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Federal Law + Healthcare + Language Access

Author
Devin Gilbert
How long?
15–25-minute read
Published
Last Updated

This article is meant as a concise introduction. If you want an exhaustive treatise on this topic, then you’re going to have to look somewhere else đŸ€“. I’m not a legal expert, and there are tons of people who know more about this topic than I do, so feel free to reach out (DevinG@uvu.edu) if you think anything is wrong or could be clarified.

I’m going to link to sources where you can read the laws themselves, and I’ll ask some questions about certain parts of the language in these laws. As you read through the article,

  • use the little floaty checklist at the bottom of the screen:
    1. Scroll to the matching number for each checklist item (you can click on the text of the checklist item to auto-scroll to it) đŸ€“
    2. Check off each item as you complete them đŸ€˜
    3. Click the “Yee Haw!” button once you’ve finished the whole list đŸ€ 

We’re only going to look into these two major federal laws that most affect language access in healthcare:

  • Title VI of the Civil Rights Act of 1964
  • Section 1557 of the Affordable Care Act (2010)

Title VI of the Civil Rights Act of 1964

No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.

— Section 601, Title VI of the Civil Rights Act of 1964

Follow the quotation source link above and then find the quoted passage in its natural habitat 🐯🌿 (in the full text of the law). I suggest using ctrl + f (cmd + f on Mac) to search for “SEC. 601”.

What’s language got to do with it?

This lil’ piece of statute is quite clear, but it does not explicitly mention language, right? It does mention “national origin,” and over time the courts have fairly consistently identified language discrimination as a “proxy” for national origin discrimination. The first court cases to establish this precedent came from lawsuits in school systems, but this proxy principle has been applied to healthcare systems receiving federal funding as well. Here are two examples:

Read about at least one of the above court cases. If choosing Lau v. Nichols, the quickest summary is the 1st paragraph in the PDF.

Who does this apply to?

A lot of people think that you’re not allowed to discriminate in the United States of America. However, private individuals and other entities actually are allowed to discriminate in a variety of situations. Who is legally allowed to discriminate (and in what situations) is a very complex topic in law, so let’s focus only on healthcare providers in the context of this specific law.

Go back up to the quoted section 601 of Title VI, and ask yourself, Who does this law say cannot discriminate?

In the context of healthcare, think about the federal financial assistance programs Medicare and Medicaid.

Now ask yourself, How many hospitals, clinics, and/or physicians do you think there are in the country that do not accept Medicare or Medicaid?

Executive Order 13166 (2000)

Now, the law is one thing, but enforcement is often another. This is why the Clinton administration’s Executive Order 13166 (2000; Federal Register) was so significant. Section 602 of Title VI of the Civil Rights Act of 1964 states that, once approved by the President, Federal departments and agencies have the power to enforce compliance with Section 601 for the Federal programs and activities they oversee. Of course, a major part of this order was that it directed federal agencies themselves to have a plan for providing language access to LEP individuals, but it also consolidated and strengthened mandates for Federal agencies to enforce the law with, among others, healthcare systems and hospitals.

Use the link in the previous paragraph to skim-read some of Executive Order 13166. Ask yourself how this order affected enforcement of Title VI of the Civil Rights Act with healthcare providers.

Who can sue and when?

Long-story-short, there was this case called Alexander v. Sandoval (532 U.S. 275 (2001) | GovInfo summary | GovInfo PDF) that resulted in a sort-of win-lose for language access:

  • The case affirmed non-English speakers must be acommodated when it comes to services receiving Federal financial assistance (in this case, it had to do with driver’s license tests, not healthcare).
  • However the Supreme Court’s decision also created a distinction between
    • Intentional discrimination: This refers to treating someone different on purpose because of a protected characteristic.
      • The Supreme Court held that private individuals can sue in cases of intentional discrimination.
    • Disparate impact: This refers to a neutral policy that unintentionally harms a protected group more than others.
      • The Supreme Court held that private individuals cannot sue in cases of disparate impact. Only the government can sue in these cases.

This is all more complicated than we have time/space for here, but basically it means that if a hospital’s language access plan is inadequate (but not intentionally discriminatory), it will be harder for Joe Schmoe to sue them, but the Federal government can still go after them. The typical recourse for individuals is to a complaint with the HHS Office for Civil Rights.

Despite this, language can still figure into malpractice lawsuits. The most famous example in the U.S. is the case of Willy RamĂ­rez (Wikipedia), which happened 20 years before Alexander v. Sandoval. Could this lawsuit have gone differently post 2001?

Follow the above link to Wikipedia to read about the bad interpretation that caused Willy RamĂ­rez to receive improper treatment, something that irreversibly altered his life.

Section 1557 of the Affordable Care Act (2010)

(a) In General.--Except as otherwise provided for in this title (or an amendment made by this title), an individual shall not, on the ground prohibited under title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), title IX of the Education Amendments of 1972 (20 U.S.C. 1681 et seq.), the Age Discrimination Act of 1975 (42 U.S.C. 6101 et seq.), or section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), be excluded from participation in, be denied the benefits of, or be subjected to discrimination under, any health program or activity, any part of which is receiving Federal financial assistance, including credits, subsidies, or contracts of insurance, or under any program or activity that is administered by an Executive Agency or any entity established under this title (or amendments). NOTE: Applicability. The enforcement mechanisms provided for and available under such title VI, title IX, section 504, or such Age Discrimination Act shall apply for purposes of violations of this subsection.

(b) Continued Application of Laws.--Nothing in this title (or an amendment made by this title) shall be construed to invalidate or limit the rights, remedies, procedures, or legal standards available to individuals aggrieved under title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), title VII of the Civil Rights Act of 1964 (42 U.S.C. 2000e et seq.), title IX of the Education Amendments of 1972 (20 U.S.C. 1681 et seq.), section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), or the Age Discrimination Act of 1975 (42 U.S.C. 611 et seq.), or to supersede State laws that provide additional protections against discrimination on any basis described in subsection (a).

(c) Regulations.--The Secretary may promulgate regulations to implement this section.

— Section 1557 of the Affordable Care Act (2010), (emphasis added)

Follow the quotation source link above and then find Section 1557 in its natural habitat 🐯🌿 (in the full text of the law). This is a loooong law, so I suggest using ctrl + f (cmd + f on Mac) to search for ‘1557’.

Notice that Section 1557 mainly reaffirms previous laws, but it does lock things in specifically for ...any health program or activity..., which is perhaps more broad than the language used by Title VI of the Civil Rights Act (...any...private organization...which is principally engaged in the business of providing...health care...).

Thinking back to the topic of enforcing the law, this “Dear Colleagues” Letter from HHS details Language Access Provisions published by the Office of Civil Rights. These provisions outline how Section 1557 should be implemented more specifically, even giving guidelines regarding qualified interpreters and translators.

Follow the link above to the “Dear Colleagues” letter and read about the following concepts on pages 2 and 3:

  • Definition of an Individual with LEP
  • Definition of Meaningful Access
  • Language Assistance Services
  • Requirements and Use of a Qualified Interpreter

Executive Order 14224 (2025)

Executive Order 14224 (2025; whitehouse.gov) designated English as the official language of the United States, and it revoked Executive Order 13166 (2000), as well as any policy guidance documents that were issued as a result of 13166 (asking for replacement guidance to be published by the Attorney General).

What I would like to ask anyone who works in language access in healthcare: have you seen language access requirements change in the health system you work in since this executive order was issued? For me personally, it feels too early to judge what the consequences of this Executive Order are.

One thing is sure, this or any other executive order cannot change statutory law, so Title VI of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act of 2010 are still in force.

Additional Resources