Administration and Policy in Mental Health and Mental Health Services Research

, Volume 40, Issue 5, pp 364–370

Children’s Mental-Health Language Access Laws: State Factors Influence Policy Adoption

Authors

  • Mary Schmeida
    • Kent State University
    • Department of Political ScienceUniversity of Northern Iowa
Original Article

DOI: 10.1007/s10488-012-0428-6

Cite this article as:
Schmeida, M. & McNeal, R. Adm Policy Ment Health (2013) 40: 364. doi:10.1007/s10488-012-0428-6
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Abstract

Despite federal legislation to equalize healthcare for children with limited English language proficiency, some state healthcare agencies and programs fall short in providing children’s linguistic services for mental healthcare. While some states have been aggressive in passing cultural and linguistic laws aimed at providing protection for children, other states have not, limiting children of all ages to potential substandard care. This research uses state-level data and multivariate regression analysis to explore why some states are adopting these laws, whereas others are not. We find two dissimilar forces with unrelated goals must work in tandem to bring about policy change—the desire of civil rights and liberty groups to ensure equality in the delivery of healthcare services, and the desire of state legislature to reduce healthcare costs.

Keywords

Children’s language lawsLimited English proficiencyMental-health public policyEquitable healthcare accessMultivariate regression analysis

Background

The Civil Rights Act of 1964 prohibits discrimination on the basis of race, color, or national origin (Public Law 88-352 1964), however, children with limited English proficiency and mental illness are still less likely to receive quality healthcare services when compared to the general population. The inaccessibility of language interpreter services in patient settings, the lack of multicultural staff training, and limited state-local public health funding are a few underlying conditions contributing to this inequitable care.

Although limited English can impede equal healthcare access for Americans of all ages, it is the children with co-existing limitations, such as, limited English language skills and mental illness that are most susceptible to substandard care (AHRQ 2004). In 2009, 24 % of children ages 5–17 who indicated speaking a language other than English at home identified speaking English with difficulty (U.S. Department of Education 2011). Children of minority are particularly susceptible to the consequences of limited English proficiency. Parents of Latino children, for example, report language problems to be a healthcare access barrier for their children, with associated adverse clinical outcomes, such as substandard medical care, misdiagnosis, incorrect medication and/or hospitalization (Flores et al. 1998). This finding indicates a potential threat to receipt of quality healthcare that hinges on communication, such as that between patient and mental-health therapist.

Out of a plethora of legislation passed by states addressing language access laws, only 18 states have targeted laws aiding children with mental illness—the most vulnerable of groups (Commonwealth Fund National Health Law Program 2008). This study explores why more states have not passed language access laws for children with limited English proficiency and mental illness.

State Response to Federal Legislation on Children’s Limited English Proficiency

Historically, federal laws applicable to children’s limited English proficiency, such as the Title VI of the Civil Rights Act, have been poorly enforced. Following the passage of the Civil Rights Act, additional federal laws have been passed, but state response to them varies placing the children population at a disadvantage for equitable mental healthcare. For example, the 2000 Executive Order 13166 “Improving Access to Services for Persons with Limited English Proficiency,” requires all federal agency programs and activities to promote better service access for both children and adults who are limited English language users (Executive Order 13166 2000). This federal law emphasizes the strengths of the Civil Rights Act, and has potential to greatly improve upon equitable healthcare services for children with mental illness. However, state response has been inconsistent as many states fail to even meet the minimum standards set by the federal government. In other states, the legislature exceeds the minimum standards in protecting youth with limited English proficiency and mental illness. Those states favoring the federal law passed cultural and linguistic laws aimed at providing additional protection for this particular youth population. Only 18 states had gone beyond standards set by the federal government—AL, AK, AR, CA, CO, FL, IL, LA, ME, MA, MN, NJ, NM, NY, OR, PA, RI, and WA (Youdelman 2008). The state laws that have been passed are far from uniform. For example, New Mexico requires child and adolescent mental health agencies to use bilingual/bicultural professionals and paraprofessionals for patient communication.1 In Oregon, when interpreter/translator services are required for translating a child’s intensive in-home service to the parent whose primary language is other than English, the cost of the translator service would not be counted as part of the maximum monthly budget for the child.2

While 18 states have passed language laws promoting equitable mental-health services for children with limited English proficiency, 32 states persistently lag in passing these laws. Why have some states passed children’s mental-health language access laws, whereas others do not? To understand the factors that may or may not be associated with state adoption of these laws, this study begins with an overview of the Communications Model.

