Colored quote balloons saying the word "health" in various languages

Topics

Access to Care

Care Delivery

Colorado Health Access Survey

Health Equity

Language and Culturally Responsive Care in Colorado

Barriers, Access, and Room for Improvement

Key Takeaways

People who speak a language other than English at home are less likely to have accessed health care in the past 12 months than English speakers.
These Coloradans are more likely to experience barriers to care such as being unable to take time off of work to access care or being unable to afford care at all – challenges that were likely exacerbated by the COVID-19 pandemic.
Policymakers and providers can take steps to more effectively support the health care needs of people whose primary language is not English.

March 4, 2022

May 11, 2023

The ability to communicate with a health care provider and others in the health care system is a critical factor when it comes to accessing care. As the diversity of languages spoken in Colorado increases, it is crucial that the state’s clinical workforce be able to meet the needs of these Coloradans.

The 2021 Colorado Health Access Survey (CHAS) offers insight into the health care experiences of Coloradans who speak a language other than English at home. These Coloradans are less likely to have received care from a general doctor in the past year than those who speak English at home. They are also less likely to have health insurance coverage, more likely to have lower incomes, and less likely to have access to consistent transportation — all factors that affect access to care.

These barriers, combined with issues related to health literacy — the ability to obtain, communicate, process, and understand basic health information and services — and lack of trust in health care institutions, contribute to health disparities such as poor general and mental health status. But there are opportunities for policymakers and providers to more effectively support the health care needs of people whose primary language is not English.

Language in Colorado

According to the CHAS, more than 937,000 people spoke a language other than English at home in 2021. That’s about one in every six Coloradans. Of this group, about two thirds spoke Spanish at home (see Table 1).

To have groups large enough to analyze effectively, this brief includes data about three groups of Coloradans: those whose primary language is English, those who speak Spanish, and those whose primary language is any other language. The third group includes speakers of Russian, French, Chinese, Vietnamese, Japanese, and other languages, and people who identify as multilingual.

Language and immigration go hand in hand. According to the American Community Survey in 2019, one in 10 Coloradans was born outside of the United States, nearly half of them (49.6%) in Latin America. And many face language barriers: Four in 10 Colorado immigrants (42.9%) were Limited English Proficient (LEP) — which means they do not read, write, or speak the language fluently — or spoke the language less than very well. Immigration status affects access to public programs, health insurance, and other factors that influence the health care these Coloradans get.

Undoubtedly, a share of Coloradans who identified on the CHAS as speaking a language other than English at home may be proficient in reading, writing, and speaking English. Regardless, the CHAS finds that those who speak languages other than English at home were more likely to face barriers to accessing health care and were more likely to have lower incomes, be uninsured, have less than a high school diploma, and not own their homes. Many obstacles can hinder a person’s ability to afford basic necessities, achieve economic self-sufficiency, and access health care, which in turn influence health and well-being.

Table 1: About Two in Three Coloradans Who Speak a Language Other Than English at Home Speak Spanish

Access and Barriers to Care

Coloradans whose first language was not English were less likely to visit a general doctor or a specialist than those whose primary language was English.

Spanish speakers were less likely to visit a general doctor, a specialist, or have a mental health care visit compared to English speakers (see Figure 1). Those who spoke a language other than English or Spanish were less likely to use specialist care compared with English speakers (31.5% compared with 44.9%, respectively) and general doctor care (65.8% compared with 77.8%, respectively) but had similar rates of use of mental health care.

People Who Speak Spanish at Home Were Less Likely Than Other Groups to See a Doctor

Cost, Transportation, and Time Off Work Stand in the Way

Navigating the health care system can be complicated and intimidating for anyone. For people whose preferred language is not English, accessing needed services can be even more difficult.

According to the CHAS, those who speak languages other than English were more likely to face a range of barriers when seeking care (see Figure 2). Spanish speakers were more likely to face barriers related to work compared with English speakers: about one in six (16.9%) Spanish speakers reported they did not get care because they couldn’t take time off work, compared with only one in eleven (9.4%) English speakers.

Those who spoke Spanish (4.7%) or another language (5.5%) were more likely to go without care they needed because they didn’t have a way to get to the appointment, while those who spoke a language other than Spanish or English were more likely to report issues with doctor’s offices or clinics not accepting their insurance types (12.6%).

Of those who spoke a language other than English or Spanish, 15.9% reported they could not get care because they could not take time off from work, while another 5.5% reported they did not have adequate transportation to get to their appointment.

Those who speak a language other than English were also more likely to report that they did not get care because they could not afford it (see Figure 3). About one in five Spanish speakers (19.3%) reported they did not get general doctor care due to cost compared to 11.0% of English speakers. Spanish speakers were also more likely to report not getting specialty care (17.0%) or filling a prescription they needed (14.4%) due to cost.

The COVID-19 pandemic disproportionately affected those who spoke a language other than English and may have impacted their ability to afford health care. For example, Spanish speakers were more likely than English speakers to report having reduced income or hours due to the pandemic, according to the CHAS: 46.8% compared with 26.8%. Those who spoke another language were also affected: 37.0% reported reduced income or hours due to the pandemic.

