PNS Report: How Do You Say ‘Pass the Buck’ in 300 Languages?

Investigative Report by Hilary Abramson, Pacific News Service


Few immigrants know they have a right to a free professional medical interpreter when they see a doctor. Many legal and healthcare advocates charge that the Bush administration wants to keep it that way.

January 15, 2004 – Tell the doctor, “It hurts, here.” Then listen to the diagnosis and instructions. Sounds simple.

But people who live in the United States communicate in more than 300 languages, and more than 30 million residents speak little or no English. And when it comes to who should pay for medical interpreting, everyone passes the buck. Horror stories of the consequences of amateur medical interpreting abound, from violations of patient privacy to death.

Now — as President Bush appears to be calling for dignity for immigrants with his proposal to extend temporary legal status to undocumented workers — many legal and healthcare professionals are questioning the administration’s real commitment to newcomer communities. They charge the Bush administration with weakening federal advice that guarantees medical interpreting for this population. And many doctors blame the Bush administration for failure to promote the only federal dollars earmarked for medical interpreting — matching funds to states through the federal Center for Medicare and Medicaid Services (CMS).

Former President Clinton put the civil rights of America’s burgeoning population of limited English proficient residents on the federal map in 2000, with an executive order and subsequent policy guidance guaranteeing free oral and written translation to them as patients. Although President Bush has upheld the order, his health agency has issued a new “guidance” that his administration calls “more flexible” and critics attack as a “shocking departure” from Clinton’s.

Without professional interpreting, Chong Choa Cha, who speaks only Hmong, believed doctors would only cleanse his infected foot.  It was amputated.

In a recent letter to federal civil rights health officials, the National Health Law Program (NHELP), a public interest law firm, charges that by changing mandatory orders to voluntary language, the Bush guidance invites providers to disregard their interpreting obligation by stating that language assistance is not necessary in “certain circumstances.” Fifty-nine national and local health and legal organizations are on record supporting the letter.

Gone is the Clinton guidance that said using amateurs for interpreting and translating is “life-threatening.” Critics charge that softened language in the Bush guidance opens the possibility that, for instance, a victim of domestic violence or child abuse could end up with the alleged abuser as his or her interpreter.

Chong Choa Cha’s missing right foot is one of many examples of how the medical system can break down without professional interpreting. The 47-year-old refugee, who only speaks Hmong, is suing the University Medical Center in Fresno, Calif., for amputating his infected foot. An investigation by the state health department agreed with Cha’s story. Cha, who had no professional interpreter present, believed doctors would only cleanse his foot.

Less dramatic encounters happen every day, with similarly profound consequences, says Barbara Reyes, president of the Arizona Interpreters and Translators Association and secretary of the National Council of Interpreting in Healthcare. In the absence of professional interpreters, “little children deliver awful news to the parent they love. Friends and neighbors hear sexual and other personal history that should be private,” Reyes says.

Medical interpreting is a tool that doctors need and want, says Cindy Roat, co-chair of the National Council on Interpreting in Healthcare. “The patient population has changed. We need to communicate.”

Richard Campanelli, director of the Office of Civil Rights at the Department of Health and Human Services, says the new Bush guidance offers providers flexibility and adds that the guidance “is not a regulation.” The Department of Justice (DOJ) has the lead on questions each federal agency must address in its guidance on language access, he says, and the health department follows the DOJ template.

“Interpreting services for limited English proficient patients are mandatory. Saying that it’s too expensive when you receive federal funds is not an acceptable excuse not to pay for it.”

The NHELP letter disputes Campanelli’s claim that his agency’s guidance is in line with DOJ’s.

Alex Acosta, assistant attorney general for civil rights at DOJ, declined to speak on the record.

Four years ago, CMS issued a letter offering states federal matching funds for medical interpreting for Medicaid recipients and low-income children receiving federal funds. Only 10 states have applied for and received these funds, according to the NHELP, which has monitored the issue for the past decade. Besides states, the American Medical Association (AMA) has unsuccessfully urged Medicaid officials for the past three years to re-issue the Clinton-era letter and clarify what mechanism would unlock funds to states.

The AMA warned the administration that physicians might stop accepting Medicaid patients if doctors have to bear most interpreting costs.

“The bottom line here is that interpreting services for limited English proficient patients are mandatory,” says Mary Kahn, CMS spokesperson on language access. “Saying that interpreting is too expensive when you receive federal funds is not an acceptable excuse not to pay for it.”

The AMA has been in contact with high-level administration representatives in the relevant agencies about the issue, says Robert Mills, AMA senior public information officer. “Unfortunately, both the (health department’s) Office of Civil Rights (OCR) and CMS keep passing the buck. CMS tells us it’s not their issue, and OCR tells us they have nothing to do with payment issues.”

Most hospitals are aware of their interpreting obligation, but advocates say countless doctors and small clinics may not believe they have to pay for it unless threatened with state and federal enforcement.

One longtime, high-level federal health staffer who requested anonymity characterizes Washington’s commitment to the issue this way: “Language access is not a high priority around here. The way bureaucrats know something is not high priority is when they’re told NOT to do something, like re-issuing the matching funds letter.

“This administration will not force — or help — states provide language access.”


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PNS contributing editor Hilary Abramson ( has covered health care issues on a national level for over a decade. is committed to presenting diverse points of view. However, the viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at IMD.