WEST SACRAMENTO, Calif. — On any given day at the Salud Clinic, Lucrecia Maas might see 12 patients. They come to the community health center tucked away in an office park needing cavities filled, prescriptions renewed and babies vaccinated. When they start to speak, it’s rarely in English. They might speak Hindi. Or Dari. Or Hmong. Or Russian.
Maas is fluent in English and Spanish, but that gets her only so far. On most days, she guesses, her patients will speak about six languages. She often has to hop on the phone with a medical interpreter, who relays her questions to the patient and then translates the patient’s answers. “It just takes a little more time,” the nurse practitioner says.
The future of American health care looks a lot more like the Salud clinic than Norman Rockwell’s iconic small-town doctor’s office. The country is on course to lose its white majority around 2050. That future is already visible in Sacramento, where by 2013 the combined population of Hispanic, black, Asian and other nonwhite residents had edged out whites in Sacramento County and neighboring Yolo County, where West Sacramento is located. With immigration driving much of the new diversity, hospitals and doctors are grappling with complex cultural, language and financial challenges.
In West Sacramento, a historically working-class community across the river from the state capital, more than 2 out of 5 public school children already speak a language other than English at home. Sacramento-area hospitals, community health centers and doctor’s offices have had to adapt. They’ve hired more multilingual, bicultural staff. They’ve contracted with interpretation services. The medical school at the University of California, Davis, is trying to figure out how to recruit more Latino students to a profession that remains largely white and Asian. And all doctors are being trained to deliver culturally appropriate care to patients of all backgrounds.
When a diabetic, pregnant Afghan woman wanted to fast during Ramadan, the Salud Clinic’s nutritionist recalculated the best time of day to measure her blood sugar. If Mexican mothers say they’re rubbing gentian violet on their baby’s umbilical cord area to keep it clean—a harmless natural remedy—doctors encourage them to keep doing so.
Similar stories are playing out across California, which is one of the most diverse states in the country and which became a majority minority in 2000. In some cases, health systems are using new data tools to get a better handle on just who they’re serving–and where the trend-lines are pointing. Kaiser Permanente, the state’s largest health insurer, began a decade ago to break down its patient data by race and ethnicity and uses that information to identify and fight health disparities. County health departments, nonprofits and clinics have invested in recruiting and training bilingual community health workers.
Insurance doesn’t always pay for the extra costs of services like translation. Patient visits take extra time, straining schedules for doctors and nurses. But Maas and her colleagues at the Salud Clinic are showing that health care providers can get ahead of these challenges–and they must.
“You can’t really help somebody if you don’t understand how they value health, and how they understand health and the health care system,” says Robin Affrime, CEO of CommuniCare Health Centers, the nonprofit that operates the Salud Clinic.
Immigrants Drive Change
The question of what America should look like became a big political issue over the past year, with Donald Trump infusing his presidential campaign with nostalgia for the smaller, whiter towns of the past. As president, he moved quickly to restrict illegal immigration across the Mexican border and make even legal immigration harder for many people trying to travel to the U.S.
Demographers say that no matter what politicians do, however, it won’t be possible to turn back the clock. In the coming decades America is only going to get more racially and ethnically diverse. Most of the nation’s population growth since the 1960s has come from the immigration of nearly 59 million people from foreign countries who settled in the U.S. in that time, mostly from Latin America and Asia, according to the Pew Research Center.
Hispanic, black, Asian and multiracial babies in the United States already outnumber white babies. In three years’ time, a majority of U.S. children and teenagers will be some race other than non-Hispanic white. And in about 30 years, whites will cease to be the national majority, demographers say.
“The one thing that’s going to be fairly certain over time is that we’re going to have very slow growth, and very soon decline, of our white population,” said William Frey, a demographer at the Brookings Institution, a centrist think tank in Washington, D.C.
A more diverse patient population may mean a different mix of health conditions, since some are linked to country of origin. People who were born in Asia are particularly prone to Hepatitis B, for instance. African-Americans are more likely to have sickle cell anemia, an inherited blood disorder more common in Africa, the Middle East, India, and parts of southern Europe and Latin America.
