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Report To Congress. Assessment of the Total Benefits and Costs of
Implementing Executive Order
No. 13166: Improving Access to Services for Persons with Limited
English Proficiency
March 14, 2002
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EXECUTIVE SUMMARY
Executive Order No. 13166 ( Improving Access to Services for Persons
with Limited
English Proficiency) ( Aug. 2000) is designed to improve access to
federally conducted programs
and activities and programs and activities of recipients of Federal
funding for persons, who as a
result of national origin, are limited in their English proficiency
( LEP) . The Administration has
emphasized the importance of ensuring that LEP individuals receive
appropriate language
assistance services and has commenced an effort to implement the Executive
Order s provisions.
In order to accomplish that goal in an efficient and effective manner,
the federal government
should create clear and uniform standards defining how federal agencies
and recipients of federal
funds should implement the Order. Many entities, such as schools, local
police departments,
doctors, and hospitals, may receive funding from multiple federal agencies.
It is critical that
these recipients be able easily to understand and implement with policies
issued by multiple
agencies, so that LEP individuals receive language assistance in a
uniform and consistent
manner.
Pursuant to Congressional mandate, this report assesses the total costs
and benefits of
providing language-assistance services under the Executive Order. 1
OMB has ( i) reviewed the
1 The FY 2002 Treasury and General Government Appropriations Act included
a provision directing the
Office of Management and Budget to submit a report to the Appropriations
Committees assessing the total
benefits and costs of implementing Executive Order 13166. The relevant
language in the appropriation law
states, . . . That of the amounts appropriated, not to exceed $ 6,331,000
shall be available to the
Office of Information and Regulatory Affairs, of which $ 1,582,750
shall not be obligated until the
Office of Management and Budget submits a report to the Committees
on Appropriations that provides an
assessment of the total benefits and costs of implementing Executive
Order No. 13166: Provided further,
That such an assessment shall be submitted no later than 120 days
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published literature, ( ii) surveyed federal and state agencies, (
iii) solicited public comment
through a Federal Register notice, ( iv) devised rough numerical
estimates of national costs and
qualitative assessments of national benefits, and ( v) performed case
studies of the potential
impact of the Executive Order in four sectors of American society:
healthcare, welfare,
transportation, and immigration.
The report focuses on the benefits and costs of providing language-assistance
services to
LEP persons pursuant to Executive Order 13166 and the Title VI regulations.
In simple terms,
benefit-cost analysis compares what has occurred or is expected to
occur with a given policy
change to what would have occurred in the absence of that change. 2
Under the Executive Order,
[ e ] ach Federal agency shall prepare a plan to improve access to
its federally conducted
programs and activities by eligible LEP persons. In addition, [ e ]
ach agency providing Federal
financial assistance [ to hospitals, universities or a myriad of other
state and other entities ] shall
draft Title VI guidance.
Federal agencies are currently in the process of implementing this
Executive Order.
Because of a lack of baseline information, we are currently unable
to evaluate the incremental
benefits or costs of implementation of the Executive Order. Thus, to
assess the benefits and
costs of LEP plans generally, this report uses data and assumptions
about different types of
language-assistance services that are being provided or that could
be provided to LEP individuals
in a variety of contexts.
The benefits of language-assistance services for particular LEP individuals,
while not
readily quantifiable in dollar units, can be significant. Improved
access to a wide variety of
after enactment of this Act. This report responds to this congressional
request by using available data to estimate benefits and costs.
2 OMB s March 2000, Guidelines to Standardize Measures of Costs and
Benefits and the Format of Accounting Statements.
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services ranging from the delivery of healthcare and access to food
stamps to motor vehicle
licensing and law enforcement can substantially improve the health
and quality of life of many
LEP individuals and their families. Moreover, language-assistance services
may increase the
efficiency of distribution of government services to LEP individuals
and may measurably
increase the effectiveness of public health and safety programs.
The twenty most common foreign languages spoken in the United States
are, in order of
frequency, Spanish, French, German, Italian, Chinese, Tagalog, Polish,
Korean, Vietnamese,
Portuguese, Japanese, Greek, Arabic, Hindi, Russian, Yiddish, Thai,
Persian, French Creole, and
Armenian. Although there are many different native languages spoken
by LEP persons, Spanish
is by far the most common. Accordingly, agencies should strongly consider
making services for
Spanish-speaking LEP individuals a substantial focus of their LEP plans.
The costs of enhanced language assistance are difficult to quantify,
but may also be
significant. Based upon the limited data available and the range of
assumptions set forth herein,
we anticipate that the cost of LEP assistance, both to government and
to the United States
economy, could be substantial, particularly if the Executive Order
is implemented in a way that
does not provide uniform, consistent guidance to the entities that
it covers. Of the economic
sectors examined in the report, provision of language services could
be most costly for the
healthcare sector. This conclusion is tempered by the fact that many
government agencies and
private entities that serve a significant LEP population have already
taken certain steps to
provide language services. To the extent that such services are already
being provided, the
economic impact of implementing the Executive Order will depend upon
the cost of any
additional steps taken. Unfortunately, there was insufficient data
to make a proper determination
regarding current levels of language assistance provided by these entities,
and we were unable to
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take into account in our cost estimates current levels of language
assistance. Accordingly, the
estimates herein address the overall cost of LEP assistance, not the
possible additional costs that
may ultimately be required to implement the Executive Order and agency
guidance.
In sum, the ultimate benefits and costs of the Executive Order will
depend on how it is
implemented, a process that we understand has begun among the Federal
agencies. We hope that
this Report will assist Congress and provide these agencies with information
that will be useful
to them as they take steps to implement the Executive Order.
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INTRODUCTION
The FY 2002 Treasury and General Government Appropriations Act included
a provision
requiring the Office of Management and Budget to report to the Appropriations
Committees an
assessment of the total benefits and costs of implementing Executive
Order 13166 ( Improving
Access to Services for Persons with Limited English Proficiency) .
The Order is designed to
improve access to federally conducted programs and activities and programs
and activities of
recipients of Federal funding for persons, who as a result of national
origin, are limited in their
English proficiency ( LEP) . The Order requires each Federal Agency
providing federal financial
assistance to publish guidance explaining federal-funds recipients
obligations under Title VI
regulations and to describe the steps recipients may take to satisfy
these obligations. The Order
also requires Federal Agencies to develop a plan to ensure appropriate
LEP access to their own
federally conducted programs and activities.
The Executive Order gave the Department of Justice ( DOJ) the responsibility
of assisting
agencies in developing the plans and guidance documents mandated by
Executive Order 13166.
Title VI regulations as well as the Executive Order specifically require
reasonable steps to
ensure meaningful access. What constitutes reasonable steps to ensure
meaningful access
turns on a consideration of the totality of the circumstances. DOJ
has identified a four-factor
analysis to help agencies determine whether this standard has been
satisfied. These four factors
are ( i) the number or proportion of LEP individuals, ( ii) the frequency
of contact with the
program, ( iii) the nature and importance of the program, and ( iv)
the resources available and
costs.
To date, ten agencies have published LEP guidance: Corporation for
National and
Community Service, Department of Education, Department of Justice,
Department of Health and
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Human Services, Department of Labor, Department of Transportation,
Department of Treasury,
General Services Administration, National Aeronautic and Space Administration,
and National
Science Foundation. 1 These guidance documents, however, are not entirely
uniform. Some rely
on DOJ s four-factor test; others do not. Since certain State or private
entities receive funds
from multiple federal agencies, such entities could conceivably be
subject to inconsistent
guidance and obligations.
On October 26, 2001, DOJ issued a memorandum clarifying questions raised
regarding
Federal Agencies responsibilities under the Executive Order. . The
memorandum directed
agencies that have issued LEP guidance documents to notify the Department
of Justice and
publish a notice asking for public comment on the guidance documents
they have issued.
Agencies that had not yet published guidance documents were to submit
agency-specific
guidance to the Department of Justice. DOJ continues to work with federal
agencies to develop
these documents.
OMB has undertaken this benefit-cost analysis in a four-month period.
OMB has ( i)
reviewed the published literature, ( ii) surveyed federal and state
agencies, ( iii) solicited public
comment through a Federal Register notice, ( iv) devised rough
numerical estimates of national
costs and qualitative assessments of national benefits, and ( v) performed
in-depth case studies of
the potential impact of the Executive Order in four sectors of American
society: healthcare,
welfare, transportation and immigration. In addition, this report has
been reviewed by three peer
reviewers.
1 See http: / / www. usdoj. gov/ crt/ cor/ 13166. htm
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METHODOLOGY
Data Collection Efforts
To assess the benefits and costs of implementing Executive Order 13166,
a significant
amount of data is required. Agencies are currently in the process of
implementing the Executive
Order. Because of a lack of baseline information on benefits and costs,
we are at present unable
to evaluate the incremental benefits or costs of implementation. Thus,
this report instead uses
data and assumptions about different types of language-assistance services
that are being
provided or could be provided to the LEP population. This Report follows
a multi-faceted
approach to data collection:
1. Literature Review: We reviewed numerous studies relevant to our assessment,
many of
which were recommended to us by public comments and federal agencies,
including:
Existing studies of the benefits and costs of improving the quality
of communications
and interactions between LEP individuals and the federal government
or federally
funded services through the use of oral and written translation services.
Existing studies of the benefits and costs of increased provision of
English instruction
and the returns to proficiency in English.
Existing studies of similar language or translation issues in the international
arena, ( e. g.
Canada, European Union, United Nations, and the Organization for Economic
Cooperation and Development [ OECD ] ) .
Existing studies of the LEP population, including their characteristics
and the services
that they typically need and access.
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2. Agency Data Call: Federal agencies were asked to provide information
about the number or
proportion of LEP individuals served, their frequency of contact with
the agency/ program,
the nature and importance of the agency/ program, and the resources
available and costs.
Specifically, we asked the following of all federal agencies:
Figure 1.1: Agency Data Call Number or Proportion of LEP Individuals:
Does your agency have a working definition of Limited English Proficiency
? If so, please provide.
How many LEP persons are served by the agency? What proportion of the
population served by the agency are LEP individuals?
How does this vary by program? Please explain.
How many different languages does your agency s clientele speak? What
are they?
Frequency of Contact with the Program:
How many encounters does your agency typically have ( ( per month and/
or per year) with LEP individuals served? What is the nature of these encounters?
Are they typically in-person, over the phone, or by form ( email or mail)
? How much time do LEP individuals spend accessing the services your agency
provides ( preferably on a per person basis) ? Do LEP individuals typically
spend more or less time per encounter than non-LEP persons served by the
agency? How does this vary by program?
Nature and Importance of the Program:
What are the major programs serving LEP individuals in your agency?
How many are served overall in each program? Are there specific programs
that serve high
numbers of LEP individuals? Please provide a breakdown by major program,
if available.
What special services are typically provided by the agency for LEP
individuals? How does this differ by major program?
General Information: Is your agency aware of any existing studies of
the benefits and/ or costs of
improving the quality of communications and interactions between LEP
individuals and the federal government or federally funded services? If
so, please provide copies or citations/ references.
Please provide several examples of real-world case studies that illustrate
the benefits and costs of providing translation services to LEP individuals,
as
envisioned by Executive Order 13166, and related agency guidance. We
are seeking examples from multiple perspectives, including LEP individuals,
federal
agencies/ recipients of federal funds, and the international context.
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While it was useful to collect information from agencies on a variety
of topics related
to Executive Order 13166, it was not possible to rely solely on the
federal agencies for data
regarding the benefits and costs of Executive Order 13166 implementation.
The federal
agency data call revealed significant gaps not only in the information
available on the
benefits and costs of Executive Order 13166, but also on the more basic
questions of the
number of LEP individuals served and costs of the services that were
provided before the
Executive Order was adopted. Thus, precise baseline data on pre-Executive
Order
conditions, necessary information to conduct a benefit-cost analysis
of the Executive Order,
are lacking. Indeed, most agencies are in the very early stages of
their implementation
process, and few, if any, have collected data on benefits and costs.
This data gap only
widened as we attempted to understand the benefits and costs at the
State/ community and
business level where various entities such as law enforcement organizations,
non-profit
organizations, schools and firms accept federal funding and are therefore
affected by the
Executive Order and related guidance documents. Despite the lack of
complete data from all
agencies, we obtained relatively useful data to inform our report.
Agency information was
used to provide context for our assessment, and was supplemented by
information obtained
through the literature review and public notice.
