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By Ewa Matuszewski

Are you among the LEP? Likely not, because you’re reading this. But as someone in the healthcare sector, it’s an acronym you should not only know, but understand, particularly as it relates to health literacy and equity. LEP is Limited English Proficient, and the U.S. Census Bureau describes it as individuals over age 5 who report speaking English less than “very well”. It reports that number as over 25 million –  9% of the United States population in 2015, the year the report originates.

Flash forward to today in a heightened era of health literacy, DEI and social determinants of health and LEP takes on new significance. It’s not just race, ethnicity, gender identification and socio-economics. We need to expand the conversation to include those that, literally, can’t join in – at least not without assistance. Regardless of one’s views on immigration, we must acknowledge and deal with the reality that we are not necessarily a nation of native English speakers.

But interpreters are expensive – isn’t that why insurers include them as part of general overhead? Yes, but…aren’t hospital admissions and readmissions even more expensive. Medical consumers want to have a relationship with a primary care provider who speaks their language. When that’s not possible, ailments typically handled in the physician’s office can send non-English speakers to the emergency department or urgent care instead. Talk about costly! And when the LEP population are admitted to the hospital and ultimately discharged, how do they understand post-hospitalization summaries and self-care with a language barrier on top of the existing challenges to full recovery and avoidance of hospital readmissions?

I continue to be amazed, and admittedly frustrated, by patient education materials available only in English. How helpful is such information when given to Michigan’s Spanish speaking community? Or to our large Arabic population? Or the residents of Hamtramck – once home to English as a second language Poles and now revitalized as the home of our growing Bangladeshi population? One need not be bi-lingual to think bi-lingually.

While offering an interpreter via telehealth is an option, it’s not ideal, notably because continuity of care requires consistency. What if the interpreter changes with every visit? As a child of immigrants (and an immigrant myself) I was the interpreter for my Polish-speaking parents. While my father, for example, would respond with “just the facts” when I spoke on his behalf in a medical situation, I was quick to offer the many symptoms he was experiencing beyond what Dad said. Yet, I’m not the patient – and my dad’s healthcare deserved the privacy of patient relationship not possible with my presence. An unrelated interpreter assigned to the physician’s office would have mitigated this situation.  

 Regarding behavioral health, the challenge is already great in meeting the demands of our nation’s mental health crisis. We must also address how to provide access to those who can’t communicate their emotional health issues in English. These are no easy fixes, but recognition of the situation is a first step.

Michigan’s Medicaid plans do cover the cost of interpretation services, and the Americans with Disabilities Act (ADA) requires interpretation services to be provided at no charge for those covered by the Act, so we’re not at ground zero. But if a physician provides interpreter services for LEP individuals not covered or Medicaid, the service can’t be billed for one simple reason: there is no billing modifier code or diagnosis code– again, because insurers don’t generally cover the service. As benevolent as they may be, PCPs can’t shoulder these costs or fight to get them covered. That’s what we need to do – not only for PCPs but the patients they are caring for.

To preach on the social determinants of health and their impact on access without including a factor like language barriers seems disingenuous. As we continue to uncover unnecessary discrepancies in care in this country, we need to get the greater health care community engaged with – and championing – the removal of obstacles that impede access and inclusion. Give it some thought. Is there a way you can use your influence to be part of the solution?