Asians and Hispanics—the groups likely to drive population increase going forward—actually have longer life expectancies than whites. Hispanics are less likely to suffer from many chronic conditions than whites even though they’re typically poorer and less educated.
Yet second- and third-generation Hispanic-Americans are often less healthy than their immigrant parents. One theory is that with assimilation, younger generations pick up bad American habits such as eating fast food and not getting enough exercise. And health continues to vary by subgroup. For instance, Californians with roots in Mexico are much more likely to be obese than Californians with roots in Puerto Rico, survey data show.
Health Challenges
Besides variations in disease burden, health care providers have found that serving a diverse population presents a couple of broad challenges.
One is obvious: many new immigrants can’t speak English. “Too few people are aware of how big a problem this is,” says Glenn Flores, a physician and chair of health policy research at Medica Research Institute, a nonprofit research group. About 60 million Americans speak a language other than English at home and about 25 million can’t speak English very well, according to the U.S. Census.
Jose Arevalo, a Sacramento-based physician, has witnessed a few tragic miscommunication mistakes during his 35-year career in medicine. There was the time a young man who had recently hit his head was brought into the emergency department with blood pooling in his brain. He hadn’t understood instructions to seek medical attention if his headaches got worse. Or there was the time one of Arevalo’s patients went to see a specialist who told her, in broken Spanish, that she had anemia. The patient heard the Spanish word for leukemia, and believed she was going to die.
Salud tackles the language challenge about as well as it can be done. The clinic doesn’t typically bring in in-person interpreters, because they’re more expensive. But they do contract with a phone interpretation service, a business that’s growing rapidly across the county. The service provides real-time translation between English and at least 12 other languages. But the system isn’t flawless; some of the less common languages, like Hmong, need to be scheduled in advance. And there have been instances in which the interpreter speaks the wrong dialect of a language like Dari, spoken in several countries in Central Asia.
Often a staff member can help. When someone shows up who doesn’t speak English, “right away, we try to get them to at least say the language,” says Donna Paul, the longtime clinic manager. The health center has doctors and nurses who speak Hindi, Urdu, Punjabi, Tagalog and Spanish, and has hired administrative staff and medical assistants who speak Hmong and Mien.
But even with the telephone service and a multilingual staff, challenges remain. Mien, a language spoken by some Indochinese refugees who fled to the United States during the Vietnam War, has no written language. And some cultures and languages have concepts that defy easy translation. “There are some words where we really cannot use the translator,” said Rubina Saini, a Salud physician who speaks several South Asian languages.
Other clinics don’t do as well as Salud. Under federal civil rights law, hospitals, nursing homes and other providers that receive federal funding must take reasonable steps to accommodate patients who can’t speak English well. But the legal requirement isn’t well enforced and services can be spotty. “Where people need language services isn’t necessarily where they’re being offered,” says Melody Schiaffino, an assistant professor at San Diego State University’s graduate school of public health.
In a recent study, Schiaffino found that about 30 percent of all hospitals nationwide don’t offer translation services. The share is even smaller for public safety-net and for-profit hospitals, even in diverse cities. That’s because the government hospitals can’t afford to do so, she said, and for-profit hospitals tend to serve well-insured patients who speak English.
State policy helps determine who gets interpretation and translation help. Only 15 states have taken the option to directly pay for interpreters needed by Medicaid patients. California isn’t one of them, although a 2009 task force created by the state Department of Health Services recommended the change. (California does require private health insurers to provide —although not necessarily pay for —language services. The state also requires health plans in its state Medicaid program, Medi-Cal, to translate certain written materials into common languages.)
Most Salud Clinic patients have a Medi-Cal insurance plan that will cover the cost of interpretation, Paul says. If a patient doesn’t have coverage, they could theoretically be on the hook for those costs. Instead, CommuniCare Health Centers absorb the cost.
Then there’s the need to navigate cultural differences. The front-office staff know that Southeast Asians may be uncomfortable making direct eye contact, and that Russians may speak loud and fast, Paul, the clinic manager, said. They’ve learned not to take such things personally.
