Why Language Matters for Expanding Healthcare Access

Comprehensive health reforms like the 2010 Affordable Care Act (ACA) have been important in expanding access to health coverage and care. Modeled after Massachusetts’ state-level health reform, the ACA increased access to Medicaid, provided subsidies for coverage to middle income individuals, and prevented health insurance companies from denying coverage to individuals with preexisting conditions. 

Despite attempts to repeal it under the Trump Administration, the country’s uninsured rate reached an all-time low of 7.7 percent in 2023, down from 16.8 percent in 2013 before the ACA was implemented. However, access to coverage is still a challenge for many: most immigrants are excluded due to federal-level documentation status restrictions, and income-eligible people living in the 10 states that still have not expanded Medicaid remain uninsured. But for an estimated 68 million people who speak languages besides English, language presents a huge barrier to (re)enrolling in coverage and navigating the complicated U.S. healthcare system. Even for primary speakers of English, confusing health insurance jargon make enrolling in and understanding coverage a challenge.

Health Reform Expanded Healthcare Access, but That was Not Enough

My research examining Boston Latinx immigrants’ healthcare access under the MA and ACA reforms indicate that access to health coverage does not guarantee access to health care. Among the 207 immigrants, healthcare professionals, and immigrant and health advocates that I interviewed, language access was a constant theme that made getting coverage and care more burdensome. Enrollment materials available primarily in convoluted English deterred some immigrants–despite their eligibility–from applying for coverage. For those who applied and got coverage, figuring out how to use that coverage was the next challenge. Phone calls to insurance companies or doctors’ offices to ask questions or schedule appointments were made more onerous by lack of options to communicate with someone in their primary language. This extended to healthcare encounters: lack of quick access to medical interpreters increased patient wait times and immigrants felt less of a connection to their providers. The bottom line: lack of language-appropriate care worsens healthcare access.

Race, Legal Status and Language Matter Too

Language maps onto other social determinants of health like race, ethnicity, and legal status. For people of color and non-citizens with limited English proficiency (LEP), language compounds other structural disadvantages they experience in the healthcare system and the broader society. While much research has found that structural racism has produced negative healthcare experiences for Black Americans, racialized legal status–the intersection of race, ethnicity and legal status–has been linked to negative health outcomes for Latinx and Asian Americans, who are also more likely to remain uninsured. Negative healthcare experiences are magnified for LEP individuals, especially those of color. Latinx immigrants I interviewed in Boston felt they experienced discrimination and delayed wait times to see providers due to lack of medical interpreters. Some recounted being explicitly mistreated due to their inability to communicate with providers and staff.

Language Magnifies Barriers to Accessing Coverage and Care

Language affects healthcare access in two key ways.

First, through enrollment, as most materials (in print or online) are primarily available in English without the ability to change the website language. For LEP individuals without connections to non-profit organizations (like Health Care for All) that can provide enrollment assistance in multiple languages, this barrier can prevent people from enrolling. Beyond that, producing necessary documentation (e.g. proof of state residence, documentation status, income) to establish eligibility can also be a challenge.

Finally, receiving coverage paperwork in the mail in English may cause further confusion, particularly if applicants are denied and have questions about why. Once people have coverage, they experience additional challenges, also known as administrative burdens, navigating the system. These include identifying primary care physicians on complex insurance websites, scheduling appointments, and navigating hospitals with signage in English. Much of this process is complicated for English speakers, but even more so without the ability to effectively communicate with office and hospital staff over the phone or in person.

Suggestions to Improve Language Access in Health Care

Providing effective language access in healthcare demands proactive measures. Here are four strategies bolstered by existing federal policies to bridge this crucial gap:

1. Enforcement of Title VI of the 1964 Civil Rights Act. This policy guarantees language access as a civil right in institutions that receive federal funding.
    
2. Compliance with Section 1557 of the Affordable Care Act which requires healthcare organizations to develop effective language access procedures like providing information on qualified translators and interpreters as well as lists of translated materials.
    
3. Increase of funding to hire and train more multilingual healthcare navigators who enroll people in coverage and can help the newly (re)enrolled effectively navigate the system.
    
4. Increase of funding for English for Speakers of Other Languages (ESOL) classes to help LEP individuals learn English, which would help them communicate with their providers and others with whom they come into contact. 

Ultimately, improving language access today will improve health outcomes and reduce healthcare costs tomorrow.