3. Federal Register Notice and Outreach Activities: On November 30,
2001, we placed a notice
in the Federal Register seeking information to inform the development
of this report. The
public was given 30 days to provide comments and information in response
to the notice. We
received approximately 450 comments from individuals and organizations,
which are
summarized in the Public Comment section. The Federal Register notice
provided an
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explanation of the assessment being conducted and requested that the
public offer assistance
by providing relevant information. We also encouraged commenters to
provide qualitative or
descriptive information in cases where quantitative information was
not available or useful.
The specific topics about which we sought assistance from the public
are as follows:
Figure 1.2: Federal Register Questions By what method may one
quantify the numbers of LEP individuals and which languages they
speak?
How may one understand the number of different languages spoken by
LEP individuals, and their geographic distribution?
How may one characterize the interactions of LEP individuals with both
federal and federally funded entities?
all levels? types of services that LEP individuals access more or less
frequently than non-LEP individuals?
How may one determine the benefits and costs of improving English language
proficiency among LEP individuals?
By what means may one understand and quantify the level of services
provided by the government or government-funded organizations to address
the special needs of LEP
individuals prior to Executive Order 13166? be necessary to
For example, how frequently do LEP individuals interact with government
at What types of government services do LEP individuals typically access?
Are there
To what extent will changes achieve full compliance with Executive
Order 13166 and related guidance?
How may one quantify and describe the costs to the federal government
or recipients of federal funds of providing oral and written translation
services?
How may one quantify and describe the benefits to LEP individuals and
society as a result of having oral and written translation services available,
in accordance with Executive Order 13166?
By what method may one identify any existing studies of the benefits
and costs of improving the quality of communications and interactions between
LEP individuals and the federal
government or federally funded services? Are there comparable studies
of similar language or translation issues internationally ( e. g. Canada,
European Union, United Nations, and OECD) ?
Where can these studies be found? By what method may one identify any
existing studies of the benefits and costs of improving
the quality of communications and interactions between LEP individuals
and the federal government or federally funded services? Are there comparable
studies of similar language or
translation issues internationally. Where can these studies be found?
By what method may one identify real-world case studies that illustrate
the benefits and costs of providing translation services to LEP individuals,
as envisioned by Executive Order 13166,
and related agency guidance? It is important to consider examples from
multiple perspectives, including LEP individuals, federal agencies/ recipients
of federal funds, and the international
context.
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By what method may one identify existing academic research and real-world
case studies from the following sectors: health, social services/ income
maintenance, education,
transportation, law enforcement, and trade? Are there recommendations
from additional sectors or perspectives from which to address this issue?
By what method may one identify any other information or resources that
the public believes will assist in the effort to assess the benefits and
costs of Executive Order 13166?
In addition to soliciting information through the Federal Register notice,
we also
discussed the benefits and costs of Executive Order 13166 with several
small groups of
representatives from organizations that had commented on the Federal
Register notice.
Case Studies
We also developed case studies to gain a better understanding of the
benefits and costs of
Executive Order 13166. While they do not yield representative data,
the case studies provide
real-world insight and serve as a check on aggregate estimates of total
benefits and costs
developed through modeling and assumptions. These areas included transportation,
welfare,
immigration, and healthcare. Each case study is discussed in more detail
in the sections below.
The case studies are designed to highlight how Executive Order 13166
might impact services
provided across a spectrum of service delivery systems.
Figure 1.3: Summary of Case Studies Examined Case Study Type Characteristics
Motor Vehicle Administration A relatively low intensity interaction
with a relatively large percentage of the public on a periodic basis.
Services are not for specialized populations. Interaction is relatively
important, ( e. g. , determining whether an individual may drive
legally) .
Services are delivered by State or local government agency. Healthcare
System Can be a relatively high intensity interaction
( hospital stay) or a low intensity interaction ( one time trip to
a clinic for an immunization) . Relevant to all segments of the
population. Services sometimes provided by State or local government.
However, services are often delivered by private providers
who receive payment from Medicare of Medicaid on behalf of the
patients, making them recipients of federal funds.
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Welfare/ Food Stamp Offices A relatively high intensity interaction.
Must see a large number of persons on a regular basis
( re-certification every 3-6 months) . Relevant to a specialized
portion of the public ( i. e. , those comprising the low-income community)
. Services delivered by State or local government agency. Immigration/
INS Can be a relatively high intensity interaction. Immigration
process may require great deal of paperwork and take many years. Relevant
to immigrants and their families or sponsors.
Services delivered by the federal government.
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AN APPROACH TO UNDERSTANDING THE POTENTIAL COSTS AND BENEFITS OF
IMPLEMENTING EXECUTIVE ORDER 13166
The discussion below is organized into four main topics. First, we
briefly consider the
nature of the LEP population in the United States. Next, we turn to
an evaluation of four case
studies that consider the potential costs and benefits of implementing
the Executive Order in the
economic sectors of transportation, welfare, immigration, and healthcare.
We then use a
different approach to cost estimation and develop a range of aggregate
estimates for the
incremental cost of serving LEP persons. Finally, we consider various
steps that agencies may
wish to take in order to serve the LEP population most efficiently.
1. The LEP Population
To assess the costs and benefits of implementing the Executive Order,
an initial question
is what constitutes a person with limited English proficiency. LEP
individuals are persons
who do not speak English as their native language and who have a limited
ability to read, speak,
or understand English. Whether a person is considered LEP in a particular
circumstance may
vary, however, depending on the type and degree of English skills necessary
to participate in
specific programs and services. In some cases, English-speaking ability
may be less essential
than reading and writing skills ( e. g. , where participation
in a program or activity requires reading
and filling out a form) . In other cases, speaking skills may be as
important or even more
important than reading and writing skills ( e. g. , a hospital
emergency room) .
Determining the size of this population is difficult. The Census, including
Census block-
level data, may provide a rough, though possibly inaccurate, measure.
The Census survey,
however, does not address reading and writing skills. Many educated
immigrants may have poor
English speaking ability yet have substantially better skills in verbal
understanding, writing, and
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reading English. On the other hand, many people speak and understand
English well, but have
limited English reading and writing skills. Another conceivable
measure may be drawn from immigration data. These data can
occasionally be useful as a rough proxy for the LEP population because
immigrant status and
English proficiency may be strongly ( though not perfectly) correlated
variables. However, only
a portion of foreign-born persons are LEP. As of March 2000, about
10.4% of the United States
population was foreign born. The most common foreign languages
spoken in the United States are, in order of
frequency, Spanish, French, German, Italian, Chinese, Tagalog, Polish,
Korean, Vietnamese,
and Japanese ( see Figure A. 1 in Appendix A) . However, given that
many individuals speaking a
foreign language at home are also proficient in English, the most common
native languages
spoken by the LEP population differ from the distribution of all foreign
languages spoken in the
United States. Although there are many different native languages spoken,
Spanish is by far the
most common language spoken by LEP individuals, surpassing the total
of all others combined.
Accordingly, agencies should strongly consider making services for
Spanish-speaking LEP
individuals a substantial focus of their LEP plans. The LEP population
consists primarily of adults, since those who are born or come to the
United States as children typically become fluent in English. Adult
immigrants to the United
States who are deficient in English skills confront economic hardships.
Limited English
proficiency can be a significant barrier to employment, restricting
employment to low-skill, low-
wage jobs where English proficiency is not required.
2. Case Studies
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Our analysis focuses on the benefits and costs of providing language-assistance
services
to LEP persons as contemplated by Executive Order 13166. Benefit-cost
analysis typically
requires comparison of what occurred or is expected to occur given
a policy change with the
counterfactual that is, , what would have occurred in the absence of
the change. 1 Because of a
lack of baseline information, we are at present unable to evaluate
the incremental benefits or
costs of implementation of the Executive Order. Instead, our assessment
of benefits and costs
will focus on specific types and degrees of language-assistance services
for the LEP population.
Potential Benefits of Executive Order 13166
While it is not possible to estimate, in quantitative terms, the value
of language-assistance
services for either LEP individuals or society, we are able to discuss
the benefits of the Executive
Order qualitatively.
We identified two general categories of benefits that eligible LEP
individuals experience
when they receive meaningful access to federally-conducted programs
or activities or to the
programs or activities of recipients of federal financial assistance.
First, LEP individuals may
experience the intangible but very important benefit connected with
the fulfillment of a legal
right. Second, LEP individuals may benefit from an increase in access
to federally-conducted
programs or activities or to the programs or activities of recipients
of federal financial assistance.
Government and American society likewise may benefit from Executive
Order 13166.
Increasing access to government programs may lead to cheaper, more
targeted early intervention,
avoiding long-term and more costly services to government and society.
For example, the use of
primary healthcare services aimed at prevention or early detection
and treatment of disease could
1 Guidelines to Standardize Measures of Costs and Benefits and the Format
of Accounting Statements. Office of
Management and Budget, March 2000.
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reduce the cost of late-stage disease treatment or emergency visits.
Additionally, education or
training programs could potentially lead to decreased costs for social
service benefits such as
Temporary Assistance for Needy Families ( TANF) , Food Stamps, and
Medicaid.
Other efficiency gains may also result from the Executive Order. Providing
language-
assistance services to LEP individuals could decrease the amount of
time that an LEP individual
must interact with the benefit agency. 2 If forms are translated or
bilingual staff is available to
assist the individual, LEP interactions could take less time than requiring
the LEP person to
make multiple trips to the provider s officer for services. This could
benefit both the individual
and the agency. More standardized provision of language services, moreover,
may likewise lead
to efficiency gains for the organizations providing them. Patchwork
policies that have existed
in the past, such as heavy reliance on telephonic interpreter services,
could be reduced once
formal policies are put in place. Finally, increased access to LEP
services may reduce the harms
associated with language constraints and improve the efficiency of
the flow of goods and
services from federally-conducted and federally assisted programs and
activities to the intended
recipients.
Illustrations of Benefits in Selected Sectors
The benefits discussed above are clearly very difficult to quantify
in units comparable to
the costs of the Executive Order. Instead, we provide illustrations
of the potential benefits of the
Executive Order for each of the four sectors examined in this report.
2 State Government Survey of State Departments, Agencies, and Programs:
Persons with Limited English
Proficiency. Preliminary report, December 21, 2001. The state of Maryland
just completed this study of the state s ability to provide equal access
to public services to LEP persons. The study found that of the state' s
departments, agencies, and programs encountering LEP clients, 28% reported
delays in the provision of services due to language barriers, while 72%
reported no delays.
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Case Study I: Transportation
By requiring Federally funded DMVs to provide language assistance services,
Executive
Order 13166 might provide the following benefits:
Access: LEP individuals could have greater access to DMV services, enhancing
their
ability to obtain a valid driver s license or other documentation.
Efficiency: LEP services could improve the efficiency of interactions
with DMVs and LEP
persons. For example, a greater number of forms translated increased
the chances that an
LEP individual entering a DMV office would be able to read, understand,
and complete a
required form in a shorter amount of time. The use of bilingual staff
in DMV offices could
reduce the time per interaction because the bilingual staff can answer
questions
immediately without having to schedule a future meeting or call to
request telephonic
interpreter services. This time savings might also benefit the DMV,
reducing cost to the
DMV offices. However, these savings could be offset to some extent
by the increased cost
of providing more translation services ( e. g. bilingual premiums
for staff, paying for written
translations, and use of paid interpreters. )
Case Study II: Food Stamps
By requiring Federal agencies to take reasonable steps to provide language
assistance in
the context of the Food Stamps program, Executive Order 13166 might
foster the following
benefits:
Access: Anecdotal evidence points to increased utilization of social
services, such as Food
Stamps, by LEP individuals when bilingual services are made available.
Without language
assistance services, LEP individuals might be discouraged from completing
the application
process since they may be unable to communicate with the food stamp
office. Increased
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access to the food stamp program could enhance the diets of the entire
LEP household,
resulting in both immediate and long-term health benefits.
Efficiency: An interview between an LEP food stamp applicant and the
food stamp worker
may take longer to complete and lead to errors in eligibility determination
and payment
levels if there are communication problems. While an eligibility interview
for an LEP
individual utilizing an interpreter could take longer than the same
interview for a non-LEP
individual, time would also be saved as a result of a decreased need
to reschedule
appointments and other activities around the LEP individual s ability
to supply a translator.
Based on anecdotal evidence obtained from the States of Texas and California,
the use of a
translator could double the amount of time taken for an eligibility
interview with an LEP
individual as compared to the same interview with a non-LEP individual,
due to the need to
restate both questions and answers. In contrast, the use of bilingual
staff persons would
minimize this time delay.
