1. Language Access Checkup: Taking Healthcare’s Vitals Part 1 Joana Ramos WASCLA Language Access Summit 2014 www.wascla.org

2. Basic Glossary O ASL (American Sign Language) O Bilingual/multilingual O ELL (English Language Learner) O Interpreter vs. translator O LAP ( Language Access Plan) O LEP (Limited English Proficiency/Proficient) O Target language-source language O R/E/L (Race/Ethnicity/Language) 2

3. Civil Rights Act of 1964, Title VI O Section 601 provides O No person shall “ on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance. ” 42 U.S.C. 2000d O Subsequent DOJ Guidance to recipients of Federal financial assistance : O Must “ ensure meaningful access to their programs and activities by persons with limited English proficiency. ” 28 CFR 42.104 (b)(2) O Forbids recipients from “ utilizing criteria or methods of administration which have the effect of subjecting individuals to discrimination because of their race, color, or national origin… ” 28 CFR 42.104(b)(2) 3

4. Executive Order 13166 O To comply with Title VI, Federal agencies must take steps to ensure meaningful language access,and ensure that recipients of federal funds do the same. O 1974 Supreme Court decision in Lau v. Nichols defined LEP status as a factor in national origin discrimination O Federal agencies must provide guidance to recipients on access requirements. O Reaffirmation of Mandates of Executive Order 13166 in 2011 65 Fed. Reg. 50121(2000). http://www.justice.gov/crt/about/cor/lep/DOJFinLEPFRJun182002.php http://tinyurl.com/7nv5l9x http://www.lep.gov/13166/eo13166.html 4

5. Americans with Disabilities Act of 1990 O Title III- Public Accommodations O prohibits discrimination on the basis of disability in "places of public accommodation" (businesses and non-profit agencies that serve the public) and "commercial facilities" (other businesses) O Applies to all businesses, regardless of size O Covers wide range of businesses, including health care facilities and providers O Basis for language access services mandate for those who are deaf, deafblind, hard-of-hearing (HoH), blind, visually impaired US Dept. of Justice, ADA http://www.ada.gov/publicat.htm 5

6. Washington Law and Policy O Reyes Consent Decree (1991) to provide and pay for meaningful language services for applicants & clients of State medical and social services programs as resolution claims of civil rights violations O RCW 74.04.025 DSHS shall ensure that bilingual services are provided to non- English speaking applicants and recipients of services. O WAC 388-03 WAC (2000) Rules and Regulations for the certification of DSHS Spoken Language Interpreters and Translators O DSHS Administrative Policy 7.21 (1989; rev.2008) Requires equal access to programs & services provided by DSHS to all eligible LEP clients, guidelines for providing..services. O RCW 43.20.275 (3) (2006). Governor’s Interagency Council on Health Disparities has the responsibility to: “…recommend initiatives for improving the availability of …interpretive services within public and private health-related agencies.” O RCW 49.60.030 (1995) WA Law Against Discrimination. Establishes the civil right In Washington to be free from discrimination based on race, creed, color, national origin, sex, or the presence any…handicap. O WAC 284-44A-120 (2010) Rules that apply to forms translated from English to another language.( regarding Health Care Service Corporations) O WAC 182-503-0110 (2014) Washington apple health—Limited-English proficient (LEP) services. 6

7. What do Rules Mean for WA? O All federally-provided and federally-assisted programs must provide meaningful language access to applicants and clients with LEP O States must ensure meaningful access is provided, but are not required to pay for language services themselves, as this is responsibility of the provider O WA State provides & pays for language services for Medicaid patients under the terms of the 1991 Reyes Consent Decree 7

8. WA Interpreter Services Timeline #1 O Pre-1980, provided by families & friends O 1970s: specialty clinics & Seattle-King County Public Health services by bilingual staff O 1980: Interpretation Service in Seattle for hospitals, community clinics O 1983, 1987: lawsuits & civil rights complaints > more services in cities including Seattle 8

9. WA Interpreter Services Timeline #2 O 1991: Reyes Consent Decree: DSHS begins offering & paying for Medicaid& DSHS interpreters O 1996: DSHS begins testing & certification for interpreters (WA is 1st state in nation) O 1998: DSHS begins reimbursing for IS O 2003: DSHS brokerage contracts for interpreters O 2005: WASCLA established 9

10. WA Interpreter Services Timeline #3 O In 2010, 2011, 2012: end of Interpreter Services program proposed in Governor’s budget O 2010: collective bargaining rights for DSHS contract interpreters, Interpreters United Local 1671 of WFSE O 2011: funding of IS restored with cuts, service reforms, brokerage to end July 2012 O 2011: 1 st union contract; IS & ASL moved to HCA O 2012: IS restored - 20% cut; new contract w/new sole statewide vendor ASL interpreter requests rarely filled O 2014: Work on ASL services; IU proposed contract; Rulemaking to revise 388-03 WAC; procedural issues 10

