As demonstrated this past year, many deeply rooted issues within the American healthcare system were unmasked. One such challenge is the communication between Limited English Proficiency (LEP) patients and medical professionals.

 According to 2019 US Census Data, about 66 million of the population of individuals 5 and older in the United States speaks a language other than English. Around 38 percent of that population, or about 25 million people, “speak English less than ‘very well’” or have LEP, and this number is expected to grow. 

 This raises a question on how healthcare systems can become culturally competent for LEP patients. Cultural competence, as defined by the Centers for Disease Control and Prevention (CDC), is “the integration and transformation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes used in appropriate cultural settings to increase the quality of services; thereby producing better outcomes.” In a qualitative study, Australian researchers sought to understand culturally competent healthcare systems and explored the experience of LEP patients. The study found patients had concerns over being able to self-advocate, assuming a passive role in their health, feeling overlooked by staff, feeling guilty over having LEP and having concerns about relying on family members to make health decisions. Usage of professional interpreters was found to be delayed or underutilized because healthcare staff were more inclined to call on ad-hoc interpreters. 

 Ad-hoc interpreters could be a family member, friend, bilingual staff or individual in the hospital setting, who are not professionally trained but are called on to interpret during emergencies. In a 2006 national survey involving 157 U.S. academic health centers and over 3,000 resident physicians, 84 percent of residents facing language barriers used ad-hoc interpretation by adult family and friends and 22 percent used interpretation by children. 

 Although seemingly fluent, ad-hoc interpreters may not be able to accurately interpret what the patient or medical provider is saying, especially under stressful conditions. Details of medical history or medical terminology may be incorrectly translated, which can delay or interfere with treatment plans. Ad-hoc interpreters may not even want to reveal the diagnosis due to fear of burdening patients. These culturally different nuances must be addressed, but leaving patients in the dark about their health situation must not be a solution. 

 In a 2010 UC Berkeley School of Public Health report, inadequate language access has been linked to nearly one in 40 malpractice claims. In one case, a 17-year-old Taiwanese girl acted as her own interpreter in the emergency room. Two weeks prior to admittance, she was hit with a tennis racquet which induced a three-day fever and an increasingly painful headache. Not only was the patient a minor, but she was an interpreter for her family until she went into respiratory arrest, which delayed treatment. She was later taken to surgery and confirmed she had a brain abscess. The patient died the next day. Research has shown LEP patients who do not receive adequate interpretive services have lower patient satisfaction and outcomes. 

 With a large LEP population, the United States has several pieces of legislation that tries to protect this vulnerable population. The Civil Rights Act of 1964 labeled denying adequate interpretive services to LEP patients as discrimination, and in 2003, the Department of Health and Human Services provided guidance on how to provide LEP individuals access to federal health care programs. The Affordable Care Act extended these anti-discrimination provisions to state-based and federally facilitated Health Insurance Marketplaces. These laws aim to protect LEP individuals which begs the questions: why do healthcare interpreters remain underutilized and why do malpractices linked to inadequate language access continue to flourish?

One reason could be cost. For individuals who do not have Medicaid and federally funded health care plans, healthcare providers are expected to pay the costs. Interpretation services can range from $45 to over $200 per hour. In one study, the estimated cost of providing interpretive services was $279 per person per year, but most Medicaid programs pay physicians ~$30 to $50 per office visit leaving some providers paying out of pocket to see LEP patients. 

 Historically, providers fail to give adequate interpreting services for LEP patients due to potential financial burdens for providers. As the pandemic progresses, financial and economic concerns have increased on clinicians nationwide, and interpreting services may be endangered. Insurers could adopt reimbursement models such as paying providers for interpreter services per visit, adjusting reimbursement rates to indirectly account for interpreter costs or contracting with remote interpreting services.

 COVID-19 has brought attention to health disparities within the U.S., and lack of adequate access to interpreters is one of innumerable issues that need to be addressed. Language barriers can only be eliminated if we standardize interpreters’ training, implement reimbursement policies for interpreting services and practice cultural humility. Without these approaches, disadvantaged populations will have to continue bearing the consequences of a broken system.

Angie Li is a Weinberg College of Arts and Sciences junior at Northwestern. She can be contacted at [email protected]. If you would like to respond publicly to this op-ed, send a Letter to the Editor to [email protected]. The views expressed in this piece do not necessarily reflect the views of all staff members of The Daily Northwestern.