Centers for Medicare and Medicaid Services: Understanding Communication and Language Needs of Medicare Beneficiaries

This issue brief from the Centers for Medicare and Medicaid Services (CMS) describes the communication and language needs of Medicare beneficiaries. CMS conducted an analysis of the 2014 American Community Survey (ACS) Public Use Microdata Sample (PUMS) data to explore details about Medicare beneficiaries with limited English proficiency, as well as beneficiaries with visual and hearing disabilities who may also require communication assistance services. The ACS collects data on self-reported English proficiency, and self-reported hearing and vision impairment.

In the ACS, limited English proficiency is assessed through a series of questions, starting with: “Does this person speak a language other than English at home?” If the answer is “yes”, they are asked, “How well does this person speak English?” Answer options are “Very well”, “Well”, “Not well”, or “Not at all”. Individuals responding other than “Very well” are considered limited English proficient, especially when communicating about potentially complex issues such as health care, when precise vocabulary and understanding is vital. However, CMS also analyzed data for individuals who report that they speak English either “Not at all” or “Not well” to try to focus on those that might be in the greatest need for language assistance services. The ACS does not include questions about whether or how well a person reads English.

Visual and hearing disabilities are assessed in the ACS with the following questions: “Is this person blind or does he/she have serious difficulty seeing even when wearing glasses?” and “Is this person deaf or does he/she have serious difficulty hearing?” Visual and hearing disability questions in the ACS do not include a ranked scale to assess extent of disability.

The ACS data serves only as a proxy for understanding the scope of need for language and communication assistance services among Medicare beneficiaries in health care settings. Although it does not include questions specific to health care settings, it provides a nationally and regionally representative sample of the size of the self-reported limited English proficiency, blind and low vision, and deaf and hard of hearing Medicare population.

According to the 2014 ACS, there are more than 52 million Medicare beneficiaries in the United States. Over 4 million or 8% of these 52 million beneficiaries self-reported limited English proficiency  n=4,087,882; 7.7%). 57% of Asian Medicare beneficiaries, 49% of Hispanic beneficiaries, 27% of Native Hawaiian and other Pacific Islander beneficiaries, and 11% of American Indian/Alaska Native beneficiaries self-reported limited English proficiency. Nationally, over half (n=2,112,135, 52%) of the limited English proficient Medicare beneficiaries spoke Spanish at home (as their primary language). The next most common spoken languages nationally were Chinese, Vietnamese, Tagalog Korean, Russian, Italian, and French Creole.

The percentage of Medicare beneficiaries with limited English proficiency also ranges widely across states, with the highest percentages in California (22%), Hawaii (19%), New York (16%), Texas (13%), New Jersey (12%), Florida(12%), Massachusetts (11%), New Mexico (10%), and Rhode Island (10%). There is great variation across states with regards to the most common languages other than Spanish, and these differences largely reflect variations in immigrant and Native American populations. For instance, in California, the most common languages after Spanish are Tagalog, Chinese, and Vietnamese; and in New York they are Chinese, Russian, and Italian. In New Mexico, however, the most common languages after Spanish include Navajo, Zuni, and Keres. An appendix to the report lists the most languages spoken in each state by Medicare beneficiaries.

The ACS data can also be analyzed at more granular city and county levels, which helps identify where language assistance services might most be needed. For example, in Michigan, although the most commonly spoken language after English is Arabic at both the state and local level, Romanian is the second most commonly spoken language in Dearborn, though it is not even within the top 15 commonly spoken languages other than English for the state of Michigan as a whole. Hindi and Hungarian are similarly spoken in Dearborn but not commonly spoken throughout the state of Michigan. If providers in Dearborn only post taglines in the top 15 languages other than English spoken in the state of Michigan, they could very well neglect the needs of their Romanian, Hindi, and Hungarian speaking beneficiaries and expend resources on languages that are rarely spoken in their community. Further, providers and health care organizations could miss an important opportunity to improve the coordination and delivery of care, and population health outcomes within their local community. As a result, awareness of differences like these are important for providers and organizations to ensure compliance with laws and equitable care for future and beneficiaries.

Just under 8% of the Medicare beneficiaries self-reported that they were blind or have low vision (n=4,077,447, 7.7%). American Indian and Alaska Native Medicare beneficiaries self-reported over twice the prevalence of being blind or having low vision (15%), compared to other ethnic and racial groups.The percentage of Medicare beneficiaries self-reporting that they were blind or have low vision also ranges across states, with the highest percentages in West Virginia (12%), District of Columbia (11%), Mississippi (11%), Oklahoma (10%), Alaska (10%), New Mexico (10%), Kentucky (10%) and Texas (10%). As a state, California has a blind and low vision prevalence among Medicare beneficiaries of approximately 7%, just below the national average, but northeast Merced County has visual impairment rates among beneficiaries of more than 26%. An endnote lists the local areas with the highest percentage of Medicare beneficiaries self-reporting that they were blind or have low vision.

Nearly 15% of Medicare beneficiaries self-reported that they were deaf or hard of hearing (n=7,733,886, 14.7%). Medicare beneficiaries who are American Indians and Alaska Natives self-reported the greatest percentage of being deaf or hard of hearing(20%), followed by Whites (16%), Native Hawaiians or other Pacific Islanders (15%). and Hispanics (13.5%). The percentage of Medicare beneficiaries self-reporting that they were deaf or hard of hearing ranged from Alaska (21%), New Mexico (19%), West Virginia (19%), North Dakota (19%), Oklahoma (19%), Idaho (19%), Oregon (18%), Arkansas (18%), Kentucky (18%) Wyoming (18%), Washington (17%, and South Dakota (17%).  While the percentage of residents in New Mexico reporting that they are deaf or hard of hearing is one of the highest nationally, there was an even higher percentage of Medicare beneficiaries self-reporting that they are deaf or hard of hearing in northwest New Mexico, in the Navajo Nation (28%). Some parts of southern Miami-Dade County have rates of over 30% Medicare beneficiaries self-reporting that they are deaf or hard of hearing. An endnote lists the local areas with the highest percentage of Medicare beneficiaries self-reporting that they were deaf or hard of hearing.

Estimates such as those discussed throughout this report may be useful for providers and health care organizations as they work to understand the communication and language needs of the community in which they practice. They can also be helpful as providers and health care organizations work to identify those languages most commonly spoken in their communities and develop language access plans where their approach is laid out to ensuring meaningful access and providing communication and language access services for those patients and consumers who are eligible to be served or likely to be encountered.

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