11. State Language Access Services O HCA Interpreter Services oversees language services by certified/authorized interpreters/translators for medical & social services clients (spoken & signed) O DSHS Language Testing & Certification of contract interpreters, translators, state employees for state medical and social services programs 11

12. Support for Language Services O Medicaid funds: O Disproportionate Share Hospitals: public health districts & facilities, federally qualified health centers O Reimbursement for services to Medicaid and CHIP clients, 50% and 75%, respectively O Only 12 States + DC utilize federal funds for Medicaid + CHIP interpreters (WA was 1st in nation) O State funds combine with federal “match” O Affordable Care Act: new provisions 12

13. US LEP Population - 2010 13 Migration Policy Institute, LEP Data Brief, 2011, http://tinyurl.com/8v2vcwp

14. WA Households with LEP 2012 Population Age 5 and above. Data from Census American Factfinder http://www.ofm.wa.gov/trends/social/maps207.asp 14

15. WA Top 30 Spoken Languages O Amharic O Arabic O Burmese O Cantonese O Chuuk O Farsi O Hindi O Japanese O Karen O Khmer O Korean O Lao O Mandarin O Marshallese O Mixteco O Nepali O Oromo O Punjabi O Romanian O Russian O Samoan O Somali O Spanish O Swahili O Tagalog O Tigrinya O Turkish O Ukrainian O Urdu O Vietnamese 15

16. Languages and LEP in WA O 18% age 5+ report speaking a language other than English at home (~25% in King County, 20% in US) O ~ 50% speak Spanish; next Chinese, Vietnamese, Korean, Russian, Somali, Korean, Ukrainian, Amharic, Punjabi, “Other African Languages” O On average, 8% speak English “less than very well” O 12% in KC ; almost 50% of speakers of Spanish and of some API languages O 4% in “linguistically isolated households” (avg. 12% among Spanish-speakers) O WA reported LEP population grew 210% in past 2 decades O ~165,000 in 1990; > 512,000 in 2010 16 US Census Bureau American Community Survey 2010 Migration Policy Institute. “Limited English Proficient Individuals in the United States: Number, Share Growth, and Linguistic Diversity.” December, 2011 http://www.migrationinformation.org/integration/LEPdatabrief.pdf. http://www.migrationinformation.org/integration/LEPdatabrief.pdf

17. What Does Language Access have to do with Health? O LEP persons and their children are more likely to O Be uninsured and not have job-based insurance O Lack regular access to care O Live in poverty O Suffer more and more serious, medical errors, including mistakes with prescription medicines O Be hospitalized more often, have longer hospital stays, and more hospital readmissions O Undergo more diagnostic tests and procedures, even when not medically necessary O Have low health literacy and trouble understanding instructions O Have worse health outcomes and higher mortality rates IOM 2003, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care http://www.nap.edu/catalog.php?record_id=10260 RWJF, Aligning Forces to Reduce Racial and Ethnic Disparities, 2010 http://tinyurl.com/8kef857http://tinyurl.com/8kef857 Language Access in WA State Under the Patient Protection and Affordable Care Act,http://www.wascla.org/search/item.456370http://www.wascla.org/search/item.456370 17

18. National Initiatives on Healthcare Language Access O HHS Enhanced National Standards on Culturally and Linguistically Appropriate Services (CLAS),Sept. 2013; original CLAS Standards, 2000 https://www.thinkculturalhealth.hhs.gov/content/clas.asp O Joint Commission standards for hospital accreditation include language access services in the Patient-Centered Communication requirements as of July 2012. http://www.jointcommission.org/Advancing_Effective_Com munication/ http://www.jointcommission.org/Advancing_Effective_Com munication/ O National Committee for Quality Assurance, Health Plan Accreditation Program, Multicultural Health Care Distinction http://www.ncqa.org 18

19. Closing the Health Equity Gap O Despite all the evidence, most efforts to improve patient safety and quality of care by improving health literacy occur in isolation from strategies to address cultural and language barriers in healthcare services. 19 Andrulis & Brach (2007) Am J Health Behav. 31(Suppl 1)S122-133; Center for the Health Professions at UCSF, Bringing Equity Into Quality Improvement (2012) http://tinyurl.com/b7uqtt9