And Salud’s staff tries to educate each other about their cultures, occasionally bringing in food that’s common in their home countries. “It’s like constant coaching amongst each other,” Paul said.
Ethnic disparities
Treating a more diverse population will also mean confronting troubling differences in the quality of care different racial and ethnic groups receive.
These gaps in care go beyond socioeconomic status. African-Americans, and in some cases Hispanics, tend to receive lower-quality care than whites even after controlling for income, age and symptoms, according to a landmark 2003 report by the Institute of Medicine (now the National Academy of Medicine). Black patients are less likely to be prescribed pain medication than white patients, for instance, and less likely to receive antiretroviral drugs if they’re HIV positive.
There’s no simple reason for the quality gap, which still persists, although researchers say unconscious bias or stereotyping by physicians, cultural and language gaps, and even geography play a role. “Race and ethnicity matter, whether you like it or not,” says David Acosta, associate vice chancellor for diversity and inclusion at the University of California, Davis health system.
To erase the gap, medical schools are adopting strategies to better prepare the next generation of doctors. One of these is to recruit and train more minority students. The second is to train all students to examine their own biases and be more sensitive to cultural differences.
In California, where almost 40 percent of residents are Latino, 4 percent of physicians are. Twenty percent of all physicians in the state speak Spanish, but Acosta says bilingualism isn’t enough. As a Latino physician, he says he’s both bilingual and bicultural, familiar with his Hispanic patients’ approach to health, such as the folk remedies they might try. That kind of cultural match improves trust between doctors and patients.
Black and Hispanic physicians are also underrepresented in the physician workforce nationwide. Increasing their numbers could also help ease the shortage of primary care physicians, Acosta said, since black and Hispanic physicians are more likely than white and Asian physicians to provide primary care to low-income, minority communities desperately short on doctors.
UC Davis launched an effort to recruit more Latino students to health careers last summer, funded by The Permanente Medical Group, a physician group affiliated with Kaiser Permanente. “What Kaiser said is … our enrollment of Latinos in Kaiser is growing. We have to get on the ball and we have to invest,” Acosta said.
Getting more minority students into medical school starts with preparing them to take tough science and math courses at the high school and undergraduate levels. But such students also need encouragement and guidance, particularly if they’re the first in their families to consider college.
The UC Davis program, called Prep Medico, is aimed at undergraduates from north and central California and starts with a summer session at the UC Davis medical school. Participants get ongoing support from mentors, access to research opportunities, and help studying for the medical school admissions exam.
Aubrey Alvarenga, 23, attended the first six-week summer session last year. Unlike the average aspiring doctor, whose parents tend to be wealthy, Alvarenga was brought up by a single mom who cleans houses for a living. He spent several years studying at a local community college, first majoring in psychology before switching to chemistry and taking more science and math courses.
“We got told over and over again: You deserve to be here,” Alvarenga said of Prep Medico. Surrounded by 39 other students with similar backgrounds, he attended lectures and study sessions, shadowed doctors and other health care professionals and practiced hands-on skills. His dream of being a pediatrician began to seem achievable. He transferred to UC Davis last quarter.
Once students reach medical school, they need to be trained to treat patients of a different race, ethnicity, culture, sexual orientation or socioeconomic status than their own. Twenty-one states, including California, have adopted health equity standards that help guide physician training.
But there’s a debate over how best to teach so-called cultural competency. The concept is often presented to students like another task to master or acronym to memorize, said Jann Murray-Garcia, an assistant adjunct professor at UC Davis’ school of nursing. But it’s not something you can memorize with flashcards. “There’s just no way to master the complexities of other people’s lives and personhoods,” she said. And recognizing one’s own racial biases and stereotypes, and learning how to deliver good care despite them, can be a lifelong process, she said.
Crunching Data
To get a handle on the challenges, Kaiser Permanente has turned to data as a tool that can help it track these new populations and make sure they are getting the care they need.