Nearly one in five Spanish speakers (19.6%) lost a job due to COVID-19, compared with 11.0% of English speakers. Spanish speakers were more than twice as likely to report issues affording rent or their mortgage due to the pandemic (35.9% to 14.0%, respectively). Those who spoke a language other than English or Spanish were also impacted: 14.3% reported losing their job and 30.0% reported struggling to afford their rent or mortgage.

Non-English Speakers Were More Likely to Face Barriers When Seeking Care

Those Who Speak Spanish Were More Likely to Report Cost as a Barrier to Getting Care

Other Barriers to Care-Seeking

Fear of unfair treatment or the consequences of accessing care leads many Coloradans who speak a language other than English at home to avoid care (see Figure 4). In 2021, nearly twice as many Spanish speakers and three times as many of those who spoke a language other than Spanish or English reported skipping care due to these concerns compared with their English-speaking counterparts (4.7%, 6.6%, and 2.6%, respectively).

Being uninsured impairs access health care. One in five (20.1%) Spanish speakers were uninsured in 2021, compared to only 4.7% of English speakers. Those who spoke a language other than Spanish at home also had a higher uninsured rate than English speakers at 9.0%. Not having adequate coverage has implications for care seeking, which could explain the differences in utilization patterns for Spanish speakers.

Other factors that influence people’s likelihood of seeking care are not captured in the CHAS. For instance, research has suggested that negative rhetoric about immigrants and immigration policies have led to avoidance of public programs and services among both immigrants and their family members.

Coloradans Who Speak Other Languages Than English Were Most Likely to Skip Care Due to Fear of Unfair Treatment or Consequences

Culturally Responsive Care, Discrimination, and Language

People who spoke a language other than English at home were about twice as likely as English speakers (6.6%, compared with 3.2%) to feel like they were treated with less respect or received services that were not as good as what other people get when engaging with the health care system, according to the CHAS.

Discrimination when seeking health care services can lead to increased stress, medical noncompliance, lower patient engagement, and avoidance of health care services, all of which contribute to the prevalence of poor health outcomes among disproportionately affected groups. This points to a need for culturally responsive care — the ability of health care providers and systems to deliver care that meets the social, cultural, and linguistic needs of patients that they serve.

Coloradans also report a need for culturally and linguistically responsive care: About 7% of Coloradans reported that they needed health care that was responsive to specific characteristics, including race, gender identity, sexual orientation, a disability, and language, among others. Of these Coloradans, about one in four (24.3%) identified their language as a characteristic that made a difference in the kind of care that they needed.

Language, Health Care, and Policy

Access to care that is culturally responsive is important in reducing poor health outcomes. Policies at the federal and state level — and programs within health systems and schools — can make a difference.

The 1964 Title VI Civil Rights Act and the Department of Health and Human Services identify failure to provide access to language interpretation in hospitals that receive federal funding as discrimination. Additional safeguards under the Affordable Care Act protected the right of patients with LEP to have access to interpretation and translation services, but the Trump Administration removed some of these protections in 2020. One example of the removed provisions was the requirement for resources called taglines for those receiving federal dollars. Tagline provisions – small sentences that were posted in the top 15 language groups about availability of language assistances services – were previously required on website content and documents used to obtain health insurance coverage or access health care coverage.

While these protections are no longer mandated at the federal level, Colorado policymakers have continued to push for improved language access. The 2021 Colorado Standardized Health Benefit Plan Act, also known as the Colorado Option, aims to reduce health care disparities among diverse communities with provisions focusing specifically on language access. For instance, the act requires culturally responsive health care networks whose providers reflect the diversity of their enrollees.

To date, Colorado policies have emphasized ensuring written translation of health information for LEP patients. These policies leave the option of obtaining interpreters (dealing with language in real time) up to providers. From one hospital or clinic to another, interpretation services vary from 24/7 telephone services to in-person staff to video-calling, where it can take anywhere from 10 minutes to 72 hours to be paired with the right interpreter depending on the service used.

Lack of standardization of interpreter expectations and service types can lead to issues such as family members, often children, inappropriately being used as interpreters; patients being matched with an interpreter of the wrong dialect; or patients being turned away due to the inability to find the correct interpreter. A goal of the Colorado Option is to better standardize expectations of interpreter services.

The COVID-19 pandemic has only highlighted how crucial it is for patients and providers to be able to communicate. Telephone interpretation is difficult while wearing full personal protective equipment or when standing six feet away. Not having time to find an interpreter when a patient is in critical condition can be the difference between life and death.

Health systems and medical training programs can play a role in changing these dynamics. Integrating culturally responsive learning into training curriculum can help provide the workforce with tools to meet the needs of patients. Programs and providers can take steps to increase the linguistic diversity.

Conclusion

The many languages spoken by Colorado’s residents contribute to the richness and diversity of the state. Making sure health systems reflect this diversity is of utmost importance.

Coloradans who speak a language other than English at home experience the intersection of barriers to seeking care and were more likely to experience financial stressors of the COVID-19 pandemic. Access to culturally responsive care and the reduction of harmful health care experiences due to discrimination are integral in increasing the use of care and quality of care experienced by Coloradans.

Access to translation and interpretation services within the health system is of utmost importance. Establishing culturally responsive and diverse health care networks and creating uniform policies to protect patients’ rights are some ways to help reduce barriers experienced by different language groups across our state.

Aya Ahmad contributed as a co-author of this report.