to do so, and interpreting is part of their job responsibilities. To be a qualified interpreter, one must have extensive training on interpreting protocols and ethics and be familiar with the vocabulary and medical concepts needed for a particular encounter. However, our research shows that bilingual staff without interpreter training are often called upon to provide medical interpreting services at Kansas health care agencies.
Like many parts of the Midwestern United States, Kansas has recently experienced increased immigration from Central America, including speakers of Indigenous languages. When it comes to less common languages, such as the Indigenous languages from Guatemala that are spoken in many parts of rural southern Kansas, clinicians and non-clinical staff not familiar with the languages may have difficulty identifying patients’ communication needs. Speakers of Akateko, a Mayan language from the western highlands of Guatemala, may attempt to communicate in their second language, Spanish, even though they may not speak Spanish fluently. National interpreting agencies, such as Propio, do offer Akateko interpreting, but those services may need to be scheduled in advance.
Furthermore, very few Kansas healthcare agencies have language access plans, documents that outline the language access needs of the area and explain how language access services will be provided at the facility, how staff will be educated about language access policies and procedures, and how the services will be evaluated. A new rule on Section 1557 requires healthcare entities to have language access policies and procedures in place, and most healthcare entities (those with 15 or more employees) are also required to have a Section 1557 coordinator. However, most healthcare agencies in Kansas do not comply with these rules, making them less than optimally prepared provide quality services.
These are just a few examples of the challenges that Kansas healthcare entities face in attempting to provide equitable interpreting services. To address these problems, our white paper offers ten interconnected recommendations to the state of Kansas. The recommendations can be summarized as follows:
Phase 1:
- Support health care entities in the development of language access policies and procedures
- Create systems to evaluate the accessibility and quality of the interpreting services funded by the MCOs
- Determine how health care agencies can be reimbursed for interpreting services not funded by the MCOs
- Provide trainings on culturally responsive care and language access
- Engage local health departments in supporting language access services in their regions
- Ensure that the Kansas Medicaid program and the contracted MCOs are compliant with the new Section 1557 regulations
- Encourage the Kansas Medicaid program to expand education/outreach to their enrollees about the availability of language services
Phase 2:
- Make it possible for hospitals to bill Medicaid for their own staff/contract interpreters when they don’t use MCO interpreters
- Provide financial support for interpreter training and certification programs
- Generate strategies so that speakers of less common languages receive qualified language access services to meet their needs.
You can read our full white paper here.
Alce su Voz is a community-engaged program at Wichita State University whose mission is to improve health equity for speakers of Spanish and Indigenous languages in the United States, with a focus on Kansas and the Midwest. For more information or to get involved, please send an email to alcesuvoz@wichita.edu. You can also join our email list and follow us on Facebook, Instagram, LinkedIn, and YouTube.