Language Barriers for Texas Medicaid Patients
Medicaid and CHIP
On March 21, 2018 I attended the Texas Senate Committee Hearing on Health and Human Services in Austin, Texas. The meeting lasted seven hours, but I only stayed for three. The public hearing was meant to discuss two topics: Medicaid Managed Care Quality and Compliance and Health Care Cost Transparency. I was more concerned with the first topic of quality and compliance for Medicaid patients. I work at a pharmacy in a low-income area. Most of our patients are Spanish-speaking only, while over half of them have insurance solely through Medicaid. Staying aware of their healthcare coverage encourages me to attend informative events such as the hearing and learn more about the Medicaid payment model that Texas currently implements. If I do not put in my best efforts to understand their insurance, then they will continue to struggle with their healthcare medication costs.
Honestly, most of the public hearing was hard to follow, but one line did stick out to me. It is a line I will never forget.
“Texas has one of the best Medicaid models in the nation.”
Unfortunately, I cannot remember exactly who said this, but it was proclaimed by a member of the Health and Human Services Committee. I found this statement to be both amazing and alarming.
Texas Medicaid and the Children’s Health Insurance Program (CHIP, which works through Medicaid) are the most commonly used insurance plans that I see at work. These services provide “medical coverage for more than 4 million low-income Texans” and “cover half of all children in the state” (Texas Health and Human Services, 2016). The current model involves the state paying third party managed care health plans for Medicaid and CHIP services so that patients pay a zero or reduced copay. These government healthcare programs do so much good for Texas patients, but not everyone is receiving the same value of care.
In Figure 1 above, we can see that the lack of a federal Medicaid expansion in Texas could be causing more harm than good. There are 2,502,000 potential patients which Medicaid could offer assistance to, yet Texas has not worked towards helping them. Even with the model Texas Medicaid has now, there are still covered patients who do not have access to a proper standard of care.
Language in Texas
One of the hardest parts of working in the healthcare field is overcoming language barriers. In 2015, the U.S. Census Bureau recorded a population of 27.45 million in Texas (US Census Bureau, 2016). Of this 27.45 million, 65% speak only English at home. The most common non-English language spoken in Texas is Spanish — with almost 7 million Spanish speakers recorded in 2015 (Ura & McCullough, 2015). As seen in the image to the left, 24.9% of Austin households speak Spanish. For a state with the second highest number of Spanish speakers, Texas still cannot provide the same quality of care to its minority and non-English speaking population as it does to its white, English speaking counterpart.
A study in 2000 was conducted in 14 US states, Texas included. This study examined “whether consumer reports and ratings of care in Medicaid managed care vary by race/ethnicity and language” (Weech-Maldonado et al., 2003). The researchers surveyed almost 50,000 adults enrolled in Medicaid and found significant results. Racial/ethnic and linguistic minorities do in fact experience a different level of care. These groups reported worse care than did whites. Even further, linguistic minorities reported worse care than did racial and ethnic minorities. The study concluded with the suggestion that “racial and ethnic minorities and persons with limited English proficiency face barriers to care, despite Medicaid-enabled financial access. Health care organizations should address the observed disparities in access to care for racial/ethnic and linguistic minorities as part of their quality improvement efforts” (Weech-Maldonado et al., 2003).
These reportings make sense. When a patient can’t communicate with their doctor (or nurse, pharmacist, optometrist, etc) then how can they expect to receive the care they need? Healthcare is moving towards a patient-based model (the patient matters most), but right now this movement has done nothing for those who either know limited or no English.
States are required to provide language services to those who are of Limited English Proficiency (LEP), but they are not required “to reimburse providers for the cost of language services, nor are they required to claim related costs to Medicaid/CHIP” (Centers for Medicare & Medicaid Services, n.d.). This means although there are third-party providers which include LEP services, these providers can be difficult for patients to find and receive services from. Texas is one of the few states to directly reimburse providers for language services, but this is only for sign language interpreters (Youdelman, 2017). Without proper language services, LEP members of Medicaid will always struggle to obtain satisfactory care. In fact, language barriers can significantly harm LEP patients through “excessive ordering of medical tests, lack of understanding of medication side effects and provider instructions, decreased use of primary care, increased use of the emergency department, and inadequate follow-up” (Escarce, J.J. & Kapur, K., 2006). As long as there is a language barrier, there will always be patients receiving inadequate care in our healthcare system.