Communications Model of Intergovernmental Policy Implementation

In exploring variation to state compliance with federal standards for protecting youth with limited English proficiency, we apply the Communications Model designed to frame intergovernmental (federal, state-local) policy (Goggin et al. 1990). The basis of this model is Communication Theory and it emphasizes the importance of the transmission and receipt of information, processing of information by various actors, such as interest groups, leading to decisions and communication feedback (Goggin et al. 1990, pp. 30–31). The model’s goal is to depict implementation over time and determine why there is variation in how states implement federal laws, in this case laws protecting youth with limited English proficiency and mental illness. The dependent variable under this framework is state implementation of a federal law. State implementation includes outputs characterized as agency efforts to implement the legislation, and outcomes involving the impact that the law has had on society (Goggin et al. 1990), such as equal access to mental-healthcare services for all children.

In the Communications Model, the intervening variables are state organizational capacity referring to items such as a state’s administrative efficiency and competency, and ecological capacity concerning the “contextual environment in which state government operates” (Goggin et al. 1990, p. 911), such as the economical, political, and situational context. The independent variables are federal-level and state-level inducements and constraints to implement federal legislation. An example of a federal level inducement is the allocation of resources to states to implement children’s language laws. Conversely, a restraint would include sanctions against those states that fail to implement a law as directed (Goggin et al. 1990). The main federal policy regarding children’s mental-health language laws stems from Executive Order 13166 “Improving Access to Services for Persons with Limited English Proficiency.” While it calls on agencies to develop a strategy for increasing access to their services for citizens with limited English proficiency, it provides neither inducements nor constraints for a strategy. As stated in the order: “This order is intended only to improve the internal management of the executive branch and does not create any right or benefit, substantive or procedural, enforceable at law or equity by a party against the United States, its agencies, its officers or employees, or any person” (Executive Order 13166 2000).

Goggin et al. (1990) argue that communication between federal and state-local agencies, leadership, and interest groups among other players takes center stage in policy implementation. The content and message behind the law, in addition to the level of communication between federal and state-local agencies may also affect the success or failure of the policy implementation. In this study, the 2000 Executive Order 13166 “Improving Access to Services for Persons with Limited English Proficiency,” is the message itself. Some of the states did not favor the message and failed to implement it, whereas, other states favored it, passed and implemented different cultural and linguistic children’s mental-health laws. Messages can also be transmitted through inter-government, within or across states (Goggin et al. 1990). Within a state, the messengers are primarily interest groups and the message is the lobbying effort—they may push for the same law as the federal government or pull for a different law. Although actors at the federal and state levels may attempt to influence state policy, such as limited English proficiency laws, states may still disregard these players and enact its own preferences. This can occur if the “messages” sent by these actors are not considered credible (Goggin et al. 1990, p. 119).

The Communications Model suggests a number of state level factors that can influence state compliance with federal policy, such as organizational capacity and ecological capacity, state level inducements and constraints. In the next section, we explore whether these state level factors influence state implementation of federal policy for protecting youth with limited English proficiency. Multivariate logistic regression analysis of fifty state data will be used to test state response to the federal law as of January 2008.

Empirical Model: Data and Measurements

The dependent variable Language Access in Healthcare Facilities for Children’s Mental-Health is constructed to measure whether a state has adopted children’s mental-health language access laws. It is a dichotomous variable coded 1 for states that passed these language laws and 0 otherwise, for the year 2007–January 2008 (Youdelman 2008). It is coded with higher scores representing an increased chance for adoption of these laws.

The main independent variables under the Communications Model are federal and state-local level inducements and constraints. Inducements and constraints regarding this policy are primarily at the state-local level in the form of interest group activities. Actors at this level (interest groups, local officials and agencies) can shape the implementation of legislation (McNeal et al. 2003; Schmeida et al. 2007). Depending on how legislation impacts local groups, they may either act to boost or hinder implementation. Civil rights interest groups are historically known for promoting equitable services for vulnerable populations and across policy areas, and are expected to be active in children’s mental-health language access policy. The number of Civil Rights/Liberty Groups acts as a measure of interest group strength (Project Vote Smart 2007) and is expected to have a positive influence on policy adoption and implementation. Project Vote Smart (2007) categorizes each interest group registered in the state based on its mission statement or a description of the organization provided by the group. A measure for “good government” groups was considered but not used due to multicollinearity.

