Los Angeles County, where I live, is incredibly diverse, both racially and linguistically. According to the Asian Pacific American Legal Center’s 2008 report on Language Diversity and English Proficiency in LA County (pdf file), more than half of Los Angeles County residents speak a language other than English at home. “The 10 most frequently spoken languages countywide are: English, Spanish, Chinese, Tagalog, Korean, Armenian, Vietnamese, Farsi, Japanese and Russian.” The report lists 39 distinct languages and almost 10,000 residents speak another language not on the list. About 29% of county residents are Limited English Proficient (LEP), which means they have some degree of difficulty communicating in English.
All of these people will have some contact with the health care system at some point in their lives and ideally, at more than one point. And, according to the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality, having a health care provider who speaks the same language as the patient has lots of important benefits to patient care (internal cites omitted):
A growing body of literature finds that language concordance between patients and providers (i.e., both speak the patient’s primary language well) results in greater patient understanding, leading to increased satisfaction, better medication adherence, greater understanding of diagnoses and treatment, greater well-being and better functioning for persons with chronic disease, and more health education.
The report goes on to note that only some of these problems can be mitigated by having the conversation interpreted. Using an interpreter can also disrupt the human connection between provider and patient and curtail full discussion. Interpretation, no matter how competent, is somewhat cumbersome and inefficient. This all means that having the health care provider be bilingual is by far the best solution, both for patients and providers. And often, cultural conceptions of health issues like pain, disability, and mental illness can be very important in understanding how a patient is describing symptoms or experiences, so a native speaker is the best.
The problem, of course, is that not all health care providers are bilingual. This means those who can speak another language are relatively valuable, so they can be more exclusive or take more high-paying jobs. If you are a patient who can afford to pay high rates or has great insurance, you may be able to get a provider who speaks your language, but you’re not guaranteed. And if you are a poorer patient and rely on emergency rooms and county health clinics for care, you just have to hope to get lucky. As I once heard it put, “If you’re a Cambodian therapist, you can basically write your own ticket. You’re not going to work at the County Department of Mental Health.”
So how can we go about getting more bilingual health providers, especially for relatively low-paying jobs to care for low-income patients? There’s no obvious answer. Here are some ideas, and their potential drawbacks:
- Require all health care providers to become fluent in another language. Providers all go through some training and licensing procedures, so we could build in a language requirement. There are some obvious difficulties – how would we ensure languages were proportionally represented? would we match providers to areas where there was a need for the language they spoke? how do we make sure someone learns, say, Hmong? would the cost of administering all those language proficiency tests be better spent elsewhere in the health care system? It also doesn’t serve our goal of having providers be native speakers.
- Recruit more native speakers of non-English languages to become health care providers. This could take a lot of different forms – scholarships and incentives for these people to enter training programs or medical schools, reaching out to younger kids to stimulate interest in health care professions, providing tutoring or other support resources, or a number of other methods. Most of these things would take a very long time before they resulted in a change in the makeup of health care providers. It’s also unclear how effective any of these methods are, and how much they cost.
- One possible solution is always to throw money at it. We could dedicate a lot of funding to paying big salaries for providers who speak other languages. While that would probably work, and relatively quickly, it would cost a lot of money. And would continue to cost a lot of money to maintain. And, most importantly, would not do anything to increase the total number of health care providers who teach non-English languages and if more were induced to enter the profession because of the high salaries, it would cost more and more money over time. To compensate, there would be fewer and fewer health care providers overall, or some other significant effect on the health care system from the significantly shrinking resources.
Personally, I support a little bit of all three. (Equivocation is a policy-maker’s prerogative.) Increasing incentives for health care professionals to know and learn non-English languages, aggressive recruiting for native non-English speakers to become health care professionals, and paying bonuses or other incentives to bilingual providers. To make the best of the current situation, I also support training interpreters and ensuring they’re used appropriately.
Are there other policies you think would help the problem?