Case Study III: Immigration
By requiring INS to take reasonable steps to provide meaningful access
to immigration
programs and activities, Executive Order 13166 may provide the following
benefits:
Access: Given the complexities of immigration law and regulation, clarity
in the
application procedures for benefits might allow individuals to access
these services better
and better understand the requirements for obtaining immigration benefits.
This increased
access to information could better enable LEP individuals to comply
with immigration law
and other requirements.
Efficiency: A greater understanding of the immigration system, requirements,
and rules
may mitigate the number and/ or frequency of immigration violations.
Individuals often are
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not aware of the necessary procedures that must be followed to maintain
a certain status,
and consequently fall out of legal status due to a missed application
filing or appearance at
an INS service center. Reducing immigration violations would benefit
the agency by
reducing the cost of immigration proceedings. In addition, it would
allow for otherwise
eligible non-immigrants and immigrants to lawfully remain in the United
States.
Case Study IV: Healthcare
The benefits of providing language services in the healthcare sector
include increased
access of LEP individuals to quality healthcare and better communication
with healthcare
professionals. Among Hispanics, those whose primary language is English
find it easier to
understand materials from the doctor s office than those who speak
primarily Spanish, with 51
percent of English-speakers able to understand versus only 37 percent
of Spanish-speakers.
Almost all individuals, LEP and non-LEP, need to access the healthcare
system at
multiple points in their lives. Making these interactions more effective
and more accessible for
LEP persons may result in a multitude of benefits, including: increased
patient satisfaction;
decreased medical costs; improved health; sufficient patient confidentiality
in medical
procedures; and true informed consent and understanding of other legal
issues. .
Possible decreases in number and severity of misdiagnoses or other medical
errors:
Individuals who have been the victims of medical errors may experience
pain and suffering,
and even death. Medical errors can be costly for the providers and
insurance companies, and
they can impart a large human cost as well. Some have estimated that
44,000, and possibly
20 20
20Page 21 22
up to 98,000 hospital deaths per year are attributable to medical errors.
3 Medical errors can
be extremely costly ( estimated to be between $ 17 billion and $ 29
billion annually) . 4 It is not
known if these adverse events are experienced in any large number by
LEP individuals or
whether LEP status has contributed to this problem to any significant
degree. One small
study found that patients who did not speak English as their primary
language were more
likely to report drug complications and other medical complications.
5 Agencies should
consider whether provision of language services to LEP individuals
could help reduce
medical errors by increasing the quality of information a provider
obtains regarding their
patient s condition. It may also be possible that language services
to LEP individuals could
decrease non-compliance with medical instructions, which can lead to
severe consequences
such as drug-resistant infections and unchecked progression of diseases.
Increased patient satisfaction: LEP patient satisfaction with healthcare
has generated a
significant amount of literature. 6 Language barriers appear to have
a negative impact on
patient satisfaction. For example, in a recent study, 33 percent of
Hispanics cited
communication problems with their doctor ( versus 16 percent of non-Hispanic
Whites) .
Similarly, data suggest that Hispanic and Asian American patients are
less likely to find doctors
information very easy to understand. 7 Despite apparent communication
difficulties, less than
one-half of non-English speakers who said that they needed an interpreter
said that they were
3 To Err is Human: Building a Safer Health System. National Academy
of Sciences Report. National Academy
Press: Washington, DC; 1999. 4
To Err is Human: Building a Safer Health System. National Academy of
Sciences Report. National Academy Press: Washington, DC; 1999.
5 Ghandi T. K. , et al. Drug Complications in Outpatients. Journal
of General Internal Medicine 2000; 15: 149-
154. 6 For example, consider Providing Health Care to Limited English
Proficient ( LEP) Patients: A Manual of
Promising Practices published by the California Primary Care Association.
.
21 21
21Page 22 23
always or usually provided with one. 8 Quality interpretation might
decrease this satisfaction
gap between LEP individuals and non-LEP individuals.
Decreased medical costs ( as unnecessary emergency room usage decreases
with an increase
in outpatient visits) : At least one researcher has concluded that,
when use of a trained
interpreter is available, primary and preventive care increases, and
ER use decreases
significantly. 9 When an ER visit does occur, the presence of a language
barrier could
increase the range and cost of diagnostic tests that are necessary
and might increase the time
that a patient remains in the ER. 10 Certain research has suggested
that interpreters decreased
this cost-differential but did not have an effect on the longer length
of stay. 11 The presence
of a language barrier may also result in an increased probability of
admission into the
hospital, but that increased probability is significantly reduced (
but does not disappear) with
the presence of an interpreter. 12 Finally, emergency room patients
who received
interpretation services when necessary may be more likely to keep follow-up
appointments
and less likely to return to the emergency room within 30 days of the
first visit. 13
True informed consent and understanding of other legal issues: : Medical
consent
documents can be difficult to understand, even for native speakers.
If medical procedures
7 Collins, Karen S. , et al. Diverse Communities, Common Concerns: Assessing
Health Care Quality for Minority
Americans. The Commonwealth Fund. . , March 2002. 8 Collins, Karen
S. , et al. Diverse Communities, Common Concerns: Assessing Health Care
Quality for Minority
Americans. The Commonwealth Fund. . , March 2002. 9 Jacobs, Elizabeth
J. , et al. Costs and Benefits of Interpreters. Unpublished paper, Cook
County Hospital/ Rush Medical School, 2001. 10
Hampers, L. C. , et al. Language Barriers and Resource Utilization
in a Pediatric Emergency Department. Pediatrics , June 1999; 103
( 6 Pt 1) : 1253-6.
11 Hampers, Lou. AAP Meeting 2000.
12 Lee, E. D. , et al. Does a Physician-Patient Language Difference
Increase the Probability of Hospital Admission?
Academic Emergency Medicine , March 1998; 5 ( 3) : 277. 13 Bernstein,
J. , et al. The Use of Trained Medical Interpreters Affects Emergency Department
Services, Reduces
Charges, and Improves Follow-Up. Unpublished paper, Department of Maternal-Child
Health, Boston University School of Public Health, 2000.
22 22
22Page 23 24
and associated documents, such as power of attorney forms, are successfully
explained to
LEP patients or their family members, legal and other problems might
be avoided.
Potential Costs of Implementing Executive Order 13166
The provision of language assistance services to LEP individuals requires
Federal
agencies and federal-funds recipients to incur additional costs. Because
sufficient information
was not available on the cost of providing language-assistance services
before and after issuance
of the Executive Order, we were unable to evaluate the actual costs
of implementing the
Executive Order. Instead, this report uses assumptions about different
types of language-
assistance services that could be provided to the LEP population to
assess costs. As the
following case studies describe, additional costs could result from
expenditures on translated
documents, bilingual staff and associated premiums, contracts for oral
interpreter services,
agreements for telephonic interpreter services, a variety of capital
investments, central planning
and data collection, and additional staff time needed to serve LEP
persons. In addition to these
specific case studies, national cost estimates are also presented using
aggregate United States
data.
Case Study I: Transportation
Introduction
The Department of Motor Vehicles ( DMV) State offices are utilized
by most adults in the
United States. DMVs provide a wide array of important functions, including
driver licensing and
vehicle registration. In fact, about 191 million drivers were licensed
and 218 million vehicles
23 23
23Page 24 25
were registered in 2000. 14 Among numerous other services, DMVs also
often record vehicle
ownership, maintain driving records, provide emissions testing, and
issue non-driver
identification cards.
To accurately assess the costs of implementing Executive Order 13166
in the DMV
sector, information about the level of services already provided to
LEP individuals prior to
implementation of Executive Order 13166 ( i. e. , the baseline
) and the level of services
contemplated by Executive Order 13166 is needed. Because such information
is unavailable, we
must make assumptions for the purposes of estimating any benefit and
cost figures.
State DMVs appear to provide varying levels of language services, depending
on the
funding resources available and the diversity of their respective population.
Largely because of
the Dymally-Alatorre Bilingual Services Act and the diversity of the
state population, California,
in particular, has taken numerous steps to ensure that its services
are accessible to LEP
individuals. California has also calculated the annual expenditures
for the provision of language
services.
Dymally-Alatorre Bilingual Services Act
The Dymally-Alatorre Bilingual Services Act, 15 enacted in 1973, requires
state and local
agencies in California to ensure that they provide information and
services in the various
languages of their constituents. In particular, when state and local
agencies serve a substantial
number of non-English speaking people, they must: : ( i) employ a sufficient
number of qualified
bilingual staff in pubic contact positions, and ( ( ii) translate documents
explaining available
services into the languages of their constituents.
14 Highway Statistics 2000 , United States Federal Highway Administration.
15 California Government Code § 7290 et seq. .
24 24
24Page 25 26
For state agencies, the Act defines several of the above terms and
phrases. A substantial
number of non-English speaking people consists of 5 percent or more
of the people served by
any local office or facility of a state agency. Qualified bilingual
staff are employees who have
passed written or oral examinations that certify their ability to speak,
write, and understand
another language. Public contact positions are those in which employees
meet, , contact, and
deal with the public while performing the agency s function. To determine
whether a state
agency serves a substantial number of non-English speaking people,
each local office must
conduct a biennial survey to determine the language assistance needed.
The Act also requires the
State Personnel Board to provide technical assistance to state agencies
and oversee the statewide
language survey.
California Department of Motor Vehicles
The California DMV complies with the Act by recruiting and hiring qualified
bilingual
persons to ensure a satisfactory level of service for California s
diverse non-English speaking
population. Bilingual needs are identified by biennial statewide language
surveys and ongoing
needs assessments. Each of the approximately 310 field offices throughout
the state conducts a
language survey for a two-week period. During the survey period, each
public contact employee
records each public contact as well as the constituent s language.
If the percentage of contacts in
a non-English language exceeds five percent, the field office is mandated
to provide some
bilingual services and printed materials in that respective language.
DMV unit managers are
responsible for alerting department administration when they perceive
that a language need is not
being met. 16 From the most recent language survey, the California
DMV estimates 273,684,211
16 California State Auditor, Dymally-Alatorre Bilingual Services Act:
State and Local Governments could do more
to address their clients needs for bilingual services, , November 1999.
. The California State Auditor notes that this
informal approach may be inadequate because some field managers may
not actually request the translated materials.
25 25
25Page 26 27
public contacts per year. Of that total, about 52 million ( 19 percent)
are estimated to be non-
English customer contacts. 17
The DMV attempts to address customers language needs uniformly, , regardless
of office
size. For larger offices, language needs are met by employing the mandated
number of bilingual
staff, along with the provision of other language services such as
interpreters and translated
material as needed. For offices with 25 or fewer equivalent full-time
employees, language needs
are met by one or more of the following methods: hiring bilingual staff,
using contracted
telephone interpretation services, using bilingual staff in other locations
for interpretation
services, and providing written translated material.
Transportation Costs at a National Level
The total annual cost for the California DMV to provide language services
is about $ 2.2
million. ( This number was derived from the Califonia DMV' s response
to Dymally-Alatorre
compliance questions for an Assembly Budget Hearing and an estimate
of language survey
costs. ) Although we do not conclude or assume that this same level
of service would be
appropriate in every State under the Executive Order, we think it is
helpful to understand the
costs of California s plans. If the entire nation employed the California
system, we might
estimate the national costs as follows. Using data from the Census
Bureau, we calculated that
there may now be 4,311,169 individuals in California who would indicate
that they speak
English less than well. 18 Extrapolating that information to the national
level, it appears that
this California population represents about 26 percent of all individuals
who report speaking
17 Phone conversations with California DMV, Human Resources Division.
December 10 & 11, 2001.
18 This number represents the estimated number of persons in California
who report speaking English less than well
who are California LEP persons 18 years and older in 2000. To arrive
at this number, the number of LEP persons
26 26
26Page 27 28
English less than well nationwide ( ( 16,520,770) . 19 If one assumes
that the California DMV
costs of $ 2.2 million per year represent about 26 percent of total
costs, costs for all states to
provide the same level of DMV language services as California would
be about $ 8.5 million per
year. The above estimates assume a constant cost to provide language-assistance
services to
each LEP individual. In reality, the cost of providing language-assistance
services to each LEP
individual would vary by State for a number of reasons, most notably
due to the demographic
differences among states and the variety of services that might be
appropriate for differing
concentrations of LEP populations.