Although actors at the federal and state-local levels may attempt to influence state policy, a state may still disregard these players and enact its own preferences. Not all states have the same ability to ignore messages made by other actors in the federal system. Those best capable of carrying out their own preferred policies have resources that make this possible (Goggin et al. 1990, p. 911). Among these assets is state wealth. A state’s ability to decline federal monies, if made available to implement policy, is based on its own fiscal health. In addition to helping states decline federal monies tied to compliance, wealth permits states the ability to experiment with different policies for addressing public problems, such as equal access to healthcare services for children with limited English proficiency. State wealth was controlled for using Median Household Income for the year 2008 measured in dollars (U.S. Census Bureau 2011).

Other resources may include the attitudes of the citizens as well as public officials. One variable found to be important in the adoption of healthcare policy is partisanship. The Democratic Party has historically been a champion on children’s health policy promoting equitable healthcare for this vulnerable population. It is expected that states with greater Democratic control are more likely to adopt children’s language laws. As a measure of partisanship, Democratic Party Controlof State Government was added to the regression models, and is calculated by dividing the total number of Democrats in both houses (upper and lower houses) of the state legislatures by the total number of legislators in the state government (National Conference of State Legislatures 2007). Legislative Professionalism may also serve to enhance adoption of policy, and is measured by an index (Squire 2007) using the U.S. Congress as a baseline against which to measure the salary, staff, and time-in-session of the 50 state legislatures. States with more professional legislatures are expected to adopt children’s mental-health language laws since state decision makers may have greater familiarity and expertise in children’s policy areas (Lester et al. 1983; McNeal et al. 2003).

States are more likely to respond to an issue if the public believes that a problem exists (Game 1980; Lester et al. 1983; Meier 1994; Schmeida 2001). Among the study variables used as an indicator of need/demand for children’s mental-health language access laws are Children’s Mental-Health Service Utilization measured as the percent of children ages 2–17 that required and received mental-health care in 2007 for an emotional, behavioral, or developmental problem (Commonwealth Fund 2009a). Also included is Non-English as Primary Language at Home measured as the percent of the state resident population 5 years and over speaking a primary language other than English at home (U.S. Census Bureau 2005). It is expected that states with a higher utilization of children’s mental-health services and non-primary English speaking residents (age 5 and over) will adopt and implement language access laws for children’s mental-health services.

Resources embedded in state agencies or institutions that oversee the policy implementation will also determine how much leeway a state has in carrying out its preferred policies. Among the controls used for resources of the implementing agency (organizational capacity) is a measure of state budget for mental-health services calculated as the State Mental Health Agency (SMHA) Per Capita Mental-Health Services Expenditures for fiscal year 2006 (Kaiser Family Foundation 2010). These particular expenditures range from $25.58 for New Mexico to $353.86 for Maine.

Other indicators of state agency resources are Growth Management Innovation (Clark 1979), Adoption of Reinventing Government Practices (Brudney et al. 1999), and Equitable State Health System Performance for 2007 (Commonwealth Fund 2009b). Growth management innovation is a measure of a state’s ability to both anticipate and respond to pressures related to population growth and decline. Specifically, it is an index based on the presence of programs that address the state’s ability to manage both growth and population decline for the year 1975. The programs range from land-use management strategies to technical training programs for the unemployed (Clark 1979). Larger scores indicate higher levels of growth management innovation. The reinventing government practices score measures the degree that reinvention implementation has been developed at the agency level in the state based on an examination of 93 different agencies within the state for the year 1994–1995. This measure is based on core principles of reinventing government including the relaxing of administrative rules, less government spending, and creating a market-oriented government by leveraging change through market competition of government goods and services (Brudney et al. 1999, pp. 22–23; Osborne and Gaebler 1992). Higher scores are associated with higher levels of reinvention implementation. Lastly, equitable state health system performance measures the average of a state’s rank across indicators of equitable performance, such as race/ethnicity, income, and insurance coverage (Commonwealth Fund 2009b). It is expected that states with more resources to innovate and health systems that perform more equitably are more likely to satisfy stakeholders and adopt children’s mental-health language access laws.

