The Minority Majority
In 1950 US-born whites comprised about 90% of the U.S. population. By the 2000, the percentage declined to 71%, and according to forecasts by the U.S. Bureau of the Census, by the middle of the twenty-first century, whites will comprise a numerical minority of the U.S. population. The U.S. will be a minority-majority. Today four states are minority-majorities (California, Texas, New Mexico, and Hawaii) and by 2010 there could be as many as eight. Today, nearly 18% of Americans speak a language other than English at home. Additionally, with a world-wide shortage of skilled workers, health care professionals have become a global commodity. Health care workers are increasingly looking to migrate to countries with shortages that recruit internationally, including the US. These demographic characteristics have major implications for the healthcare industry:
- Language barriers requiring the use of interpreters
- Distrust between patient and provider
- Complicated patient/provider communication
- Cultural differences in family dynamics that complicate the care process
- Cultural differences in understandings of causes of ill-health which complicates adherence to regimen
- Cross-cultural conflict among healthcare staff can affect the functioning of the unit
Together, these factors threaten to reduce the quality of healthcare, cause healthcare organizations to devote resources to ancillary services, cause healthcare providers to spend time on activities that are not reimbursable, and increase the length of medical encounters. These result in increased healthcare costs, reduced profitability, and possibly increased liability exposure.
Regulatory Environment
The regulatory environment has been changing rapidly at both the national and state levels. At the national level Title VI of Civil Rights Act (1984), bans discrimination on the basis of national origin. Policy Guidance on the Act (published 2000) applies specifically to healthcare. The US Department of Health and Human Services, Office of Minority Health developed 14 standards that require cultural and linguistic competence in health care. Executive Order 13166 (2000) requires federal agencies and organizations that receive federal funding to provide translators to individuals with limited English proficiency (LEP). Medicaid regulations require providers and participating agencies to render culturally and linguistically appropriate services. Medicare encourages providers to make bilingual services available to patients wherever the services are necessary to adequately service multilingual populations. The Emergency Medical Treatment and Active Labor Act (1986) make hospitals potentially liable for civil penalties as well as relief to the extent deemed appropriate by a court if they do not provide language services. And, the Joint Commission (formally the Joint Commission of Accredited Hospital Organization) requires every recipient of federal financial assistance to provide “meaningful access” to their LEP applicants and beneficiaries. The Joint Commission is also developing further “competencies” that may become part of the hospital accrediting process.
Over the past five years, three states (California, Washington and New Jersey) have passed legislation requiring cultural competency training for healthcare workers. A similar bill in Maryland, HR 1295, failed in the 2006 legislative sessions, but according to the bill’s sponsor will be reintroduced in the next legislative session. However, the Maryland legislature has passed HR 524, which charges a workgroup with developing training and educational materials for licensure or license renewal for mental health professionals currently licensed in Maryland.