This is only a rough estimate , of course, and may overstate actual
costs. As discussed
above, to estimate the costs of implementing Executive Order 13166,
one must have data
regarding the level of services already provided to LEP individuals
prior to implementation of
Executive Order 13166 and the level of services contemplated by Executive
Order 13166. Our
analysis assumes that no language services are being provided. If one
assumes that a substantial
level of language-assistance services are already being provided, then
the cost in the DMV sector
would be considerably lower.
Case Study II: Food Stamps
Background
According to the Food Stamp Act of 1977, the purpose of the Food Stamp
Program is to
permit low-income households to obtain a more nutritious diet by increasing
their purchasing
power. The Food and Nutrition Service is the agency within the United
States Department of
Agriculture responsible for implementing the Food Stamp Program, which
provided
18 years and older who reported speaking English less than well in 1990
was multiplied by California s 18.9 percent
growth rate over the past decade to arrive at 4,311,169 LEP persons.
19 This number includes only individuals 18 years and over.
27 27
27Page 28 29
approximately 17.3 million people with food assistance in 2001. The
Food Stamp Program
provides benefits either electronically or through coupons via a network
of retail stores across the
nation. Federal, State and local governments share the costs of administering
the program,
typically with the federal government paying 50 percent of program
administrative costs and 100
percent of program benefits. 20 Because food stamps are widely available
to most people who
meet the income and resource standards set by Congress, the Food Stamp
Program serves a
broad spectrum of the low-income population. In fiscal year 2000, the
average food stamp
household contained 2.3 persons, had a gross monthly income of $ 620,
and received
approximately $ 158 in monthly food stamp benefits. 21
Since the passage of the Food Stamp Act in 1977, the Food Stamp program
has required
its services to be accessible to non-English speakers. The regulatory
requirement is intended to
ensure that individuals who do not speak or write English are not prevented
from accessing
needed food services because of language barriers. The regulation states,
[ w ] here a significant
proportion of the population of the area served by a local agency is
composed of non-English or
limited English speaking persons who speak the same language, the State
agency shall take
action to ensure that Program information is provided to such persons
in the appropriate
language orally and in writing. 22
Food Stamp Costs at a National Level
Each of the approximately 4,000 food stamp program offices nationwide
is required to
assess the language usage of the community it serves. If the percentage
of contacts in a non-
English language exceeds five percent, the local office is required
to provide applications and
other printed materials in that particular language, as well as oral
translation. Because translation
20 7 CFR. 273.10. Characteristics of Food Stamp Households: Fiscal Year
2000. Mathematica Policy Research, Inc.
28 28
28Page 29 30
services for LEP individuals have been mandated in the Food Stamp Program
since its inception,
Executive Order 13166 may have no additional impact on the benefits
or costs of providing such
language services.
This case study utilizes cost information obtained from State agencies
and local food
stamp offices in Texas and California. By using the data provided on
expenditures as a
benchmark, one can obtain an estimate of the costs of provision of
services to LEP individuals in
the Food Stamp Program. While the Food Stamp Program has not instituted
a systematic means
of evaluating the language needs of the communities it serves, evidence
suggests that State
agencies and local offices have typically provided significant levels
of both oral and written
translation services as a matter of customer service.
This cost estimate is based primarily on information provided by the
California
Department of Social Services and is comprised of: ( 1) written translation
services ( 2) oral
translation services ( 3) wage premiums paid to bilingual staff and
( 4) the opportunity cost of
additional time spent in eligibility interviews with LEP individuals.
Food Stamp Program Language Services and Expenditures: Written Translation
The Food Stamp Program provides many forms and brochures to inform
its clients of
program benefits and requirements, and to enable them to provide the
food stamp office with the
information necessary to make accurate eligibility and benefit decisions
regarding their case.
While it is uncertain exactly how many forms and brochures have been
translated and into how
many different languages, we make assumptions based upon anecdotal
information. For
example, from July 1999 through June 2000, California s Department
of Social Services has
21 Characteristics of Food Stamp Households: Fiscal Year 2000. Mathematica
Policy Research, Inc.
22 7 CFR. 273.10.
29 29
29Page 30 31
translated over 3,000 pages of written materials into 24 different
languages. 23 Because in
California the food stamp program is operated at the county, rather
than State level, this does not
represent the total number of documents translated, since some counties
may translate additional
forms. Several State commenters noted that they believed their States
to be in compliance with
Title VI of the Civil Rights Act of 1964, but are not certain about
the scope of obligations under
the Executive Order. Despite having some materials available in some
foreign languages, certain
State commenters suggested that Executive Order 13166 and the accompanying
DOJ guidelines
might require a more systematic approach to the provision of LEP services.
24
California pays approximately $ 73,000 per year to provide written
translations for the
food stamp program. Extrapolating this figure to the national level
yields $ 1.86 million for
written translation. 25 To the extent that California counties also
provide written translation
services in addition to these, written translation costs will be higher.
When calculating oral translation services, we take into account component
costs, such as
the wage differential typically paid to bilingual employees and the
opportunity cost of the
additional time spent with LEP clients that results from the need to
translate conversations
regarding eligibility, benefits, and other program requirements. Assumptions
regarding the mix
of oral translation services provided by each local food stamp office
are necessary. We assume
that 80 percent of eligibility interviews with LEP individuals will
be conducted by bilingual case
workers and that the other 20 percent of interviews will be conducted
via language line
23 Based on data provided by the State of California.
24 Information provided by the State of Texas Department of Human Services.
25 This assumes that the cost of written translation is heavily driven
by the number of languages for which
translation is necessary and that, on average other states will have
to translate documents into half as many
languages as California at half the cost. Therefore, the cost estimate
is ( $ 36,500 x 49 other states) + $ 73,000 = $ 1.86 million for all states.
30 30
30Page 31 32
interpreters. 26 Reports from both Texas and California indicate that
$ 100 per month is a
reasonable estimate of premiums paid to bilingual staff. 27 Since there
is no national data on the
number of bilingual public-contact staff in the Food Stamp Program,
information on bilingual
staff supplied by Orange County, California will be used to extrapolate
to a national estimate. 28
The wage premium is multiplied by the number of staff who receives
such payments in Orange
County, California. 29 Therefore, the total cost of bilingual workers
for the county is
approximately $ 428,000. Given that Orange County contains approximately
5.8 percent of
California s LEP food stamp recipients, extrapolating to the entire
State yields a total of $ 7.4
million. Extrapolating nationally yields a total of $ 21 million for
bilingual premiums. 30
Evidence from California and Texas suggests that additional time is
needed to conduct
eligibility interviews with LEP individuals. This is the opportunity
cost of the eligibility
worker s time. When interpreters/ translators are used, it could take
twice as long to conduct
interviews, due to the need to explain everything to the translator,
who then relays the
information to the LEP individual. 31 Furthermore, a one-hour interview
often takes an additional
fifteen minutes or more, even when using a bilingual worker, because
of the need to explain the
meaning of technical terms and concepts that can be complex and difficult
to translate. In order
to ascertain the opportunity cost of this additional time, we must
determine the time differential
26 This assumption is based on the proportion of costs for language
line and bilingual premium for Orange County,
California and the further assumption that as the Executive Order is
implemented, food stamp offices will find it more cost effective to utilize
bilingual workers.
27 The State of Texas reported that they pay a five percent bilingual
premium on an average monthly salary of
$ 2,017. The State of California reported that they pay $ 100 over
base salary for all certified bilingual workers. 28 In Orange County, California,
bilingual premiums vary by type of public contact staff, and typically
range from
$ 0.40 to $ 1.15 per hour over salary. Based on information that was
provided by the Orange County Food Stamp Office.
29 Using the actual wage premium amounts for each class of public contact
staff, one would obtain $ 428,016 for the
County. Based on information provided by the Orange County Food Stamp
Office. 30 Since California contains 26% of the LEP population that are
over age 18 according to Census data ( as 2000
Census data is not available, we applied a growth factor to 1990 s numbers)
, a national estimate can be obtained by
assuming that California s costs represent 26% of total costs nationally.
31 Based on information provided by local Texas Food Stamp office.
31 31
31Page 32 33
between the time required to interview the average person versus the
time required to work with
the LEP individual. We estimate that it takes an additional 0.8 hours
per LEP individual per
year. 32 If we use Census data and assume that 4.1 percent of the population
speaks English less
than well 33 and that approximately 7.5 million households participate
in the Food Stamp
Program, we would estimate that there are 307,500 Food Stamp heads
of households that are
LEP. 34 Households were used rather than individuals because it is
logical to assume that there
will typically be one individual that interacts with the Food Stamp
office on behalf of the family,
which often consists of young children.
In addition to what would be spent each year on language services,
equipment and
automation expenditures may also be necessary to accommodate the additional
tasks envisioned
to implement Executive Order 13166. For example, Texas estimates that
it will cost
approximately $ 1.2 million to upgrade its automation system to accommodate
the tracking of
language-related information. Once upgraded, the system would be able
to inform systematic
assessments of the language needs of the agency s clientele and the
services provided to them.
Further, additional telecommunications equipment, such as three-way
speakerphones,
may be needed to accommodate oral translation services. This is important
because Texas and
other States rely heavily on telephonic interpreter services for translation.
These may cost from
$ 200 to $ 400 per phone. Because these costs are ad hoc in nature
and may vary widely, they
32 Assumes two interviews per LEP food stamp recipient household per
year. Each interview averages one hour for
non-LEP applicants. 33 One of the questions on the decennial Census
asks for the respondent s ability to speak English, allowing four
responses: very well, well, not well, and not at all. According to the
Census survey data, approximately 4.1% of the
population, or about 10.4 million people, speak English less than well,
and approximately 7.65 percent of the United States population, or about
20 million people, report speaking English less than very well.
34 Based on FY 2000 administrative data from the Food and Nutrition
Service. Also, households were used rather
than individuals because it is logical to assume that there will typically
be one individual that interacts with the food stamp office on behalf of
the family.
32 32
32Page 33 34
have not been factored into the national food stamp estimate. Below
is a summary of the costs
determined thus far.
Figure 2.1: Food Stamp/ TANF Language Assistance Services and Costs
Service Explanation of Cost Cost/ Year Written
Materials Average annual written translation costs: $ 1.86 million
35 $ 1.86 million
Oral Translation
Services ( Additional
Cost to Govt. of LEP
Interaction)
Bilingual wage premium: $ 21 million 36
Language line expenditures: $ 2.3 million 37
Opportunity cost: $ 2.6 million
$ 23.3 million
National Cost Estimate 38 Cost of written materials: $ 1.86 million
Cost of oral translation services: $ 23.3 million
Total cost = $ 1.86 million + $ 23.3 million = $ 25.2 million
$ 25.2 million
Opportunity costs = $ 2.6
million
35 This assumes that the cost of written translation is heavily driven
by the number of languages for which
translation is necessary and that, on average, other states will have
to translate documents into half as many languages as California at half
the cost. Therefore, the cost estimate is ( $ 36,500 x 49 other states)
+ $ 73,000 =
$ 1.86 million for all states. 36
Based on Orange County s cost for bilingual workers of $ 428,016 extrapolated
by Orange County s share of the LEP population in California ( 5.8% ) =
$ 7.4 million for California and $ 28.4 million nationally. County costs
include 112 bilingual staff at an additional $ 2,392 per year, 175 bilingual
staff at an additional $ 1,248 per year, and
151 bilingual staff at an additional $ 828 per year. 37 Based on California
information obtained from California and Orange County. Uses Orange Co.
s cost of
providing language line services for LEP individuals in the food stamp
and CalWorks programs ( $ 49,000) to serve
approximately 5.8% of California s LEP individuals. When this number
is extrapolated, we obtain an estimate of $ 844,827 for the State ( $ 49,000/
5.8% ) and $ 3.2 million for the nation ( $ 844,827/ 26% ) . 26% represents
California s
percentage of the LEP population over age 18 for 2000. 38
In addition to the annual cost of providing language services, some
States and localities will incur additional costs to upgrade their computer
systems and purchase additional equipment. For example, Texas commented
that they
plan to spend approximately $ 1,240,000 to upgrade their computer system
to be able to identify LEP clients and the
languages they speak. Also, California commented that additional speakerphones
were needed in some offices at a cost of $ 190 each in order to accommodate
interpreter line services. In addition to the annual cost of providing
language services, some States and localities will incur additional
costs to upgrade their computer systems and
purchase additional equipment. For example, Texas commented that they
plan to spend approximately $ 1,240,000 to upgrade their computer system
to be able to identify LEP clients and the languages they speak. Also,
California
commented that additional speakerphones were needed in some offices
at a cost of $ 190 each in order to
accommodate interpreter line services.