Findings

Since the dependent variable is binary, logistic regression models are used. In Table 1, the findings show that 7 factors or variables are associated with state adoption of children’s mental-health language access laws. To begin, the coefficient for Growth Management Innovation is statistically significant and positively associated to adoption of children’s mental-health language access laws, even after controlling for all other variables. As growth management innovation increased, there was a greater chance that a state would adopt language laws. This suggests that states that have anticipated problems related to population growth and decline are more likely to adopt children’s mental-health language laws. As expected, Adoption of Reinventing Government Practices was also found to be statistically significant and negatively associated to adoption of these language laws. Therefore, states employing more principles of reinventing government (such as relaxing administrative rules, spending less, and passing fewer regulations) are less likely to pass children’s mental-health language access laws.
Table 1

Logistic regression for state adoption of children’s mental-health language access laws

Variables

Complete model

Reduced model

 

β (SE)

p > |z|

Odds ratio

β (SE)

p > |z|

Odds ratio

State-level inducements and constraints

 Civil rights/liberty group strength

0.89(0.43)

0.040

2.4

0.80(0.33)

0.014

2.2

Ecological capacity

 Democratic party control

8.96(6.42)

0.163

7803.4

 

 Median household income

−0.00 (0.00)

0.791

1.0

 

 Legislative professionalism

24.18(10.56)

0.022

3.2E+10

20.01(8.80)

0.023

4.9E+8

 Non-English as a primary language

0.28(0.14)

0.038

1.3

0.28(0.11)

0.015

1.3

 Utilization of children’s mental health services

0.05(0.10)

0.104

0.6

 

Organizational capacity

 Reinventing government score

−16.25(6.39)

0.011

8.8E−8

−14.90(5.42)

0.006

3.4E−7

 Growth management innovation

8.44(3.84)

0.028

4639.0

7.02(3.58)

0.050

1120.0

 Equitable state health system performance

0.15(0.09)

0.073

1.2

0.08(0.05)

0.109

1.1

 State mental health agency per capita expenditures

0.03(0.01)

0.026

1.0

0.03(0.01)

0.036

1.0

Constant

−19.45(11.22)

0.083

 

−9.25(3.74)

0.013

 

% Correctly predicted

91.8 %

  

90.0 %

  

Nagelkerke R2

0.803

  

0.775

  

N

49

  

50

  

Logistic regression estimates with standard errors in parentheses. Reported probabilities are based on two-tailed tests. Statistically significant coefficients at ≤0.10 in bold

As expected, the coefficient for Legislative Professionalism is significant and positive. As professionalism in a state legislature increases, so does the chance that a state will adopt children’s mental-health language access laws. The number of Civil Rights/Liberties Groups is also statistically significant and positively associated to adoption. This suggests that states with more interest group activity are more likely to adopt children’s language laws in effort to improve access to children’s mental healthcare services. Children’s Mental-Health Service Utilization was not found to be significant; however, State Mental Health Agency (SMHA) Per Capita Mental Health Services Expenditure is significant and positive. As expected, states with more SMHA expenditures are more likely to adopt these laws as a cost-cutting strategy, because children with both limited English proficiency and mental illness are most susceptible to substandard care (AHRQ 2004), that may result in costly re-hospitalizations. States with more Non-English as Primary Language at Home (for residents ages 5 and older) are more likely to adopt these laws because of greater need/demand to improve access to mental-health children’s services. Equitable State Health System Performance was also found to be positively associated with policy adoption, suggesting that more states are responding to the 2000 Executive Order 13166 “Improving Access to Services for Persons with Limited English Proficiency” to improve upon equitable healthcare services for children with mental illness (Executive Order 13166 2000). Neither Democratic Party Control nor Median Household Income was found to be significant predictors in our model.

Discussion

Even though actors at the federal, state-local levels may be attempting to influence state policy, our findings show the majority of states are ignoring federal preferences, and less than half have enacted stricter policy (Goggin et al. 1990). Only 18 states have enacted legislation beyond standards set by the federal government to protect children with mental-health and language concerns. Since current federal policy for increasing access to services for children with limited English proficiency does not provide either inducements or constraints to motivate state compliance, it is not surprising that the federal message is not treated as credible.

This study points to certain actors who are influencing policy in this policy area. Historically, civil rights and liberty interests have pushed legislation promoting equitable access for different population groups (race, ethnicity, national origin) seeking to participate in federally assisted program services and benefits (Public Law 88-352 1964). The findings suggest that these interests also have a positive association with the adoption of children’s mental-health language access laws, much in line with literature showing state professional interests playing an important role in implementing reforms that are not of strong public interest (McNeal et al. 2003). These interest groups are pushing equitable services for vulnerable population groups, such as children with limited English proficiency and mental illness, and across policy areas not typically of public interest, such as children’s mental-health language laws.

