Memo 4

Introduction

Cecily Rodriguez

In 2010, the US Census reported that individuals with limited English proficiency (LEP) accounted for 25.5 million (9 percent) of the US population. In some areas of the country, this population is the result of an 80 percent growth between 1990 and 2010. In response to this growth, public health and human service agencies have had to explore policy options that would enhance their ability to communicate effectively with this new population. These policies, commonly known as language access policies, determine the kinds of communication activities that will be become part of organizational protocol. They include activities such as oral interpretation, translation of critical documents, navigational signage, and assistive technology for individuals who are Deaf, Hard of Hearing, Late Deafened, or DeafBlind. Reflecting social justice as a core mission in human services, most stakeholders agree that providing language access services in some fashion is important to ensure equitable services to individuals whose English may create a barrier for care. Stakeholders with diverse missions and agendas have had an influence what practices are established and what policies, if any, are developed. Below is a table of stakeholders loosely organized by their area of influence. Key Stakeholders
Federal US Dept. of Justice US Dept. of HHS Office of Civil Rights US Dept. of HHSOffice of Minority Health Federal regulators State Dept. of Medicaid Assistance State Health & Human Service Agencies State Regulators Local Health and Human Service Agencies Local regulators Advocacy groups/ Associations National Health Law Program State and National Interpreter Associations Immigrant Advocacy Groups Certification Commission on Healthcare Interpreters Healthcare disparity researchers & advocates Community/Private Sector Interpreter/translator Vendors Immigrant Communities

Program administrators Direct Service Staff

Service Seekers & their families Service providers of care Bilingual staff who are used as interpreters and translators

Program administrators

Program administrators

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Clinical and Provider Associations for underserved populations

Cecily Rodriguez

Insurance Companies

Stakeholder Influence It is clear from the table above that there are a number of stakeholders who influence language access policy decisions. There are four major groups that have the most impact on policy and practices. In the absence of an overarching language access policy at the state level, the federal government is the most influential in this process in Virginia. The US Department of Justice (DOJ) is charged with providing resources, consultation, and ensuring compliance with the Civil Rights Act of 1964. A DOJ cornerstone is the principle of meaningful access. Using this principle, DOJ evaluates language services provided by recipient of federal dollars. Additionally, DOJs four factor analysis outlines the criteria that organizations are to use to evaluate whether they had to provide language services to service seekers. The emphasis on language services in federal government has ebbed and flowed depending on the administrations interest in the issue at the time. This emphasis subsequently trickles down and determines whether states and localities prioritize language services or not. The current administration has instructed the DOJ to sharpen their attention on resources and compliance for language services (personal conversation with M. Reyes, Office of Civil Rights, USHHS). As a result, policy development and implementation has become a focus over the last several years. Legal compliance and fairness/equity will be the key evaluation criterion for this policy analysis as it will tie the analysis to the guidance and expectations of the federal government mandates. DOJ Criteria for Meaningful Access The number or proportion of LEP persons served or encountered in the eligible service population The frequency with which LEP persons come into contact with the program The nature and importance of the program, activity, or service provided by the program The resources available and costs to the recipient

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Cecily Rodriguez

Another key stakeholder in this discussion is the advocacy and association contingent. This includes professional associations such as the Registry for the Deaf, the National Translators Association, Clinicians for the Underserved, and national and regional councils on interpreting, among others. This set of stakeholders also includes advocacy organizations that are interested in advancing the interests of immigrants and refugees; academic or research entities that have a mission to explore and advance health equity among minority populations; and accreditation entities for quality management and certification. The vast majority these stakeholders agree that planning for language services is important. Publication review from these stakeholders reveal that most articulate three key components to quality language services: trained and qualified interpreters, training for providers on culturally competent care, and the use of professional translators for translated material. These groups also agree that there should be standards of practice, quality and evaluation components to language services. Collectively and separately, they have published toolkits, reports, policy briefs, and research about outcomes for LEP individuals in health and human services as it relates to language services. This set of stakeholders has put forth principles that are intended to inform the efforts to improve language services. They encompass areas such as access, funding, education, quality improvement, and accountability. These principles are influencing how states and localities set up their language services. Examples include creating a language services manager position to coordinate language services, developing pay differentials for qualified bilingual staff, and standardized evaluations of interpreter services. This group has argued that comprehensive and quality language services serve the greater good because we live in communities that are impacted by poor outcomes for individuals. This helped to define social benefit as a key evaluation criterion for this policy analysis.