33 33
33Page 34 35
To estimate the costs of providing language assistance in the Food
Stamp program, one
would have to make assumptions about the following:
Baseline level ( level of services already provided to non-English
speakers prior to
implementation of Executive Order 13166) ; and
Level of services contemplated by Executive Order 13166.
Assuming that no local Food Stamp offices have yet made any effort
to make their services
accessible to LEP individuals, costs could total approximately $ 25.2
million. This cost estimate,
however, does not reflect the level of language-assistance services
that are already being
provided, nor does it quantify the efficiencies associated with the
widespread practice of
interviewing applicants for Food Stamps to determine their eligibility
for multiple assistance
programs ( e. g. , TANF and Medicaid) at the same time. To the
extent that the Food Stamp
households included in the numbers presented in this analysis also
applied and were interviewed
for other program eligibility determinations, this would represent
a significant cost efficiency.
These factors could reduce the overall estimate considerably.
Enforcement of the Food Stamp regulatory requirement that local offices
provide
bilingual services when the local LEP population achieves five percent
of the overall population
may have been hampered by the lack of systematic means to determine
the size and proportion of
LEP individuals in a service area. Rather, State and local offices
may make these decisions on
an ad hoc basis, perhaps a result of lawsuits or complaints.
Case Study III: Immigration
Historical INS Accommodations Provided to LEP Individuals
34 34
34Page 35 36
In 1999, INS conducted over 2 million interviews and inspected over
520 million people.
Although INS does not have data on how many of these individuals were
considered LEP, INS
estimates that a majority of these individuals came from either English
or Spanish-speaking
countries.
The costs of providing language assistance in all INS services for
individuals, regardless
of English language ability, could be substantial. INS provides a spectrum
of services to
individuals in the United States, ranging from asylum proceedings to
interviews for
naturalization to processing of petitions at local service centers.
A significant number of the
agency s clients, who may speak one of over 50 different languages,
are likely to be LEP
individuals.
Currently, INS utilizes a translation service to provide both telephonic
and on-site
translation for its customers. Total telephonic translation, including
translations taking place in
airports and during asylum proceedings, were $ 1.4 million dollars
in 2001. In addition, INS
provides a customer help line to provide immigration and other related
information. INS receives
between 600,000 and one million phone calls per month at its National
Customer Service Center.
Customers can ask for assistance in either English or Spanish. About
25 percent of callers opt
for assistance in Spanish. 39 In October and November 2001, 8.54 percent
of callers indicated
that they called for someone other than themselves ( e. g. ,
a family member or client) and, of this
group, 15.25 percent indicated they called for that other person because
he/ she was not fluent in
English or Spanish. 40 In total, therefore, 25 percent were Spanish
speakers and 1.3 percent
( 15.25 percent of the 8.54 percent) were calls placed in English or
Spanish for customers who
39 This number is the cost of translation services contracted out to
the Language Services of America, an outside
translation service who provides the largest percentage of contracted
translation services to the INS. 40 Memo from INS official Michael Aytes
dated 12/ 27/ 01.
35 35
35Page 36 37
spoke neither English nor Spanish. 41 Languages of greatest use, in
addition to English and
Spanish include Hindi, Chinese, Tagalog and Arabic, with each representing
on average 2% of
all calls. With an average daily volume of about 40,000 calls, this
represents between 1,200 and
4,000 calls per day in each of these four languages.
As an example, consider one INS regional office. The New York District
Office houses
an interpreter pool of over 120 permanent, intermittent and as-needed
translators. These
government employees provide a 24-hour/ day service at a cost of between
$ 14.22 and $ 26.04 per
hour. Contracted on-site interpretations supplement these efforts and
are provided for credible
fear and reasonable fear 42 interviews at a cost of approximately $
2 million annually. INS
estimates the cost of providing interpreters at asylum interviews at
$ 3.5 million per year. This
calculation is based on the current telephonic interpretation contract
with Language Service of
America, under which telephonic interpreter services cost $ 1.79/ minute.
The average asylum
interview is one hour in length; thus, the average cost of providing
an interpreter to an asylum
interview is $ 107. If the number of interviews per year remains at
36,000, and approximately 90
percent of applicants require interpreters, then at the current contract
prices, this cost would total
$ 3.5 million. 43
INS could incur further costs if it translated all forms into the languages
of the LEP
individuals it serves. INS has estimated that given its 123 public-use
forms, translation costs
fluctuate between $ 189.00 and $ 214.00 per document. 44 INS currently
has 11 forms translated
41 Memo from INS official Michael Aytes dated 12/ 27/ 01.
42 Memo from INS official Michael Aytes dated 12/ 27/ 01.
43 Memo from Michael Cronin to Merrily Friedlander, Chief, Coordination
and Review Section ( DOJ) dated
11/ 2/ 00. 44
Memo from Michael Cronin to Merrily Friedlander, Chief, Coordination
and Review Section ( DOJ) dated 11/ 2/ 00.
36 36
36Page 37 38
into several different languages ( see Figure 2.2) ; the decision to
translate a document is made on
a case-by-case basis.
Further, all immigration inspectors, detention officers, and deportation
officers are taught
Spanish as part of their officer training. Immigration inspectors and
deportation officers, as well
as special agents and border patrol officers must be fluent enough
to pass a Spanish language test
as a condition of employment.
Figure 2.2: Translated INS Public-Use Forms 45
Form No. Title Foreign Languages
AR-11 Alien' s Change of Address Card Spanish, Chinese, Korean
I-9 Employment Eligibility Verification Spanish I-90 Application to
Replace Alien Registration Spanish, Arabic, Chinese
I-94 Arrival/ Departure Document Arabic, Chinese, Creole, Danish, Dutch,
French, Icelandic, Italian,
Spanish
I-94W Nonimmigrant Visa Waiver Arrival/ Departure Document Arabic,
Chinese, Icelandic, Italian, Japanese, Spanish,
Swedish I-539 Application to Extend/ Change Nonimmigrant
Status Spanish, Chinese, Korean, Vietnamese, Russian
I-539A Supplement A to Form I-539 Filing Instructions for V Nonimmigrant
Status Spanish, Chinese, Korean, Vietnamese, Russian
I-695 Application for Replacement for Form I-688A Employment Authorization
or Temporary
Residence Card
Spanish, Chinese, Korean, Vietnamese, Russian
I-765 Application for Employment Authorization Spanish, Chinese, Korean,
Vietnamese, Russian
I-821 Application for Temporary Protected Status Spanish I-823 Application
-Alternative Inspection Service French, Spanish
I-855 ABC Change of Address Form Spanish
In addition to formal interactions with the public, INS conducts community
outreach as a
way to educate the public on immigration procedures and issues. INS
has implemented a
community relations program in districts and sectors throughout the
country. Community
45 Translated as of December 2001
37 37
37Page 38 39
Relations Officers ( CROs) , particularly in areas with high immigrant
populations, serve as a
consistent point of contact for community groups, and meet regularly
with external entities to
identify immigration or INS-related issues or problems. CROs also identify
local community-
based organizations that work with or represent potential INS customers,
and disseminate
information to grassroots community groups. The program is in the process
of producing simple
English versions of INS materials and translating them into appropriate
languages. The INS also
houses a staff with both English and Spanish language ability in the
press office. The bilingual
staff ensures that the Spanish-speaking community is kept apprised
of immigration issues,
information, and announcements. There is minimal translation of information
available online at
INS s website.
Costs of serving LEP individuals affect four areas within INS: ( 1)
Adjudications; ( 2)
Asylum Proceedings; ( 3) Detention and Removal Proceedings; and ( 4)
Inspections.
Adjudications are determinations made regarding an individual s adjustment
of status or
naturalization. Asylum proceedings include asylum interviews to determine
whether there is a
credible fear or reasonable threat to an individual s welfare to warrant
asylum in the United
States. Detention and removal proceedings occur to determine whether
an individual is
unlawfully in the United States and should be removed from the country.
Inspections occur at
points of entry into the country, which include national borders and
airports.
The Houston INS Field Office Example 46
Data on costs associated with these four areas within INS is not available.
This report
focuses on field office operations, which deal primarily with adjudications
and asylum issues.
46 Data is based on estimates provided by Roger Piper, Acting District
Director, and Mariela Melero, Executive
Liaison Officer, 12/ 18/ 01.
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38Page 39 40
The population served by Houston represents approximately two percent
of the total LEP
population nationwide. In conjunction with services provided by INS
headquarters, such as the
translation of 18 forms into several languages, and a national customer
service call center, with
services in both English and Spanish, the Houston field office employs
a 40 percent bilingual
staff. Individuals with language ability other than English are proficient
in Spanish, Chinese,
Vietnamese, German, Urdu, Korean, and French. No additional compensation
is given to
individuals with bilingual abilities and the Houston office utilizes
both on-and off-site
translation contracted services, in the event that a bilingual staff
member is unable to
accommodate an LEP individual. These contracted services are not used
frequently, because
Houston has the capacity to deal with most of their LEP clients through
their bilingual staff.
In addition, the Houston office has an agreement with the local media
to provide
immigration and naturalization information to the public. INS publishes
a weekly Spanish
column in the local newspaper, in addition to broadcasting a weekly
radio show in Spanish on a
local station and an informational television program on a Hindi-broadcast
television network.
There are no production costs to INS for the broadcasting or publication
of these materials, as the
local media feels that this is a service that its listening audience
wants and needs. The Houston
office employs an Executive Liaison to the public, who coordinates
its public information
efforts.
Immigration Costs on a National Level
In the United States, there are five languages ( in addition to English)
in which greater
than two percent of the general public is proficient. These languages
are Spanish, Chinese,
French, Korean, and Vietnamese. Assuming that these languages are the
focus of most oral and
39 39
39Page 40 41
written translations, at an average translation cost of $ 200.00 per
form per language, translation
of all 123 forms into five additional languages would amount to $ 147,600,
assuming that no
additional demand for forms would be incurred. This cost would therefore
not be annual, but
instead a one-time cost after which there would be minimal translation
costs.
INS has provided cost estimates. For fiscal year 2001, INS conducted
61,958 asylum
interviews. The asylum program office estimates that approximately
90% of applicants require
interpreters, therefore calling for 55,762 instances where interpretation
services would be used.
The average asylum interview is one hour, with a cost per minute of
translation of $ 1.79. With an
average cost for providing an interpreter calculated at $ 107 per individual
per hearing, the total
cost each year for asylum proceedings is estimated at $ 5,966,534.
INS currently has bilingual
staff in its field offices, detention and removal centers, and ports
of entry. If 60% to 70% of cases
could be accommodated by these bilingual employees, where no premiums
are given for
multilingual language skills, the costs of providing these services
would be reduced to between
$ 1,789,960 and $ 2,386,613. 47
In the adjudications arena, approximately 2 million interviews were
conducted in the
2001 fiscal year. The adjudications program office estimates that approximately
90% or 1.8
million applicants require interpreters. With an average interview
time of one hour, and cost per
minute of translation at $ 1.79, the approximate cost is $ 107 per
interview. The total cost of
providing translation services for adjudication proceedings, therefore,
is estimated at
$ 192,600,000. If 60% to 70% of these translations could be provided
by bilingual employees,
47 It is also possible that INS would have individuals whose sole responsibility
was to provide interpretation
services. For the purposes of calculating an estimate, we assumed that
either employees would be bilingual or the
$ 1.79 per minute translation line would be used. The cost for hiring
in-house interpreters would therefore fall between these two alternatives.
40 40
40Page 41 42
then the cost of contracted translation services would range between
$ 57,780,000 and
$ 77,040,000.
Individuals most frequently interact with the Immigration and Naturalization
Service for
inspections purposes at ports of entry. In fiscal year 2001, there
were 510.5 million persons who
underwent primary inspections. An additional 8.8 million individuals
were referred to secondary
inspections for administrative reasons. We assume that 88,715 non-administrative
inspections,
with a duration of one and a half hours, could require interpretation
services. At $ 1.79 a minute
for translation services, the cost of providing language assistance
is estimated at $ 14,194,400. If
60% to 70% of these translations could be provided by bilingual employees,
then the cost of
contracted translation services would range between $ 4,258,320 and
$ 5,677,760.
In the detention and removals sector, in fiscal year 2000, there were
161,572 total
removals. Voluntary departures for fiscal year 2001 have amounted to
1,249,798 48 with aliens
processed for removal under safeguard reaching 1,246,207 49 . Total
detentions in fiscal year 2001
have reached 32,865. 50 INS acknowledges that it is difficult to estimate
the amount of time
required to conduct interviews for each of the detention and removal
actions. Sufficient time to
process an interview for a removal may take up to two hours, whereas
an interview for a non-
docket controlled voluntary departure may only require half an hour.