This research points to a number of state resources that permit states to determine their own policy with regard to children’s mental-health language access laws including state legislative professionalism, state mental-health agency spending, equitable state health system performance, and resident language (age 5 and up). We find in general, more professional legislatures to be associated with policy adoption in this area since their policy decision makers carry greater familiarity and expertise in various policy areas, such as children’s laws. We also find states with more residents (age 5 and up) speaking non-English as a primary language at home are adopting these language access laws out of demand to improve the accessibility to cultural and linguistic interpreter services for its limited English proficiency children residents. Children with limited language skills and mental illness are most difficult to treat since clinical treatment highly depends on communication between provider and patient (Agency for Healthcare Research and Quality 2004) explaining why we find language as an important predictor in our model. States with long term polices in place to address population changes are also more likely to adopt children’s mental-health language access laws.

The majority of our findings point to both state and agency resources that have resulted in adoption of children’s language access laws in the states. The one exception was a strong state record of implementing reinventing government reforms. These reforms to state public administration practices emphasize a radical reform in government, pushing decentralization in government decision making, fewer rules and regulations, less government spending, among other (Osborne and Gaebler 1992). This focus on a leaner/meaner government is unlikely to result in children’s mental-health language access laws requiring funding and an expansion of state administrative services for oversight. Finally, we did not find partisan politics to be significantly related to policy adoption in this area; this is surprising given that Democratic legislatures have been associated with promoting better healthcare for children.

Conclusion

The results from this study point to the limited commitment by the federal government to this policy area as one possible reason why only 18 states have adopted children’s mental-health language access laws. Those states having adopted these laws appear to be responding to intrastate pressures including lobbying efforts of civil rights and liberty groups, and responding to the need/demand associated with large numbers of non-English speaking residents who are children. Several resources, such as more professional legislatures and greater state mental-health agency spending, have aided these intrastate pressures. Why other states have limited activity in adopting these laws may be the result of the policy area itself, that is, it is not likely to be of strong political interest among the general public. Therefore, little demand for change has been coming from within the state. Second, states are currently and historically been struggling with the ever-increasing costs associated with Medicaid, and have considered at times extreme measures for closing budget gaps, such as restricting the resources available to adopt children’s language access laws. For example, Democrat governor Christine Gregoire of Washington State has proposed a number of controversial strategies for closing the state’s current Medicaid budget shortfalls including the defunding of language interpreters (Vestal 2012).

These findings must however be considered with the understanding that the study is preliminary and has several limitations. This study relies on a cross-sectional design that depicts state action at one point in time. Both the dependent and independent variables are being measured at roughly the same time. This makes it more difficult to establish time order, therefore weakening internal validity. While this study suggests that several independent variables are associated with the adoption of children’s mental-health language access laws, it is more difficult to make the argument that there is a causal effect. In addition, the use of a cross-sectional design suggests factors which may only be relevant during this time period, even though there have been very few changes to state policy overtime. The results of a longitudinal study, on the other hand, might find that these variables are only significantly related to the adoption of this policy area during a specific time period. Such a study could find that, in the long run, other factors play a more important role.

In addition, this study has only examined policy adoption. There is little uniformity in the state policies promoting children’s mental-health language access. To help understand which of these policies are more effective; additional evaluative research is necessary. While both outcomes and impact studies would provide a sense of the effect from these laws on both the individual and society; they would be difficult to conduct since this policy area has not been particularly active. Future research can improve upon this initial study through utilizing a time-series approach, and by including measures of intermediate and end outcomes, such as improved access to cultural and linguistic services for children with limited English proficiency and mental illness, as well as improved clinical outcomes from the implementation of language laws.

Although this study is only preliminary, the findings suggest that two dissimilar forces with unrelated goals must work in tandem to bring about policy change—the desire of civil rights and liberty groups to ensure equality in healthcare service delivery, and the desire of state legislature to reduce healthcare cost. During this time period, the adoption of these policies is more likely to occur when state-level interest groups push for this legislation for promoting equitable access. The fact that only 18 states have adopted such policies however illustrates that it is not enough to frame this policy in terms of civil rights. Given concerns over containing healthcare cost, in particular those costs associated with Medicaid, advocates should also frame the issue in terms of how these policies can reduce medical cost.

Footnotes
1

New Mexico Code R. § 7.20.11.18(c).

 
2

Oregon Admin. R. 411-300-0130(1)(b)(E), 0150(8)(e), (15)(i).

 

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