Medical Examiner

It’s Illegal for Hospitals to Not Provide Translation Services. So Why Is Proper Translation Still Scarce?

It’s actually much more expensive to not provide translation.

Under the ACA, failure to provide a medical interpreter can be met with a $70,000 fine.


Do you speak a second language fluently? Sort of fluently? Or maybe you partially remember high school Spanish? Well, show up with the right friend at the wrong hospital and you too can be a medical interpreter: Let them know you can say a few words, and the job can be yours.

It sounds insane—that a hospital would give you a job you’re not remotely qualified for, especially one that could have serious repercussions for someone’s health. But the state of medical translation means that it is too frequently the case. As far back as 1996, research from Emory University School of Medicine showed that 76 percent of Spanish-speaking patients went without an interpreter in the emergency department. Data on the subject is scarce, but anecdotal evidence indicates little has changed. One doctor at Mt. Sinai in New York, a hospital that often sees patients who don’t speak English, told me her colleagues frequently ask her to interpret Arabic, a language she doesn’t even speak, because she has a Middle Eastern last name (she requested anonymity for professional reasons). This is all part of an ad-hoc system that often means if translation is provided at all, it’s likely from a bystander, family member, or friend with no idea how to say things like “mitral valve prolapse” in a foreign language.

Why? You might wonder if it’s because ER doctors have to save lives quickly, and finding an interpreter could cause delays. That sounds reasonable, but hospitals have plenty of protocols that help them achieve complicated outcomes quickly—language access ought to be one of them. Nor is it because medical interpreters don’t exist or can’t be found. Instead, underuse of medical interpreters seems to stem from misunderstanding how proper translation improves medical outcomes, and that it’s not only fiscally possible, it’s actually fiscally prudent, since it’s illegal not to offer.

Medical interpreters are supposed to be certified. Credentials from both the Certification Commission for Healthcare Interpreters and the National Board of Certification for Medical Interpreters are accepted. For additional qualifications, you can pursue a master’s in interpreting or a graduate certificate from universities across the country. Like doctors, interpreters are also required to pursue continued education every year. It’s in the National Council on Interpreting in Health Care (NCIHC) Code of Ethics: “The interpreter strives to continually further his/her knowledge and skills.”

Hospitals would never dream of letting a patient’s friend operate just because she can hold a scalpel. But they ask bilingual relatives to interpret all the time, disregarding how critical communication is to patient care. Get one word wrong and the consequences can be life-changing: After staff misunderstood intoxicado (Spanish for “poisoned”) as “drunk,” Florida teen Willie Ramirez received the wrong care and ended up paralyzed. In Oregon, Elidiana Valdez-Lemus died after 911 misinterpreted her address. Lack of proper translation has consequences outside of emergencies, too: Erika Williams, a second-year medical student at Harvard Medical School, summarized research to show that when there’s a language barrier, patients “receive less preventative care,” don’t take medication as prescribed, “and are more likely to leave the hospital against medical advice.”

Federal civil rights laws state that hospitals must provide people—all people—with equal access to care, regardless of “race, color, or national origin.” That’s the phrase used in Title VI, the first law pertaining to professional interpreters. If “national origin” doesn’t indicate language as a discriminator clearly enough, in Executive Order 13166, President Bill Clinton implicitly stated any organization receiving federal funds—like Medicaid or Medicare—must provide “meaningful language access.” If they don’t, facilities are supposed to lose those funds.

But this doesn’t always happen. Chris Carter, president of the Association of Language Companies, the U.S. trade organization for translation and interpreting providers, says hospitals rarely become proactively compliant: “Unfortunately, member companies of the ALC have noticed in recent years that healthcare organizations usually wait until they are audited by the [Department of Justice] and found non-compliant with [Affordable Care Act] Section 1557 or other laws before they shift from ad hoc service provision to implementing an organized Language Access Plan.”

Is providing interpretation prohibitively expensive? Not in the context of what medical care costs—and how expensive mistakes are. From 2005–2015, I owned an interpreting company. When we opened, an on-site Spanish interpreter cost $25 an hour. If you wanted someone by phone, it was $1.50 a minute. Interpreting services are also reimbursed by certain types of insurance. But the No. 1 sales objection we heard from hospital administrators was that professional interpreting was too expensive.

Under the ACA, failure to provide a medical interpreter can be met with a $70,000 fine—for each encounter with a patient. Which means that the cost of not providing an interpreter, even if it doesn’t lead to errors, is astronomically higher than the cost of paying for one.

At least for now. As states file ACA waivers, they aren’t just opting out of Obamacare’s better-known parts. They’re also giving hospitals permission to shortchange limited-English speakers’ care. It’s true that Title VI is there to fall back on, but it’s rarely and arbitrarily enforced. It’s the ACA’s hefty fines that have been the impetus forcing hospitals to change: Carter says that since ACA audits began, interpreting companies have seen many hospitals working with professional interpreters for the first time, an improvement he’s noticed industrywide.

“The risks are too high to give up and to say quality interpretation for everyone in America just can’t be done,” Carter says.

The right to understand what doctors are doing to your body is fundamental. The right to know your own diagnosis is basic, to know when surgery is being performed on what, to understand why people are putting needles and tubes inside you. Interpreting isn’t too expensive—it’s essential to providing accurate medical care. Hospitals’ failure to appreciate and act on this is not a failure that we should dismiss for mere budgeting. It’s a manifestation of racism that should no longer have a place in our society.