As a result, INS s estimate
for interpreter services assumes one hour of interpreter services for
each action in this sector. In
addition, INS has based its calculations on the premise that half of
all interviews require full
interpreter services, assuming that a large proportion of individuals
in these categories either can
48 This number includes voluntary departures under docket control (
relief from deportation granted by a judge or a
district director) and non-docket control. 49 This represents the number
of aliens who depart the United States after having been apprehended more
than 72
hours after entry. 50
This number represents a snapshot of aliens in detention at the end
of fiscal year 2001. The figure includes individuals both in proceedings
and those held both in INS and non-INS facilities.
41 41
41Page 42 43
speak English proficiently or can be assisted by an available INS bilingual
employee. At $ 107 an
hour 51 , the total cost of interpreter services is estimated at $
145,008,647. 52 If 60% to 70% of
these translations could be provided by bilingual employees, then the
cost of contracted
translation services would range between $ 43,502,594 and $ 58,003,458.
Figure 2.3: INS Costs -National Estimates
National Estimates provided by INS
Headquarters
Translation of Documents $ 147,600 translation cost for existing documents
National Call Center $ 6,900,000 53
Asylum Interviews Interpreter Services $ 1,789,960 -$ 2,386,613
Adjudications Interviews Interpreter Services $ 57,780,000 -$ 77,040,000.
Inspections Interviews Interpreter Services $ 4,258,320 -$ 5,677,760
Detention and Removal Interpreter Services $ 43,502,594 -$ 58,003,458
Total $ 114,230,874 -$ 150,007,831
annually plus $ 147,600 one time translation form costs
It is important to note the limitations of this cost estimate. First,
it assumes that there are
only five languages in need of oral translation. Second, the use of
interpreter services, both on-
51 Based upon the translation cost of $ 1.79 per minute, assuming a
one hour interview.
52 $ 107* [ 181,572+ 1,249,798+ 1,246,207+ 32,865 ] * 50% .
52 The National Customer Service Center provides toll free assistance
in both English and Spanish. It is estimated
that this is accessed 1.5 million times by callers nationwide, costing
$ 23,000,000 annually. At the time of publication,
INS did not have data on the number of calls made in English and in
Spanish. If 60% of these calls are
made in English, the cost of providing this customer service line in
Spanish would be $ 6,900,000.
42 42
42Page 43 44
and off-site, has not been incorporated into the cost figures. The
cost of bilingual staff is not
reflected in these cost estimates because no premium is offered for
bilingual ability, though these
individuals do provide translation services and may save INS a substantial
amount in additional
contracted translation services. Third, the alternative of hiring employees
to serve solely as
translators was not explored in this cost analysis. This alternative
may significantly mitigate
costs by reducing the need to use contracted translators. Compensation
for in-house translations
is far less than contracted individuals, with hourly rates of on average
$ 26, compared to a
contracted cost of $ 107 per hour. A fourth limitation of this analysis
is the reality of individuals
who bring friends and family to provide translation services for them.
As a result, the cost
estimates as presented may be an inflation of the true fiscal burden
that could be incurred.
Currently, INS has data on the number of individuals processed through
each of the main
areas of focus; however, data documenting the number of LEP individuals
processed as a
proportion of the total population served is unavailable. At this time,
INS is unable to estimate
the number of LEP individuals it currently serves.
Case Study IV: Healthcare
Medical Care
Almost all healthcare providers are required to provide appropriate
services to LEP
individuals. Hospitals currently are required to provide appropriate
services to LEP individuals
under the HHS Culturally and Linguistically Appropriate Services (
CLAS) standards published
in 2000 54 , the Title VI regulations, and the Joint Commission on
Accreditation of Healthcare
54 HHS s CLAS standards were issued by the Office of Minority Health
within the Office of Public Health and
Science, within HHS Office of the Secretary, , and are based upon the
requirements of Title VI of the Civil Rights
Act of 1964, as well as other State and Federal laws. Some of the standards
( that are based on Title VI) are
mandatory for those receiving federal funds, while others are suggested.
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43Page 44 45
Organizations ( JCAHO) standards of care. Most outpatient hospital
clinics, community health
centers ( CHCs) , and private doctors offices receive some funds from
Medicare/ / Medicaid
billing. Both the Title VI regulations and the CLAS standards on provision
of LEP services
would apply to these types of providers. Some Centers for Medicare
and Medicaid Services
( CMS) programs ( such as State Children s Health Insurance Program
[ SCHIP ] , and Medicaid)
may cover interpretation services.
Interpretation Services in the Healthcare Context
Throughout the country, there have been different efforts by healthcare
providers to
provide quality interpretation services to LEP individuals.
Some hospitals, managed care organizations ( MCOs) , and providers
offer a salary
premium to their bilingual medical staff. Others do not offer a salary
increase, but they
still attempt to recruit bilingual staff from the community.
Some medical schools, hospitals, and MCOs offer language classes to
physicians and
other medical personnel to allow them a sufficient ability to converse
with the LEP
individuals with which they most often come into contact. 55 These
classes focus on
obtaining the language abilities necessary to converse in a medical
setting, as opposed to
attempting to make the provider fully fluent for all settings. Studies
such as Hampers et
al have found that physician language-training programs resulted in
a decreased use of
outside interpreters, better medical histories obtained from the patient,
and increased
overall patient satisfaction.
Non-profit organizations in some metropolitan areas have started language
banks that
recruit, train, and schedule interpreters in a variety of languages
for doctors, hospitals,
55 ( Binder, Nelson, 1988; Hampers) .
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44Page 45 46
and other providers that need their services. The administrative costs
are borne by the
language bank themselves, and services are provided for a nominal fee.
Anecdotal
evidence, provided in listening sessions with advocates for LEP individuals,
suggests that
the average charge for this service runs at about $ 20 per hour. No
studies have been
performed to determine use or availability of these language banks
or actual cost.
Some hospitals, MCOs, and university groups have organized volunteer
interpreter
services. Mainly staffed by bilingual individuals from the community
or university staff
and students, many of these groups provide instruction on interpretation
( including
terminology that a bilingual individual would not necessarily know,
principles of
confidentiality, etc. ) .
Some facilities use remote simultaneous interpretation instead of traditional
interpretation services such as having an interpreter physically present
in the room or
using a language line where an interpreter is available through a phone
service. With this
method, both the provider and patient are wearing headsets, and interpretation
occurs
almost immediately as the other participant speaks.
Costs of Providing Services
We estimate below the costs of interpretation for LEP individuals for
ER visits, inpatient
hospital visits, and outpatient physician visits. The overall estimate
does not include costs to
non-physician providers such as physical or occupational therapists,
chiropractors, or mental
health professionals except psychiatrists. It does not cover care that
is not provided in an ER,
hospital, or office visit ( including phone call consultations) . It
also does not cover fixed-cost
translations of forms and hospital signs.
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45Page 46 47
It is important to note that we are estimating the costs of services
that might be provided
regardless of the ultimate payer. In many cases, the costs fall on
the individual provider, clinic,
or hospital, with little or no reimbursement from insurance providers
or government programs.
We assume that the costs will generally be the same regardless of who
bears it. It should also be
noted that we are not making any particular judgments about what a
given agency s guidance
should provide, although ( as later discussed) we believe that consistency
and uniformity in
agency guidance may be critical to reducing costs.
It is difficult to estimate the breakdown of interpretation services
that could be or are
being used in an average hospital, clinic, or private office. However,
we can make some
assumptions based on anecdotal evidence from physicians, hospitals,
and medical advocacy
groups to use in calculating average costs for each healthcare sector.
These assumptions differ
based on the site of care. Some hospital emergency departments, inpatient
units, and on-site
clinics may have an infrastructure that allows staff interpretation
in a majority of cases, either by
medical staff or by a centralized interpretation office that employs
professional medical
interpreters. Many community health centers ( CHCs) serve distinct
low-income communities,
and often employ staff from those communities. It may be possible that
those CHCs serving
areas that have a moderate or high level of LEP clients are providing
staff interpreters in a high
proportion of their LEP cases. However, doctors offices may not have
bilingual staff or staff
interpreters unless they are serving a very high volume of LEP individuals
from one language
group. We assume that some individuals will request that a friend or
family member serve as the
interpreter instead of requesting a professional interpreter.
It is possible at hospitals, community healthcare centers, and private
offices that
translation services could be provided by medical staffs, professional
interpreters, a language
46 46
46Page 47 48
bank, volunteer interpreters, friends or family, or commercial language
line services. . Each of
these interpretation services has a different cost associated with
it. Providers will not incur
additional costs based on the interactions of LEP individuals with
trained medical staff that are
( at least functionally) bilingual, except in those cases where the
staff are paid a premium for their
bilingual skills. This is because these staff would have been interacting
with the individual based
on their main duties regardless of whether or not the patient was LEP.
Professional interpreters
on staff will be paid an hourly wage ( anecdotal evidence suggests
that this wage is about
$ 20/ hour) that would not be incurred in the normal course of business.
In addition to their hourly
wage rate, these staff interpreters will receive benefits, such as
health insurance, which we
estimate to be worth 30 percent of their salary, bringing the overall
hourly cost of these
translators to $ 26. Language banks run by non-profit firms also have
a cost of $ 20 per hour,
based on anecdotal evidence. The language line cost varies, depending
on the monthly usage
and the negotiated contract price ( if the provider has entered into
a contract with the provider) .
We have estimated that the average cost for this service could be $
132 per hour, but it could be
less depending on the volume and duration of interpretation services
needed.
Given these assumptions about the types of services that will be used
to provide
interpretation and the costs of those services, one may apply the assumptions
to the data at hand
for the various healthcare sectors that are examined. Again, we note
that these estimates do not
imply a particular LEP obligation in a particular setting. Instead,
they simply summarize
possible costs if the described assistance is provided.
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47Page 48 49
Emergency Room Visits
There were 103 million visits to the Emergency Room in 1999. 56 Assuming
an LEP
population of approximately 4.1 percent of the total population, 57
this would translate to
approximately 4.2 million individuals served. Further assuming an average
interaction time in
the ER of 10 minutes ( that is, the time spent actively interacting
with hospital staff, which would
need to be translated, as opposed to time spent in the waiting room)
yields a rough estimate of
704,000 hours of interaction time with LEP individuals in the emergency
room. Given the
assumptions about the breakdown of interpretation services above, the
following costs might be
possible:
Figure 2.4: Cost of LEP Services for ER Visits
Visit Explanation of Cost Cost ER Visits For 704,000 hours of
LEP interactions in the ER:
50% medical staff = No cost
10% staff interpreters at $ 26 per hr = $ 1.8 million 15% language
bank at $ 20 per hr = $ 2.1 million
5% language line at $ 132 per hr = $ 4.6 million
10% volunteer interpreters = No cost to hospitals ( see below)
10% friends and family = No cost to hospitals ( see below)
$ 8.6 million costs to hospital
Therefore, the overall costs of providing interpreter services for emergency
room visits
might be as much as $ 8.6 million for hospitals. It is important to
note that this estimate does not
include the opportunity costs to volunteers, , friends, or family members
who might accompany
and help LEP persons understand their healthcare situation. We do not
estimate these
56 National Center for Health Statistics Ambulatory Health Care Data.
17 August 2001. National Center for Health
Statistics. http: / / www. cdc. gov/ nchs/ about/ major/ ahcd/ ercharts/
htm. 57 See footnote 33.
48 48
48Page 49 50
opportunity costs here, , but suspect they could be sizable in the
aggregate. They would,
however, be offset to the extent that the volunteer, friend, or family
member would have
accompanied and helped the individual, regardless of the need for language
assistance.
Obviously, changes in any of the assumptions underlying these calculations
would affect the
estimated cost of providing interpreter services for LEP emergency
room visits.
