Gaps in Interpretation: Health Care Challenges in Immigrant Communities

The Gaps in Interpretation series on healthcare inequities highlights the impacts of language barriers on immigrant communities.

​​​​​Vong Yang, 65, lives in a quiet two-bedroom apartment with his wife and son in South Sacramento. "I was 15 years old when I came to the U.S. in 1976,” he says. He was one of 28,000 Hmong who moved to the city from Laos at the end of the ’secret war,’ a covert U.S. led flight against communism. Yang graduated high school here so he can carry on a casual conversation in English but struggles with more difficult words. Medical appointments, in particular, are a challenge.

"Sometimes I feel scared when I go to the doctor because I don’t fully understand them. I ask for an explanation, but I still don’t understand completely,” he said.

According to the Pew Research Center, only 43% of the Hmong population born outside the U.S. are proficient in English.

Over time, Yang has understood that one of his conditions, "gout,” is the English term for "crazy foot,” as it is known in Hmong, but he still wishes he could communicate with his doctor.

"I feel that if I understand English better, I will understand how to take care of myself better.”

Every day, more than 26 million people across the U.S. and almost three million in California have challenges speaking, reading, writing, or understanding English. Language barriers in healthcare have serious consequences that can result in inaccurate diagnoses, medication errors and poor health outcomes.

Ten years ago, when Yang lived in Minnesota, he didn’t have challenges communicating because he had an interpreter present at his healthcare appointments. "The nurses or the doctor would ask me if I wanted an interpreter when they saw that I was having a hard time talking to them. They would call one for me. I never had to ask for one.”

In all his 10 years living in Sacramento though, Yang was never offered an interpreter nor was he aware that he could ask for an interpreter, at no cost to him.

Federal law requires that people who speak limited English have "meaningful access” to programs or services funded by the government. The law requires that written materials be offered in the primary language of a population when they meet a threshold of 5 percent. The Hmong population meets that threshold level in the California counties of Fresno, Merced, and Sacramento.

Federal government guidance also states that when the patient requests an interpreter, healthcare providers must make sure they provide them, at no cost to the patient. But many older Hmong immigrants like Yang don’t speak English fluently. And, they often don’t know they have a right to an interpreter, a barrier to getting get quality care.

Changes in the law

In an executive order signed on March 1, Designating English as the Official Language of The United States, President Trump stated that English has been the language since the country’s founding. The policy, he said, will encourage newcomers to adopt the "national language.”

The new policy overturns a Clinton-era executive order that required federal agencies to provide language services for individuals with limited English proficiency.

Trump’s executive order leaves it to the discretion of federal agencies as to whether they will adopt "English only” policies.

Regardless of Trump’s executive order, Cary Sanders, Senior Policy Director at the California Pan-Ethnic Health Network emphasized that "California has strong language access laws that remain in place.”

"Sometimes I feel scared when I go to the doctor because I don’t fully understand them, said Vong Yang, 65, of Sacramento, who eventually came to understand that "gout” is the English word for what he knows as "crazy foot.”

For example, California law (SB 223 – Atkins) requires insurance plans to inform members—in the 15 most spoken languages in the state—about enhanced anti-discrimination protections and the availability of free language assistance services, including translation, oral interpretation, and other support.

Sanders adds that, in the meantime, patients may be left without language assistance services or be forced to rely on family members instead of trained interpreters with medical expertise. Over time, inadequate language support can lead to serious, irreversible harm or even death for patients.

"It’s more important than ever for LEP to know their rights so they can ask for assistance when they need it,” added Sanders.

A Shortage of Interpreters

A change in the law comes amid a shortage of interpreters. According to the latest census, there are 327,000 Hmong in the U.S. and a third are over the age of 50. Only 43% of those who are foreign-born can speak English fluently, according to the Pew Research Center.

"At some hospitals, clinics, even doctor's offices or state agencies there’s not enough interpreters,” said Doreena Wong, Policy Director at Asian Resources Inc. (ARI), a nonprofit based in California. Other parts of the country have reported shortages as well. Hmong communities in North Carolina also face similar challenges and rely on family members to interpret.

Wong says ARI, together with its partners, trained 150 interpreters in California in the past two years and plan to surpass that number in 2025. They are investing in training programs, using technology for real-time language support and advocating for policies that prioritize language access as a fundamental right in healthcare settings.

ARI was also part of the previous administration's efforts to promote language access rights. The administration funded a $4 million, three-year initiative to develop and test methods to help inform patients about their right to interpreters. ARI was one of 11 organizations in the country selected to do this work.

Wong said sometimes clinics or hospitals may have interpreting services, but those services are only effective if a patient knows they can ask for one and if staff are trained to work with interpreters.