20. WA Healthcare Language Services Today O Lack of awareness of rights & responsibilities O Many unknowns; some limited data from Medicaid & DSHS programs O Patchwork of services in all sectors O Influence of political factors O Increased need for language services, due to O Population changes O Health literacy + LEP status needs O Great language diversity in western WA 20

21. Oct. 2014 Request for Help O Last week a Spanish speaking client in Eastside City asked me to assist him to get a Spanish interpreter for his upcoming appointment with Specialty Clinic for his appointment on October 3rd. The client has coverage under Medicaid and his managed care plan is ABC and he receives primary care at PCP Clinic, a well-known community clinic in the same city. O The client said when his specialist appointment was scheduled, he was told that he’d have to find and bring his own Spanish interpreter. I told him to contact PCP Clinic and ask them to call the specialist and advise them that it’s their responsibility to provide an interpreter. He said that he had done that and that PCP Clinic just told him to call the customer service number on the back of his Provider One card. He had tried to call them several times, but always the wait was too long and he had difficulties navigating their phone tree. I next called ABC plan hoping that they would contact their network provider and advise them of the rules for providing interpreter services under the ACA. The person I spoke to at ABC was not aware of the rules and when I requested to speak to a supervisor, I was transferred to a voicemail. As of yesterday, ABC had not called to let patient know if there will be an interpreter at his Specialty Clinic appointment on Friday. 21 Identities of parties in this case have been changed to protect privacy

22. What Can be Done to Improve Language Access and Services? O Education on language access rights, and legal enforcement O Collect and report comprehensive data O Use best practices in language services O Ensure strong quality assurance measures O Support interpreter workforce development O Create new service delivery and funding models O Engage communities O Promote policy initiatives and legislation 22

23. Selected Examples O WASCLA Pharmacy Language Access Workgroup, Healthcare Committee O WASCLA consumer education resources O State Action Plan to Eliminate Health Disparities O Language access state legislation 23

24. WASCLA Tools for Health I Speak Cards 24 Reverse side message in each target language: You can get an interpreter at no cost to talk to the doctor and staff at hospitals, clinics, and medical offices. An interpreter speaks English and [name of language] fluently and is trained in medical words to make sure that you and your doctor get the right information.

25. Tools for Health Consumer Education Flyers In 30 languages + English version 25

26. State-Level Work in Progress O Governor’s Interagency Council on Health Disparities O State Action Plan to Eliminate Health Disparities, July 2014 Update O Language Access Policy Paper Recommendations adopted May 2014* O CLAS Standards implementation grant 2014-15* O Interagency LEP Work Group*, ongoing O HCA asks WASCLA for language services improvement recommendations, June 2014 O HCA budget request includes $200K for targeted outreach to overcome cultural or language barriers to enrollment in Apple Health ( Medicaid), Sept. 2014 26 *For all State agencies, not only health sector. http://healthequity.wa.gov/TheCouncilsWork/LanguageAssistancehttp://healthequity.wa.gov/TheCouncilsWork/LanguageAssistance. http://www.hca.wa.gov/Documents/budget/15-17_PL-N0_Outreach_to_Select_Populations.pdf http://www.hca.wa.gov/Documents/budget/15-17_PL-N0_Outreach_to_Select_Populations.pdf

27. Access Laws in other States O California (2008): all private health plans must provide language assistance services (interpretation and/or translations) to LEP customers and collect Race/Ethnicity/Language data O Massachusetts (2001) : all hospital emergency departments and acute psychiatric facilities must provide trained interpreters for patients at all times. O NY (2012) and NYC (2009): requires language assistance services at pharmacies, with QA for interpretation and translations O NY (2008; 2013) : all hospitals must have LAP, Language Access Coordinator; interpreters within 10 min. in ER 20 min elsewhere; notify patients of rights; no interpreting by minors, relatives, strangers unless emergency 27

28. WA Legislative Attempts to Increase Access O SB 6684 (2008) Requiring language access services for persons with LEP in health care and insurance matters O SB 6170 (2014) Relating to continuing education relating to cultural competency for health care professionals O Built on ESB 6194 (2006) O Recognized need for “linguistic skills” in patient care 28

29. Cons showed limited knowledge of language services O 6684(2008): “This is the wrong approach…does not address the complexity of providing for over 200 languages…” O Lobbyists for America’s Health Insurance Plans O 6170 (2014): “I don’t know how you can teach all the cultural differentiations in a district like Keiser’s or the 30th, where I think … there were over 100 different languages there...” O Lobbyist for Washington State Medical Association 29

30. Where Do We Go from Here? O Challenges and opportunities O Take home message: focus on what we know and what we don’t know, and what we need to do O To be continued in Part #2, on language access under the Affordable Care Act 30