Inpatient Visits
There were 32 million inpatient admissions in 2000, with an average
stay of 4.9 days. 58 We
assume an aggregate of one hour of daily interactions with medical
staff that would necessitate
an interpreter ( including services such as rehabilitation, nutrition,
and social work) . This
assumption of one hour of essential interactions would translate to
6.4 million hours of
interpreted interactions with LEP individuals in the inpatient hospital
units, assuming that the
LEP population is 4.1 percent of the total population. 59
Again, given the assumptions about the interpretation services provided
in a hospital
setting, the following estimations can be made:
Figure 2.5: Cost of LEP Services for Inpatient Visits
Visit Explanation of Cost Cost Inpatient
Hospital Visits For 6.41 million hours of LEP interactions in the inpatient
units: 50% medical staff = No cost
10% staff interpreters at $ 26 per hour = $ 16.7 million 15% language
bank at $ 20 per hour = $ 19.2 million
5% language line at $ 132 per hour = $ 42.3 million
10% volunteer interpreters = No cost to hospitals 10% friends and family
= No cost to hospitals
$ 78.2million costs for hospital
58 National Center for Health Statistics Ambulatory Health Care Data.
17 August 2001. National Center for Health
Statistics. http: / / www. cdc. gov/ nchs/ about/ major/ ahcd/ ahcd1/
htm. 59 32 million inpatient admissions times 4.9 days times 4.1% LEP =
6.4
49 49
49Page 50 51
Therefore, the costs of providing services for inpatient hospital visits
could be $ 78.2
million for hospitals. Again, this figure does not incorporate an estimate
of opportunity costs for
assistance provided by volunteer interpreters, friends or family members.
Outpatient ( Office-based) Visits
There were 921.4 million visits to outpatient providers, 60 which translates
into 37.8
million visits by LEP individuals. One may assume that the doctor/
patient interaction needing
interpretation averaged about ten minutes or less. The breakdown of
interpretation services will
differ based on the type of provider. Many minorities and low socioeconomic
status individuals
are served by community health centers. As previously mentioned, many
of these are actually
chartered to target a certain type of population. For example, we talked
to providers at a
Community Health Center in San Francisco whose primary patient base
was Asian. They
provided comprehensive services for multiple Asian languages, mostly
using bilingual staff. We
assume that approximately 20 percent of LEP individuals go to CHCs,
15 percent go to
outpatient clinics affiliated with a hospital, and 65 percent go to
private physicians.
Overall, there are 6.3 million hours of LEP interactions for outpatient
visits. 61 Given the
breakdowns above, Community Health Centers will have 1.3 million hours
of LEP interactions
annually, outpatient hospital clinics will have 0.95 million hours
of interactions, and private
providers will have 4.1 million hours of interactions.
Again, given the assumptions about the types of services that will
be used for
interpretation in each of these different healthcare settings and the
breakdown of the settings for
outpatient visits, the following calculations can be made:
60 National Center for Health Statistics Ambulatory Health Care Data.
17 August 2001. National Center for Health
Statistics. http: / / www. cdc. gov/ nchs/ about/ major/ ahcd/ outpatientcharts/
htm. 61 921.4 million visits times 4.1% LEP times 10 minutes divided by
60 = 6.3
50 50
50Page 51 52
Figure 2.6: Cost of LEP Services for Outpatient Visits
Visit Explanation of Cost Cost Outpatient
Visits to CHCs For 1.3 million hours of LEP interactions: 65 percent
medical staff = No cost
5% staff interpreters at $ 26 per hour = $ 1.6 million
5% language bank at $ 20 per hour = $ 1.3 million 5% language line
at $ 132 per hour = $ 8.6 million
10% volunteer interpreters = No costs to CHCs 10% friends and family
= No cost to CHCs
$ 11.5 million cost to CHCs
Outpatient Visits to
Hospitals
For 0.95 million hours of LEP interactions:
50% medical staff = No cost 10% staff interpreters at $ 26 per hour
= $ 2.4 million
15% language bank at $ 20 per hour = $ 3.0 million 5% language line
at $ 132 per hour = $ 7.1 million
10% volunteer interpreters = No cost to hospitals 10% friends and family
= No cost to hospitals
$ 12.4 million cost to hospitals
Outpatient visits to
private providers
For 4.1 million hours of LEP interactions: 25% medical staff = No cost
5% staff interpreters at $ 26 per hour = $ 5.3 million 20% language
bank at $ 20 per hour = $ 16.2 million
25% language line at $ 132 per hour = $ 135.4 million 15% volunteer
interpreters = No cost to providers
10% friends and family = No cost to providers
$ 156.9 million cost to providers
Therefore, the costs of providing services for outpatient physician
visits could total as
much as $ 180.8 million for providers, and $ 29.1 million in opportunity
costs to those providing
free services. Again, this figure does not incorporate an estimate
of opportunity costs for
assistance provided by volunteer interpreters, friends or family members.
51 51
51Page 52 53
Possible Cumulative Costs of the Four Healthcare Sectors
Given the calculations of the four healthcare sectors, the possible
cost to providers of
providing interpretation services to LEP individuals might reach as
much as $ 267.6 million.
This cost does not include translation of forms into multiple languages,
although such cost is
likely to be small compared to the total costs estimated. We emphasize
that this a very rough
estimate and does not account for the fact that many healthcare facilities
have already taken
substantial steps to address LEP issues.
Summary of Case Studies
The four case studies above reflect four different economic sectors.
Many assumptions
were necessary to arrive at the cost estimates above. Added together,
the costs of the efforts
outlined for all four case studies sum to $ 538 million, which could
represent a significant portion
of the total costs of providing language assistance to LEP persons.
3. Aggregate National Estimate
We now turn to a top-down approach for estimating the total costs.
The Executive Order
affects two major aggregate categories: the public sector, which includes
Federal, State, and
local government and Federal funding recipients, with the largest easily
being the healthcare
sector. 62 Using various assumptions, one may estimate the amount of
government and healthcare
services provided to LEP persons. Based on the sector analyses included
in this report, we
develop a range of estimates for the extra cost of serving LEP persons
and apply this additional
cost to an estimate of the cost of the proportion of government and
healthcare services consumed
62 While there are funding recipients in a wide variety of fields, the
public comments and our own research indicated
that the costs to the healthcare sectors will greatly exceed the cost
of all other sectors combined.
52 52
52Page 53 54
by LEP persons. This approach yields estimates that are not limited
to specific programs or
communities.
Federal, State, and Local Government
General government represents about $ 1.14 trillion of GDP. This number
represents the
compensation of general government employees ( including Federal, State,
and local) plus
general government consumption of fixed capital. 63 Assuming that,
based on Census survey
data, about 4.1 percent of the population may qualify as LEP, 64 their
share of government
services ( assuming they receive the same level of service as the average
person) is roughly $ 46.7
billion.
Additional Cost of Serving LEP Persons
Given the limited amount of data and information currently available,
it is difficult to
accurately assess the additional cost involved with providing adequate
access to LEP persons
( the LEP premium ) . We have used the information available from the
transportation, health,
welfare, and immigration sector estimates to generate a range of incremental
cost percentages. 65
As a general approach, we attempted to estimate the total cost to administer
a program or service
per person and the corresponding cost for language services per LEP
person. Figure 2.7
illustrates how we used this approach to calculate an LEP premium and
demonstrates the steps
taken for this calculation. Applying this general approach to the DMV,
Healthcare, and Food
63 Economic Report of the President, February 2002.
64 See footnote 34.
65 Note that the California DMV also provided information on bilingual
pay premiums, which can be used as an
estimate for LEP premiums. The California DMV pays certified bilingual
employees a $ 100 per month pay
differential. Since the average salary of state and local employees
is about $ 61,000 per year, the $ 100 premium represents a 1.8 percent
premium.
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Stamp sectors, we estimate the LEP premium might range from 0.5 to
15 percent ( see Figure
2.8) . It is important to note that in these calculations, that no
language assistance services are
provided to LEP individuals.
Figure 2.7: LEP Premium Cost Calculation-DMV Example
LEP Premium Cost Calculation: DMV Example
Step 1: Calculate Cost Per Public Contact
California DMV Budget: $ 688 million
Number of Public Contacts: 274 million
Cost Per Contact = $ 688 million / 274 million = $ 2.51
Step 2: Calculate Additional Cost Per LEP Contact
DMV Expenditure on Language Services: $ 2.2 million
Number of LEP Contacts: 52 million
Additional Cost Per LEP Contact = $ 2.25 million / 52 million = $ 0.042
Step 3: Calculate LEP Premium by Dividing Additional Cost Per LEP Contact
by Cost Per Contact
LEP Premium = $ 0.042 / $ 2.51 = 1.7 Percent
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Figure 2.8: Summary of Sector LEP Service Premium: Additional Cost
of Services Per LEP Recipient
Sector Estimate Percentage Cost Increase 66
Department of Motor Vehicles 1.7
Food Stamp Program 15.0
Immigration and Naturalization Service See below 67
Healthcare 0.5
Motor Vehicle Administration: The cost for the California DMV to provide
services to all
constituents was about $ 687,262,000 for the current year. The DMV
spends about $ 2.2 million
per year on language services. Based on biennial language survey data,
the California DMV
estimates that there are 273,684,211 public contacts per year. Of these
contacts, about 52 million
( about 19 percent of total contacts) are public contacts with LEP
persons. By dividing total costs
by total public contacts, we estimate that it costs the DMV about $
2.51 per contact. It costs an
additional 4.2 cents ( $ 2.2 million / 52 million) per LEP contact,
which corresponds to a 1.7
percent premium ( 4.2 cents / $ 2.51) .
66 The reader might notice that the estimated LEP premium in the healthcare
and motor vehicle sectors is lower than
the food stamp program premium. This difference is likely attributable
to how the premiums were calculated. The DMV and healthcare estimates compared
the incremental costs of providing services to LEP persons to the entire
budget or expenditure in the program or sector. The food stamp estimate
compared the cost of LEP services to the
administrative costs of the program, which is a smaller base compared
to the entire budget or expenditure in the program or sector. ( 2) The
difference in the nature and intensity of interactions with the public.
In the DMV
example, interactions are relatively short and uncomplicated. On the
other hand, in the food stamp example,
interactions are much longer and involve the exchange of complex financial
and personal information. Rather than being representative of government
interaction with the public, these two examples likely represent two extremes,
within which most public interactions would fall. 67 Although included
in our case studies, INS has not been included in our calculation of a
national estimate as it is
less representative of government services because it serves such a
disproportionate number of LEP individuals due to its large number of interactions
with the immigrant community.
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Healthcare: Again, we estimate that our economy spends about $ 1.38
trillion per year on
healthcare ( 13.5 percent of GDP * GDP) . Based on data from the National
Hospital Ambulatory
Medical Care Survey, NHDS, NAMCS, and the NAHMCS, there are approximately
1,611,400,000 ER visits, inpatient hospital visits, outpatient physician
visits, and dental visits.
Healthcare costs are approximately $ 856 per visit ( $ 1.38 trillion
/ 1,611,400,000 visits) . 68 Using
the data from our healthcare sector discussion, we estimate that healthcare
providers could spend
up to $ 267.6 million on language services for approximately 66.1 million
ER visits, inpatient
hospital visits, outpatient physician visits, and dental visits by
LEP persons. This represents
about $ 4.04 per visit ( $ 267 million / 66.1 million visits) . This
is a 0.5% ( $ 4.04/ $ 865) premium.
While this is an average, the percentage premium will likely be lower
for longer, more expensive
high intensity interactions and higher for low intensity, less expensive
interactions.
Food Stamp Program: The USDA budgets about $ 2 billion to administer
the food stamp program
and provide services for all recipients. Because States share equally
in the costs of
administration, actual administrative expenditures are approximately
$ 4.1 billion. With 7.5
million households receiving food stamps, it costs about $ 547 per
household ( $ 4.1 billion / 7.5
million households) to administer the food stamp program. Using our
estimates, the Food Stamp
program would spend up to an additional $ 25.2 million on language
services. Because there are
approximately 307,500 LEP households, LEP households might cost about
$ 82 more ( $ 25.2
million / 307,500 million LEP households) , representing about a 15.0
percent premium ( $ 82 /
$ 547) .
68 This represents the average costs. The median costs are likely to
be considerably lower.
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A View of Costs on the National Level
We have assumed above that the portion of federal, state and local
government services
provided to LEP persons is about $ 46.7 billion. As noted, the LEP
premiums in our public
sector case studies ranged from 0.5% in healthcare services to 1.7%
in the DMV context, to 15%
in the Food Stamp program. Recognizing that the healthcare services
and DMV services are
likely more representative of the government services typically received
by the LEP population,
we might assume that the actual cost premium per LEP persons across
all government services
is closer to the 1-2% estimate than to 15% . Although at this point
we are unable to endorse as
accurate any single summation of LEP-associated costs across all government
or government-
funded services, we suspect that the number may be less than $ 2 billion,
and perhaps less than $ 1
billion. 69 We emphasize that this figure would correspond to the aggregate
cost of providing
language assistance to LEP persons. It does not necessarily represent
the additional cost of
implementing the Executive Order, which may be substantially less than
these figures, since
many steps have already been taken by federal agencies and recipients
of federal funds to serve
the LEP population. It is worth noting, moreover, that no estimate
of this type can be entirely
accurate without a full understanding of the effects of LEP obligations
on recipients of federal
funds ( including healthcare entities) . As addressed below, clear
and uniform guidance that
permits recipients to understand LEP obligations could help reduce
the costs of implementation.