Language in Pharmacy
My pharmacy, located in Austin, Texas, accepts Medicaid Part D and CHIP insurance. More than half of our patients use these programs while the rest are split between private insurance or simply cash/discount card use. Resolving insurance problems has been a rocky learning process for me, but communicating with patients is the most difficult task of all.
“Almost 70% of our patients are Spanish-speaking only.”
The first time I helped someone who only spoke Spanish was my most terrifying and shocking experience in the pharmacy. When the pharmacy manager told me “almost 70% of our patients are Spanish-speaking only,” I didn’t really believe him. But after an entire year of working there, I have discovered that learning Spanish is vital to becoming a successful healthcare assistant. People choose to drive 30 minutes out of their way to have prescriptions filled at our pharmacy. Why? We are famously known for having a mostly Spanish-speaking staff. In fact, my pharmacy is located in the same shopping center as a pediatric clinic which is also known for helping Spanish-speaking patients. The residents of that area rely on that particular clinic working together with our pharmacy to get the best care. I will be honest — our pharmacy is small, rundown, understaffed, and not the safest place in town, but our patients will keep coming because what we don’t have is a language barrier.
In the end, this is why I found it so important to attend the public hearing in March and why I plan to continue attending these meetings — so that I can continue giving patients the access to the care they need in spite of potential language barriers. These people might not be able to attend these types of government meetings themselves, and so I hope to speak up on their behalf. I want to help reduce the disparities for Spanish-speakers when it comes to their pharmaceutical needs, and I hope that we will soon see such changes happen here in Austin, Texas.
Bibliography
Centers for Medicare & Medicaid Services. (n.d.). Translation and Interpretation Services. Retrieved April 14, 2018, from https://www.medicaid.gov/medicaid/finance/admin-claiming/translation/index.html
Escarce, J.J., Kapur, K., (2006). Hispanics and the Future of America. National Research Council (US) Panel on Hispanics in the United States; Tienda M, Mitchell F, editors. Washington (DC): National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK19910/
Norris, L. (2017, January 01). Texas and the ACA’s Medicaid expansion: Eligibility, enrollment and benefits. Retrieved April 13, 2018, from https://www.healthinsurance.org/texas-medicaid/
Statistical Atlas. (2015, April 19). Languages in Austin, Texas (City). Retrieved April 6, 2018, from https://statisticalatlas.com/place/Texas/Austin/Languages
Texas Health and Human Services. (2016, August 26). About Medicaid and CHIP. Retrieved April 6, 2018, from https://hhs.texas.gov/services/health/medicaid-chip/about-medicaid-chip
Tufts Associated Health Plans. (2017, October 02). How Medicare Works. Retrieved April 6, 2018, from https://www.tuftsmedicarepreferred.org/how-medicare-works/how-medicare-works
Ura, A., & McCullough, J. (2015, November 26). As Texas Population Grows, More Languages are Spoken at Home. Retrieved April 13, 2018, from https://www.texastribune.org/2015/11/26/languages-spoken-texas-homes/
US Census Bureau. (2016). Population and Housing Unit Estimates. Retrieved April 6, 2018, from https://www.census.gov/programs-surveys/popest.html?intcmp=serp
Weech-Maldonado, R., Morales, L. S., Elliott, M., Spritzer, K., Marshall, G., & Hays, R. D. (2003). Race/Ethnicity, Language, and Patients’ Assessments of Care in Medicaid Managed Care. Health Services Research, 38(3), 789–808. http://doi.org/10.1111/1475-6773.00147
Youdelman, M. (2017). Medicaid and CHIP Reimbursement Models for Language Services. National Health Law Program. Retrieved April 6, 2017.