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Cecily Rodriguez

Another no less influential stakeholder group is the private sector interpreter and translator groups. This group is part of a group coined by Dr. William P. Rivers as the "Language Enterprise". They encompass everyone who enables communication among different cultures and languages who are invested and stand to profit from the development of language services. This group is financially invested in the provision of language services, which is a $15 billion a year business that includes more than 6000 businesses (Kelly et. al, 2012). This business sector has seen an annual growth of 8% since 2006, which illustrates the growing demand for such services. This constituency has been working to build public awareness of language as a profession, on par with law, accountancy, and medicine, and to gain access and influence in the public sector. They were major backers of the national accreditation and certification programs for health and community interpreters in the last five years. They have successfully influenced the way that interpreting and translating are viewed and have helped to transform them from a unskilled task of anyone who says they speak another language into a legitimate profession. Raising the bar like this influences policies at all levels and impacts the implementation of services both positively and negatively. The positive impact is related to ensuring quality communication (which strengthens access to services) and creating a uniformity to the practice which allows it to be measured and evaluated. One the other hand, if new policies require that organization use only qualified individuals, it poses a number of operational challenges such as the lack of bench strength for qualified interpreters and translators and not tapping into existing bilingual staff resources who may be quite useful for basic communication needs. Practical viability as a criterion for this analysis was influenced by this set of stakeholders. Although they are making the case for the professionalization of language services, they are also working to developing the infrastructure needed meet the coming demand for such a profession. However, their agenda certainly raises the question about whether language policies are viable before the resources are there to comply with policies.

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Cecily Rodriguez

The last group of stakeholders who have influenced the policy area are the program administrators and other payers of language services, such as insurance companies. Although it is quite reasonable to believe that many of these people are invested in the delivery of quality services, they also responsible for funding those services. An important driver for their decision making is the cost of the service. This group often determines whether language services are provided based on whether they perceive, there are sufficient resources with which to provide them. They are often focused on keeping cost to a minimum and complying with the most basic regulations. This means that although services may be provided, they may not be sufficient to ensure meaningful access to services. For example, very few private insurers defray the costs of language services for their providers. Medicare does not pay for interpreters, and only twelve states and the District of Columbia offer limited funding for interpreters in Medicaid and SCHIP (Yodelman, 2008). Therefore the message is that they arent a critical part of service provision and the burden is on provider to pay for language services. This set of stakeholders has created a perception that language services are cost prohibitive and not necessarily a critical aspect of operations. Cost and administrative viability are evaluation criteria will be used with this group of stakeholders in mind. They are the first group who will be charged with the cost of implementing any language policy. The decisions they make about this implementation will be based on the cost and ease of implementation. Therefore, they will have a great deal of influence on the ultimate policy outcome which is increasing access to services for LEP individuals.

References Kelly, Nataly, Donald A. DePalma, Robert G. Stewart. 2012. The Language Services Market 2012. Lowell, MA: Common Sense Advisory.

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Cecily Rodriguez

Martinez, Edward L. (2006). Language Access Statement of Principles. National Health Law Program. Retrieved on April 17, 2013 from http://www.healthlaw.org/images/stories/Language_Access_Statement_of_Principles.pdf Rivers, William P. (2012) "The Language Enterprise in the US: The Public and Private Sectors. Presented to the Joint National Committee on Languages and National Council for Language and International Studies. Retrieved from http://www.languagepolicy.org/ United States Department of Justice. Four Factor Criteria for Meaningful Access. Retrieved from www.lep.gov on April 14, 2013. Yodelman, Mara. (March 2008) The Medical Tongue: US Laws and Policies on Language Access. Health Affairs. vol. 27 no. 2 424-433. 10.1377/hlthaff.27.2.424.

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