4. Serving the LEP Population Efficiently
As discussed, the actual cost of implementing the Executive Order will
depend upon the
level of services that were already in place at the time the order
was issued. The actual costs,
69 This includes the 1-2% premium for government services and the $
267 million cost for the health care sector
which represents the vast majority of costs for federal funding recipients.
57 57
57Page 58 59
moreover, also might be significantly reduced by proper implementation
of the Order. There are
two primary ways in which the costs associated with implementing Executive
Order 13166 could
be mitigated by the federal government: ( 1) creating uniformity among
the federally conducted
programs and activities and the programs and activities of recipients
of federal financial
assistance with regard to the provision of LEP services, while recognizing
the need for flexibility
to address local circumstances, and ( 2) facilitating availability
of, and access to, telephonic
interpretation services, along with stimulating increased and more
efficient supply of these
services.
Most federally conducted programs and activities and the programs and
activities of
recipients of federal financial assistance already provide language
services to some extent on an
ad hoc basis. Such policies, which often include heavy reliance on
telephonic interpreter
services, may benefit from a more uniform and standardized approach.
Such standardized
approaches may make greater use of lower-cost solutions.
Uniform approaches include consistent guidance from federal agencies,
consistency in
identifying best practices, and consistency in enforcement. Such uniformity
might provide
predictability and reduce legal and bureaucratic costs. The 10 agency-specific
guidance
documents already published set forth a variety of standards that federal-funds
recipients should
use in determining whether they have complied with Title VI s regulatory
requirements. The
Department of Justice s guidance document, for example, sets forth
a four-factor analysis for
determining what constitutes reasonable steps to ensure meaningful
access for LEP persons. .
The Department of Health and Human Service s guidance to HHS funds
recipients, however,
expands DOJ s four factors to seven factors. Although most-if not all-of
the seven factors
resemble at least one of DOJ s four factors, the mere provision by
one department or agency of
58 58
58Page 59 60
an LEP analysis that differs from an LEP analysis provided by another
department or agency is
likely to create some confusion, result in increased costs, and interfere
with the receipt of
language assistance services by LEP individuals. Such confusion is
most likely to manifest with
a recipient that receives federal financial assistance from more than
one department or agency
and is, thus, required to adhere to the guidance documents issued by
those departments and
agencies. One uniform set of guidance documents, with some flexibility
to permit tailoring to
each agency s specific recipients, may reduce implementation costs.
Another way in which the federal government might mitigate the costs
associated with
implementing Executive Order 13166 would be to take appropriate action
to facilitate the
availability of, and increased access to, telephonic interpretation
and other interpretation and
translation services. These services have clear economies of scale,
especially for the less often
encountered languages. The Executive Order, by stimulating increased
demand for language
services, may increase the size and efficiency of the language service
industry, and agencies
might consider steps to facilitate bulk discounted purchasing of such
services by federal
programs and recipients of federal funds. Agencies should endeavor
to find creative ways,
including through technology, to reduce the costs to funding recipients
of obtaining necessary
oral or written translation services.
CONCLUSION
Federal agencies are currently in the process of implementing this
Executive Order, and
we were therefore unable to evaluate actual data relating to the benefits
or costs of
implementation. Instead, this report uses data and assumptions about
different types of language-
assistance services that could be provided to LEP individuals in a
variety of contexts to assess
the general benefits and costs of language assistance services.
59 59
59Page 60 61
The benefits of language-assistance services for particular LEP individuals,
while not
readily quantifiable in dollar units, can be significant. Such benefits
may include improved
access to a wide variety of services, more efficient distribution of
government services, and more
effective public health and safety programs.
The costs of enhanced language assistance are difficult to quantify,
but may also be
significant. The ultimate benefits and costs of the Executive Order
will depend on how it is
implemented, a process that we understand has begun among the Federal
agencies. We hope that
this Report will assist Congress and provide these agencies with information
that will be useful
to them as they implement the Executive Order.
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APPENDIX A: DEMOGRAPHICS Figure A. 1: 1990 Distribution of Non-English
Languages Spoken at Home
5.35%
54.45%
Spanish
Other
French
German
Italian
Chinese
Tagalog
Polish
Korean
Vietnamese
Japanese
17.49%
4.86%
4.11%
3.92%
2.65%
2.27%
1.97%
1.59%
1.34%
Source: 1990 U. S.
Census Report
61 61
61Page 62 63
APPENDIX B: COMMENTS RECEIVED
Public Response Log
Type of Org Name of Org Date Comments Congress Hispanic Caucus/
Asian Pacific American Caucus
( 19) 12/ 26 Importance of LEP svcs & LEP svcs as rights not to
be quantified
English Only Adv Eagle Forum 12/ 27 Emphasize importance of assimilation
& cost of Executive Order
English Only Adv English First High Cost of Executive Order English
Only Adv ProEnglish 12/ 28 Emphasize importance of assimilation & cost
of Executive
Order
English Only Adv Public ( 350) 12/ 31 Emphasize importance of assimilation
and/ or express opposition to the Executive Order.
LEP Advocate AARP 12/ 21 Emphasize importance of translation svcs to
LEP persons LEP Advocate AHS 12/ 31 Health
LEP Advocate Asian & Pacific Islander American Health Forum 12/
14 LEP svcs as a right-not for quantification LEP Advocate Assn of Asian
Pacific Community Health Orgs. 12/ 28 Emphasize importance of translation
svcs to LEP persons
LEP Advocate California Healthcare Interpreters Assn ( 2) 12/ 14 Stmt
that little LEP info exists to assess C/ B LEP Advocate CBPP 12/ 31 Health
LEP Advocate CLS-Philadelphia 12/ 31 General importance of svcs LEP
Advocate CUNY 12/ 28 Health
LEP Advocate F of F Workers 12/ 31 Importance of svcs
LEP Advocate GBLS 12/ 31 TANF/ FS LEP Advocate Individual 12/ 31 Importance
of svcs
LEP Advocate Lewis & Clark 12/ 31 Importance of LEP svcs, unemployment
insurance LEP Advocate MALDEF 1/ 3 General
LEP Advocate MANNA 12/ 11 Emphasize importance of translation svcs
to LEP persons LEP Advocate Michigan Hispanic Social Svcs Org. 12/ 20 Emphasize
importance of translation svcs to LEP persons
LEP Advocate National Health Law Program 12/ 28 Emphasize importance
of translation svcs to LEP persons & provide comparative info on svcs
provided
LEP Advocate National Latino Behavioral Health Assn ( 3) 12/ 19 Emphasize
importance of translation svcs to LEP persons LEP Advocate Nat' l Asian
Pacific American Legal Consortium 12/ 28 Emphasize importance of translation
svcs to LEP persons
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62Page 63 64
LEP Advocate Nat' l LEP Advocacy Task Force 12/ 28 Emphasize importance
of translation svcs to LEP persons LEP Advocate Natl. Alliance for Hispanic
Health ( bunch of
different groups) 1/ 18 Importance of svcs; Has attached files LEP
Advocate NCPL 12/ 28 Food Stamp, work force
LEP Advocate NELP 12/ 31 Labor Context
LEP Advocate New York Lawyers for Public Interest 12/ 28 Emphasize
importance of translation svcs to LEP persons & case studies
LEP Advocate NHMA 12/ 31 Emphasize importance of translation svcs to
LEP persons LEP Advocate NILC 12/ 28 General
LEP Advocate Nizhoni Bridges, Inc. 12/ 10 Unresponsive
LEP Advocate Project Vida 12/ 19 Emphasize importance of translation
svcs to LEP persons
LEP Advocate RIOS 12/ 20 Emphasize importance of translation svcs to
LEP persons & case studies
LEP Advocate Southern Poverty Law Ctr 12/ 28 Info on Sandoval Lawsuit
LEP Advocate Translator and Interpreter 1/ 1 Importance of LEP svcs
LEP Advocate Vosler 12/ 31 Translators needed
Local Govt City of San Francisco 12/ 26 Translation cost estimate Local
Govt Fresno County 12/ 28 Stmt that implementation difficult & costly
Local Govt Marin County 12/ 20 Emphasize importance of translation
svcs to LEP persons Provider AMA 1/ 2 Problems with implementing &
costs
Provider California Medical Association 6/ 8 cost concerns, cost estimates,
suggestions
Provider Center for Healthy Families & Cultural Diversity 1/ 4
Unfunded mandate, possible solutions Provider Children' s Hospital-Seattle
12/ 10 Interpreter info.
Provider El Centro " La Familia" 12/ 20 Emphasize importance of translation
svcs to LEP persons Provider California Primary Care Association 12/ 28
Benefits of Executive Order, collection of best practices
Provider John' s Hopkins System 12/ 27 Interpreter info. State Agency
AK 12/ 30 Unfunded mandate
State Agency Alabama Dept. Industrial Relations Unemployment Comp 12/
20 unfunded mandate, DOJ should take lead in providing generic LEP material,
other federal agencies ( like DOL should handle
LEP negotiations
63 63
63Page 64 65
State Agency CA Dept. of Mental Health 12/ 31 Importance of svcs &
challenges of compliance, specific threshold
State Agency CO Refugee 1/ 3 Pro Executive Order State Agency Colorado
Dept of Labor & Employment 1/ 27 cost estimates ( used threshold mechanism)
State Agency IL Dept. of Labor 12/ 31 Compliance difficulties, costs
estimate ( used threshold) State Agency Indiana Family Social Services
Administration 1/ 3 Cost estimate
State Agency Kansas Dept. of Social & Rehabilitation Services 12/
31 Challenges of compliance, use of ESL State Agency Michigan Family Independence
Agency 1/ 16 service area assessment problems, cost estimates
State Agency Minnesota Dept. of Human Services 12/ 27 Info on translation
svcs provided in response to lawsuit State Agency Montana Dept. of Labor
& Industry 12/ 28 Translation cost estimate
State Agency Nevada Dept of Employment Training & Rehab. 12/ 19
unfunded mandate, Executive Order unreasonably broad, cost estimates
State Agency New Jersey DOL 12/ 21 Use data collected for working age
LEP ( not 5 and up) , cost estimate, benefits
State Agency North Dakota Job Service 12/ 21 unfunded mandate State
Agency Ohio Dept. of Job & Family Services/ Human
Services 12/ 27 Translation cost estimate & info on svcs provided,
plan of action State Agency Oklahoma Employment Security Commission 12/
21 Stmt that Executive Order is unfunded mandate
State Agency Oregon Employment Dept 12/ 31 Cost estimate State Agency
Pennsylvania Dept of Labor & Industry 12/ 27 Cost estimate & unfunded
mandate, ambiguous guidance
State Agency South Carolina Employment Security Commission 12/ 19 cost
estimate State Agency Tennessee DOL 1/ 7 concern with costs
State Agency Texas Dept of Human Services 1/ 24 unfunded mandate, cost
estimates State Agency Texas Workforce Commission 12/ 18 Stmt that data
systems don' t track LEP info, ambiguity of
" LEP" State Agency Vermont Dept. of Employment & Training 12/
21 cost concerns, limited # of LEP persons
State Agency Washington State 1/ 9 nothing
State Agency Wisconsin Dept. Health & Family Services 1/ 8 increased
access, consistent guidelines for federal prog. , cost estimate
State Agency Wisconsin Dept. of Workforce Development 12/ 28 Translation
cost estimate State Agency Wyoming Dept of Employment 12/ 19 cost estimate,
high cost to modify existing technology
State Org NASWA 12/ 31 Concern & implications/ costs
64 64
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Study " Citizen" 12/ 29 Mexican Immigration Study Boston U. School
of Public Health 12/ 13 Emergency Care
Study Canadian Embassy 12/ 4 Language policy Study Prof. Jacobs-Cook
G Hosp/ Rush Med Col 12/ 28 Interpretation in health
Study Prof. Schneider-Inst for Health Policy 12/ 31 Medicaid & interpretation
Study Resources for Cross Cultural Healthcare 12/ 7 Interpretation &
health outcomes
Study The Children' s Hospital 12/ 27 Emergency Care
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