Health care and immigration, two hot button issues for the incoming Administration, come together in a new paper in The Milbank Quarterly on Spanish-speaking immigrants’ access to safety net providers. Robert Nathenson and colleagues Brendan Saloner, Michael Richards, and Karin Rhodes use “secret shopper” methods to assess the ability of uninsured, Spanish speakers with low-English proficiency (LEP) to access interpreter services and obtain a primary care appointment in federally-qualified health centers (FQHCs).

Trained field staff called FQHCs posing as an English-proficient relative of a Spanish-speaking LEP adult. The caller requested a primary care appointment for a relative needing language assistance. The important twist in the paper is that the authors compared access in traditional Latino destinations – areas (like Houston or Chicago) where Latinos have long-established communities – with “emerging” destinations – areas (like rural Arkansas or Atlanta) where Latinos are a relatively new, but rapidly growing population. The question is important because little is known about health care resources for Latinos in the emerging areas (see map at right). They also compared their results with data collected previously from English-proficient uninsured and Medicaid callers to the same FQHCs.

In a sample of 197 FQHCs in nine states, the authors found that uninsured LEP Spanish speakers residing in emerging destinations were 40 percentage points less likely to receive an appointment than those in traditional destinations. No comparable access differential is evident for English-proficient patient groups seeking care, as shown below.

Source: Spanish-Speaking Immigrants’ Access to Safety Net Providers and Translation Services Across Traditional and Emerging US Destinations. The Milbank Quarterly, December 2016.

This study was conducted in November-December 2014, the first year of the large-scale implementation of the Affordable Care Act (ACA). Legal immigrants who were non-citizens made substantial gains in coverage in the ACA’s first year, accounting for 1.2 million out of the total 8.7 million who got health insurance in 2014. Sixty percent of these immigrants were Latino. But significant gaps remained in coverage, by design, as many immigrants had five-year waiting periods for eligibility and undocumented individuals were excluded.

To meet the needs of this newly insured population, the ACA provided additional funding to FQHCs ($11 billion over five years). But the number of uninsured FQHC patients remained constant at about six million. Meanwhile, the number of immigrants seeking care at FQHCS grew 12% between 2010 and 2014, and the latest data indicate that 23% of FQHC patients seen from 2013-2015 were “best served in another language.”

Regardless of the outcome of the current debates on the ACA, FQHCs will continue to be the safety net provider for vulnerable populations of the uninsured, immigrant, and LEP populations, many of whom are Latino. The dispersion of Latino immigrants beyond traditional destinations such as New York, Florida, Texas, and California, to “emerging destinations in the Southeast and Midwest will likely continue as well.

This study demonstrates that LEP immigrants in emerging destinations may face significant barriers to care, especially if the supply of language resources in these areas lags behind the new demand. To ensure primary care access to this population, FQHCs in these areas will need greater bilingual resources. The stakes are high, as the authors note:

At this time, the larger U.S. health care system risks a growing gap between the demand for and supply of medical services that can adapt to LEP Spanish-speaking patient needs. Even traditional Latino areas are facing shortages in Spanish-speaking providers. Our study suggests the safety net infrastructure is lacking Spanish-speaking health care resources in areas witnessing the largest expansions in their Latino immigrant populations. Better accommodation within the public health system and social safety net will likely be key in the short-run and can influence the long-term health and well-being of current and future generations of Spanish-speaking immigrants within the United States.