Speaking the Language of Care:
Language Access and the Affordable
Care Act
Cary Sanders, MPP
January 24, 2014
CPEHN: Together We’re Stronger
Eliminating Health Disparities
Coverage does not always equal access
Affordability
Cultural &
Linguistic
Access
Network
Adequacy
Timely
Access
Geographic
Access
Foundations for Language Access
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Federal
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Title VI, Civil Rights Act 1964
Executive Order 13166 and LEP Guidances
Office of Minority Health Cultural and Linguistic Appropriate
Services (CLAS) Standards
California
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State Title VI Look-Alike (Government Code 11135-11139.8)
Dymally-Alatorre Act
Medi-Cal Managed Care Contract Provisions and Policy
Letters
Department of Managed Health Care SB 853 (Escutia)
Kopp Act
1
Title VI, Civil Rights Act of 1964

Applies to all entities that receive federal
funding

Prohibits discrimination on the basis of
race, color, or national origin (“national
origin” includes Limited English Proficient
persons)

www.lep.gov
2
State Title VI Look-Alike
California has a state law that “looks like” Title VI. It is similar
to Title VI but is broader, in that:
 Individuals have the right to sue, in discrimination cases
based on race, national origin, ethnic group identification or
color.
 Unlike in Title VI, individuals may sue in “disparate impact”
cases. This means that even when an agency didn’t mean
to hurt a group of people, it did so in its normal practices. In
this case, an individual may sue that agency.
 Applies to “any program or activity that is conducted,
operated or administered by the state or any state agency
directly or receives any financial assistance from the state”
3
Medi-Cal Expansion

Of the 1.42 million adults newly eligible for Medi-Cal,
67% (950,000) will be people of color
A&PI: 7%
Other & Multiple
Race: 4%
African
American: 8%
White: 33%
Latino: 48%
CPEHN, Medi-Cal Expansion: What’s at Stake for Communities of Color, 2013
Medi-Cal Expansion

Of the 1.42 million adults newly eligible for Medi-Cal,
35% (500,000) will speak English less than very well
Spanish
Cantonese
Vietnamese
Korean
Tagalog
389,100
34,900
25,200
14,700
10,100
CHIS 2009 and CalSIM 1.8
Medi-Cal Managed Care

Applies to Medi-Cal managed care health plans

Requirements
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Provide 24 hour free interpretation at all points of
service
Translate key materials in threshold languages
Assess linguistic capabilities of interpreters and
bilingual provider
Maintain Community Advisory Committee
Conduct group Needs Assessment
5
Medi-Cal Managed Care (continued)
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Written translations
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Threshold: 3,000 in service area, 1,000 per ZIP code, or 1,500
per two contiguous ZIP codes
List of informing materials
Timeline
Recommended process for quality assurance
Oral interpretation
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Comply with Title VI, plans must ensure access to interpreters
for all LEP members
No unreasonable delays
Cannot require or suggest that member provide interpreter
Services at no cost to member
6
Covered California

Of the 2.7 million eligible for tax credits,
66% (~1.8 million) will be people of color
A&PI: 14%
NA/AN &
Multiple Race:
2%
African
American: 4%
White: 32%
Latino: 47%
CPEHN, Achieving Equity by Building a Bridge from Eligible to Enrolled, 2013
Covered California

Of the 2.7 million eligible for tax credits, 40% (~1.09
million) will speak English less than very well
Spanish
Mandarin
Cantonese
Vietnamese
Tagalog
Korean
721,200
66,600
61,600
50,000
27,600
18,700
CHIS 2009 and CalSIM 1.8
SB 853

Applies to all health plans and insurers

Requirements
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
Collect race, ethnicity, and language data
Provide access to interpreter at all points of
contact
Translate vital documents
Monitored by the Department of Managed
Health Care and the California Department
of Insurance
7
SB 853 (continued)
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Written translations
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Thresholds
 >1,000,000 members
percent or 15,000
 >300,000 members
6,000
 <300,000 members
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
top two languages and at 0.75
top languages and at 1 percent or
5 percent or 3,000
Provides examples of vital documents and exempts
member specific materials
Oral interpretation
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No cost to member
Outlines interpreter proficiency qualifications
8
Covered California
Language Access Services

Translate materials into 13 Medi-Cal
managed care threshold languages

CalHEERS available in Spanish
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Oral interpretation in all languages
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Intent to hire bilingual customer service
representatives for 13 Medi-Cal managed
care threshold languages
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Dedicated 800 numbers in each language
Cultural Competency/Cultural
Humility
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Genuine sensitivity and respect regardless
of ethnicity, race, language, culture or
national origin
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Applying understanding of patient’s
background, cultural values, and beliefs in
health context
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Example: The Spirit Catches You and You Fall
Down
Next Steps:
Measuring Quality Care

Require Medicaid health plans/QHPs to collect and analyze
quality data by race, ethnicity and primary language
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Exchanges
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Federal Guidelines
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Adoption of CAHPS Cultural Competency Measure Set

Use of translated CAHPS should be required
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Clinical measures disaggregated by race, ethnicity and
primary language
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Oversampling in smaller ethnic populations
State Requirements (e.g. Evalue8 Module 1.7)
Medicaid

Require collection and analysis of EQRO data by race, ethnicity
and primary language
Next Steps:
Measuring Quality Care

Make quality information more
accessible/transparent for consumers
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Post quality measures on Medicaid/Exchange
website by race, ethnicity and primary language
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Provide Provider Directories that sort by:
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Doctor and/or Essential Community Provider
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Languages spoken
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Geographic region
Next Steps:
Invest in OERU

Invest sufficient resources in Outreach,
Enrollment, Retention and Utilization
(OERU)
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In-Person Assisters/Navigators extremely
important for LEP, immigrants and other
vulnerable populations!
Retention and Utilization often neglected

“I worry that people won’t be able to figure out where
to go to see a doctor once they get their insurance
card.” – Denise Lamb, Black Women for Wellness
Contact us at CPEHN

(510) 832-1160

info@cpehn.org

www.cpehn.org