"It's about making sure that every patient, regardless of language proficiency, receives the same access and high standard of care,” Wong adds.

Major health care systems in the Sacramento region, including Kaiser Permanente, UC Davis Health, Dignity Health and Sutter Health, have information on how to reach an interpreter on their websites, or front lobby. But the policy is written in English or the information line is in English.

Wong found something similar when, as part of the federal grant, ARI staff called dozens of medical and dental providers to try and reach an interpreter—like secret shoppers. The recorded messages were in English.

"You have to go through and press a button for certain languages and you can't if you don't really know English,” Wong explained. "When you call up that language line, you're expecting to get somebody to speak your language; instead, you get the regular customer service line—it’s misleading.”

Staff at Hmong Daily News had the same experience. In addition to recorded messages in English, some hospitals also have interpretation services available only on weekdays.

Hmong Daily News requested interviews with the hospitals, but did not get a response.

Although hospitals are not federal agencies, they are recipients of federal aid if they receive Medicare or Medicaid. That means they must take "reasonable steps to ensure meaningful access to the information and services they offer,” said Erin Simonitch, Directing Attorney at California Rural Legal Assistance.

"While the standard is a little vague, a voice message in English or written information in English about requesting an interpreter does not appear to provide meaningful access to services for a person with limited English proficiency,” Simonitch adds.

If patients aren’t told they can request an interpreter, that hinders access from the start.

"It also makes the provider seem unfriendly and unwelcoming. In practical terms, some people may just give up or delay treatment,” said Simonitch.

In other cases, patients may rely on bilingual family or community members to help them interpret which could also lead to less effective care. "Worst case, someone who can’t effectively seek services or tell their provider their needs may suffer more negative outcomes or even die without proper care,”Simonitch adds.

The Minnesota Department of Human Services (MN DHS) was under public scrutiny last February, when they used a poorly translated text message to inform recipients about updating their information to avoid losing their Medical Assistance or MinnesotaCare benefits. The text message was translated into five languages: Somali, Vietnamese, Russian, Spanish and Hmong. The Hmong translation was full of errors.

A Hmong Facebook user highlighted the errors. The translation was "too literal”, "confusing”, "poorly translated” and "insulting” according to bilingual Hmong. The Minnesota Department of Health Service acknowledged in a statement the poor translations and that they "need to provide more oversight and quality assurance on vendor work.”

Tools such as Google Translate may be accurate for more commonly spoken languages but not necessarily for Hmong. For one, not all English words translate into Hmong, nor do medical terms.

Staff at Hmong Daily News called medical providers in Sacramento to try to get an interpreter. In addition to recorded messages in English, some hospitals also have interpretation services available only on weekdays.

Susan Maylee Her, Executive Director at Uplift the Human Spirit, a non-profit based in Stockton that provides services to the Hmong community, including services for seniors, has been her parents’ primary interpreter since she was six years old. She can no longer interpret for them since some medical clinics insist on using their own interpreters. She says sometimes it’s frustrating for her when the professional interpreters aren’t fluent in Hmong. Last year, she accompanied her mom during a doctor’s visit and the interpreter asked, "Tus niam tias koj pos mob jaundice?”

"So, my mom said, in Hmong, ‘I don’t know what that is, I don’t have it,’” Her explained. "My mom doesn't know what jaundice is.”

The interpreter repeatedly asked the question. Her finally told the doctor that her mother didn’t understand the word "jaundice”.

The doctor denied Her’s request to take over interpreting saying that they have professional interpreters.

Finally, Her turned to her mother. "Mom, ask the interpreter what jaundice is in Hmong?” The interpreter’s response was "I don’t know.”

Just because someone is bilingual, it doesn’t mean that they can interpret in healthcare situations, said Elena Morrow, the Department Manager for Medical Interpreting Services at UC Davis Medical Center. Medical interpreting is a highly skilled profession involving knowledge of medical terms, complex procedures and new diseases. Fluency in both languages is critical. It can be emotional for the interpreter when delivering bad news to the patient or family members.

The National Council on Interpreting in Health Care (NCIHC) ​​developed the first set of standards for medical interpreting in 2005. These standards are used for interpreter training, hiring, performance evaluation and certification of professional competence. But this medical interpreter certification is only available in six languages: Spanish, Cantonese, Mandarin, Russian, Korean, and Vietnamese. Certifications are issued by the National Board of Certification for Medical Interpreters (NBCMI).

Language laws try to help immigrant communities access healthcare. And while raising awareness and bridging divides is critical, much more needs to be done so that immigrant communities aren’t disadvantaged by their inability to speak English.