When I applied earlier this year for a summer internship at Northwest Health Law Advocates, I wrote in my cover letter about seeking the opportunity to learn more about the kinds of legal questions and challenges that arise in the areas of health law and policy. As it happens, I spent much of this summer learning about challenges arising in two important areas: language access and disability access. Working in these areas required me to ask: how do individuals with limited English proficiency (LEP) and individuals with disabilities access health care, communicate their health care needs, and understand their rights and options when receiving health care services? While the legal issues and practical challenges in language access and disability access can be distinct, I now think of these areas as overlapping in two key ways: (1) both aim to overcome communication-related barriers to accessing health care; and (2) both can depend on effective legal advocacy carried out by organizations such as NoHLA.

My time as a graduate student in Library and Information Studies introduced me to language access and disability access standards for libraries and archives. My first few weeks at NoHLA challenged me to apply this understanding to health care, as the Trump Administration proposed to roll back existing rules under the Affordable Care Act (ACA) protecting language access and contemplated changing the rules’ protections for disability access. In August, in the midst of the public comment period for the proposed changes, I had the opportunity to speak to a group of health care and social service workers about what the proposed changes would mean for transgender individuals, individuals with disabilities, and individuals with LEP (who number more than 500,000 in Washington State alone). For example, these changes would eliminate important requirements for health insurers to notify people what discrimination is prohibited and to include “taglines” in many languages telling LEP individuals how to access the information in their primary language.

Fortunately, the same summer that witnessed the Trump Administration’s efforts to roll back federal protections also offered me the opportunity to work on Washington State’s efforts to safeguard language access protections. With the passage of SHB 1870, Washington State incorporated into state law several of the ACA’s protections, including nondiscrimination protections related to language access. I contributed to NoHLA’s recent comments on the Office of the Insurance Commissioner’s draft rules implementing SHB 1870. NoHLA noted that the draft rules did much to incorporate federal rules related to language access, but could go further in protecting communications for individuals with disabilities, particularly Deaf, Hard of Hearing, and Deafblind individuals.

Ensuring meaningful access to health care for individuals with LEP is integrally related to ensuring access for individuals with disabilities. Health care cannot be accessed fully without effective communications for all consumers, and advocacy must involve pushing for the best available practices, whether such communications take place in English, Spanish, or American Sign Language. NoHLA made a similar point in its comments that I helped to draft on the Washington Health Benefit Exchange’s (HBE’s) Disability Access Plan, which was modeled after its Language Access Plan. NoHLA, along with other organizations, emphasized the central place of communication by recommending improved language and disability access questions in both the on-line Healthplanfinder and paper applications for Medicaid and other public medical programs. In particular, we asked HBE to:

• Explain that interpreter services are free;
• Explain why they are asking about language;
• Split out questions regarding what language(s) someone requests the agency use for written communications and for oral communications (because they might be different);
• Ask whether the applicant needs materials in another format, such as Braille, large type, audio, or video.

In one of my latest projects, I am applying my background in (and love of) organizing information to NoHLA’s recent survey on the transition to fully integrated managed care in Washington State. Notably, in response to a question about patients’ or clients’ experiences with the transition thus far, one response noted that these experiences were “[p]oorer if the clients don’t speak English….even interpreters are hard to get when they’re sent to collections for errors in billing.”  The same respondent emphasized that improving the managed care integration for the remaining counties in Washington could involve a “lot more notifications in all appropriate languages…”

This week, as my internship with NoHLA has been drawing to a close, I had the opportunity to speak with two advocates about their experiences working with clients who have faced legal problems related to language access and disability access. Charlie Mitchell, NoHLA’s Senior Staff Attorney, described how, in one case from his time at Northwest Justice Project, a disabled child incurred a huge SSI overpayment resulting from the way his parents managed a bank account because Social Security never informed them in their primary language, Spanish, that a “resource” limit applies to SSI. The local Social Security office did not follow the agency’s own written policy that when applicants do their application interview with Spanish interpretation, all subsequent written notices should be sent in Spanish. Based on this requirement, a judge waived the family’s overpayment in an administrative hearing.

Referencing his experiences with agencies like Social Security and housing authorities—where the policies supporting language access are often not as proactive or as thorough as they are required to be for Washington’s medical assistance agencies— Charlie noted his appreciation for the language access “standards that exist and that we try to hold the medical assistance agencies accountable for.” However, as NoHLA’s recent comments on the on-line and paper applications for Medicaid show, even though policies require interpretation and translation for LEP individuals, “there is plenty of room for improvement at the agency’s very first contact with their client.”

Another advocate, Kristi Cruz from Northwest Justice Project, also took the time to share her experiences fighting for individuals with LEP and individuals with disabilities. Referencing the huge unmet need for sign language interpretation for patients in Washington, Ms. Cruz stated that “there is almost no encounter where people who communicate through sign language are not experiencing barriers to access in 2019.” These barriers extend to all kinds of encounters, including those with courts, schools, legal aid organizations, and the police.

What steps can be taken to reduce these barriers? Ms. Cruz emphasized the importance of establishing a statewide language access coordinator position to help improve access across state agencies, as well as the idea of framing language access as a civil rights issue. “There are individuals in areas of our state or in certain languages whose language needs are not being met, and that is a civil rights issue,” Ms. Cruz stated. “As a State, we need to invest in interpreter training and in getting resources to meet the language needs of our growing LEP populations. And that’s just the Medicaid program. That doesn’t tell us anything about folks who don’t have insurance, who have private insurance.” However, Ms. Cruz also noted areas of promise, stating, “I think the state has a lot to be proud about in terms of our commitment to access. We just have some silos of excellence and some deserts, where we need to bring language access to those areas.”

– Christopher Hightower, NoHLA Intern