Kaiser’s data program is one of the most aggressive programs in the country. For more than a decade, the organization has broken down its quality data by race, gender and ethnicity and used it as a guide to drive health care priorities. Winston Wong, director of Kaiser’s disparity data program, said he can think of few other health systems that crunch data quarterly to track how their patients are faring by race, ethnicity and gender. Narrowing health care disparities is a core goal of Kaiser’s internal report card.
“One of the areas that we focus on is hypertension control,” said Wong, noting that nationally, African-Americans are more likely than whites to have very high blood pressure and—partly as a result—to suffer from strokes, heart disease and end-stage kidney disease. First, Kaiser’s analysts figured out what the gap looked like for their own patients. Then they created a new set of instructions for care teams, informed partly by patient focus groups.
Among other changes, physicians were asked to prescribe African-Americans medications proven to be more effective for them. Physicians, nurses and other health workers took additional care to listen to patients, follow up and nudge them to stay on top of their treatment plan. The effort has paid off: Since 2013, Kaiser has cut the hypertension control gap between its African-American and white patients in half.
Health systems can use data to improve their language services, too, Flores says. All it takes is asking new patients a few questions to check their English fluency, and noting what other languages they speak. That way clinics and hospital systems can arrange for in-person interpreters ahead of time for patients who need them, and figure out which languages are a priority when they are hiring staff or contracting for medical translation services. “Very few hospitals around the country do this,” he said.
Nationally, health data needs to more accurately capture racial and ethnic subgroups, says Kathy Ko Chin, president and CEO of the Asian & Pacific Islander American Health Forum. The “Asian and Pacific Islander” category used by the U.S. Census, for instance, encompasses everyone from third-generation Chinese-Americans to Pakistani engineers to Cambodian refugees. People with origins in the Middle East have no U.S. Census designation of their own, and can self-identify as white, Asian, African or “other.” Without more specific data, it’s hard to know what problems local communities have and what services they need, Ko Chin says.
California policymakers have unusually detailed data at their fingertips thanks to the California Health Interview Survey, conducted by the University of California, Los Angeles. Researchers have been able to tease out findings that can inform better care, such as the fact that Korean women are much less likely to receive mammograms than Japanese women in the state.
Immigrants in the Heartland
America’s burgeoning racial and ethnic diversity isn’t just affecting coastal and border states that have traditionally welcomed immigrants. New immigrants are also arriving to states and counties in the heartland, like Allegheny County in Western Pennsylvania, which is seeing a surge of new arrivals from Asia, Latin America and refugees from all over the world.
When non-English-speaking newcomers first started to show up at local hospitals, staff struggled to find and operate their interpretation phones, says Barbara Murock, who heads the immigrants and internationals initiative at the Allegheny County Department of Human Services.
About a decade ago, Murock’s office formed a health care advisory council of immigrant-serving groups, including refugee resettlement agencies and community clinics. Four years ago, the council shared with Magee-Womens Hospital—which is part of the University of Pittsburgh Medical Center and delivers 45 percent of the babies in the county—a list of maternal health problems non-English speakers were experiencing.
Some refugees were arriving to give birth without ever having been inside a hospital before. Staff members were misspelling the names of newborns on birth certificates. One non-English speaker from Mexico gave birth without being fed because she didn’t know she could ask for food.
Now the hospital has an outreach coordinator who works to improve care for non-English-speaking immigrants. The hospital has hired Nepali-speaking nurses for its labor and delivery unit and now conducts foreign-language tours for expecting parents. And it has learned to put birth certificate paperwork on hold for parents who want to wait to name their child until completing a naming ceremony, a common practice in Africa.
It can take time and money for small health centers, let along major health systems, to develop the staff and strategy necessary to serve a more diverse population. Most of all, it takes leadership. The Allegheny health department’s efforts wouldn’t be possible without the county government’s commitment to serving all its residents–and to providing additional funding.
“All of this is possible because of our county being a welcoming county,” Murock said.
Sophie Quinton is a reporter for Stateline, a nonprofit journalism project funded by the Pew Charitable Trusts.