Trust

The two specific concepts of trust that are relevant to this discussion are technical competence and fiduciary responsibility. It is quite possible to display great competence while only serving self-regarding goals. For example, the physicians involved in the Tuskegee syphilis study constitute an example of technical competence that failed horribly to be worthy of the fiduciary trust that their unwitting patients placed in them (Gamble, Reference Gamble1997). Third-party payers of health care for covered patients may be similar to the philanthropist who endows a scholarship at their alma mater. In these cases, the individuals or health institutions paying for a service are not the direct recipients of either the competent performance or the fiduciary responsibility (Hansmann, Reference Hansmann and Powell1987). Because they are not the beneficiary patient receiving the care or the students eligible for the scholarship, benefactors—whether philanthropists or third-party payers—may have a hard time judging how well the benefit is administered. Both kinds of failure may go unnoticed when little attention is paid to the views and experiences of the beneficiary of a service/benefit in evaluating its provision. In health care, the ability of the patient to choose which provider to trust for service has traditionally been emphasized, with the patient seen as the principal and the provider as the agent. Yet with increasing regulation and at-risk managed care in state Medicaid programs, one can question whether the classic consumerism in competitive markets functions in the health care system. The concern about the increasing distance of the payer from the beneficiary of the service helps explain the emphasis on measures of patient satisfaction as a key outcome variable central to evaluating services in both the Behavioral Model and Donabedian’s work. And trust in provider of both types is closely entwined with satisfaction and its achievement in connection with an episode of care.

Because several of the trust-related items in our survey appear a priori to capture either the fiduciary or the technical dimension of trust, we could have explored the feasibility of disaggregating the analysis in the manner suggested by the theoretical literature. Instead, we chose to measure trust, our dependent variable, by constructing a composite scale from several items in our survey instrument. The decision to combine several individual expressions of trust/distrust, some competence and others fiduciary responsibility, to create our trust variable gave us greater confidence in the validity of our important, central finding: that Hispanic respondents had significantly more overall distrust of care provided to their child than non-Hispanic Whites and non-Hispanic Blacks (p < .001; see Table 1). The difference between Hispanics and non-Hispanic Black respondents exceeded 30% for both values of the trust variable, but Blacks were only 7% below White trust scale scores for both lower and higher trust (a binary variable). In the multivariate regression, the probability that the null hypothesis (i.e., no difference in reported levels of trust between the Hispanic and non-Hispanic White subgroups) was true was very remote (p < .001; see Table 2). Thus, the observation that trust was markedly lower in the Hispanic subgroup compared with the non-Hispanic White subgroup was not attributable to chance. Similarly, we contend that trust was lower in the Hispanic subgroup compared with the non-Hispanic Black subgroup. This relationship (p < .001) was also highly significant in statistical terms.

The relatively small gap between non-Hispanic Whites and Blacks compared with the chasm separating both races from Hispanics is a noteworthy finding that we did not see reported in other studies. Our conservative methodology did not lead us to expect this result. The significance of our findings is reinforced by the fact that the respondents come only from caregivers who sought appointments in the last six months. The survey skip pattern caused the exclusion of more than 1,000 children without an appointment; over half of the children excluded were Hispanic, and just under a quarter were non-Hispanic Black or non-Hispanic White. By excluding the Hispanic population that did not have an appointment, we selected for Hispanic children whose caregivers had higher levels of trust. Comparing the composite trust score for excluded Hispanics (92% lower trust) with Hispanic children included (78% lower trust) shows just how conservative our research strategy was (chi-square p = .000). Because respondents for Hispanic children rated their child as much healthier than either non-Hispanic Black or White children and their utilization was lower (data not shown), our inclusion criterion increased the likelihood that the Hispanic cases would have interacted with Medicaid medical care, thereby making them more comparable to the other two racial/ethnic groups.

By choosing to explore the question of trust in general in our Medicaid population rather than fiduciary and competence trust, we are following the bulk of the literature. In the context of patients’ trust in physician and its relationship to health and disease, Goold (Reference Goold2002), Hardin (Reference Hardin and Cook2001), Rothstein (Reference Rothstein1996), and Rowe and Calnan (Reference Rowe and Calnan2006) underscore the fundamental role played by interpersonal trust. Specifically, the authors note the uncertainty, risk, and vulnerabilities that patients perceive in relation to provider competence and commitment to serve the patient’s interests. The information asymmetries associated with the provider-patient relationship, characterized by the health provider’s command of medical knowledge, which typically exceeds that of the patient, are also highlighted. The authors contend that these circumstances demand a high level of interpersonal trust, without which patients’ incentive to access health services may be suppressed.

However, our study differs from most of the literature that we reviewed in comparing poverty-level Hispanics with similarly low-income non-Hispanic Blacks and Whites. Only 6 of 40 some sources initially reviewed for this article specified that the study population was composed of low-income individuals or families. Moreover, many of the other studies appear to lack sufficient numbers of Hispanics to allow the “minority” category to be disaggregated into Hispanics and non-Hispanic Blacks. We were fortunate in being funded well enough to survey a large number of Medicaid children and to have done so during a period when larger numbers of low-income Hispanic children qualified for Medicaid in North Carolina.

Acculturation: An explanation?

An obvious question is what might explain the large discrepancy between Hispanic and African American respondents? Perhaps some special aspect of their differing experiences as minorities might throw light on their striking differences in trust. Differing levels of acculturation to the dominant non-Hispanic White culture might differentiate between the minority subgroups. Constraints in survey design precluded us from including direct measures of acculturation. Because acculturation is a multidimensional concept, it needs to be measured with a well-validated battery of survey questions, but no such instrument exists. In the absence of a widely accepted instrument that measures the degree of acculturation (Schumann et al., Reference Schumann, Bug, Kajikhina, Koscholiek, Bartig, Lampert and Santos-Hövener2020), investigators often rely on proxies as gross indicators of acculturation, but a proxy is not the same as a well-calibrated measure. Inferences about differences between levels of acculturation can be drawn from primary indicators like preferred language, education, and satisfaction with communication that are used in this article, but such proxies, even used together, are inexact approximations. Thus, our reliance on proxies rather than a purpose-built measure requires us to acknowledge that we cannot claim to demonstrate that acculturation is so strongly related to levels of trust as to constitute an explanation for the differences in trust in provider between these two large minorities. Instead, we must use a somewhat nuanced argument showing that varying levels of acculturation are a likely explanation for the difference between average levels of trust expressed by Hispanic respondents and non-Hispanic Black caregivers.

As explained in the introduction, our successive surveys of North Carolina’s Medicaid population show that increasing numbers of Hispanic children qualified for Medicaid in the first decade of this century (see Figure 1). Moreover, census data show that the total Hispanic population in the state grew rapidly during the same period, although we cannot determine the proportions of those immigrating from abroad or from other states (Miles et al., Reference Miles, Sexton, Margolis and Sanderson2010; Pew Research Center, 2011; Tippett, Reference Tippett2014; U.S. Census Bureau, 1990, 2011). Our sampling for surveys of the adult noninstitutionalized Medicaid population at the same time that we drew the child samples showed no increase in Hispanic adults comparable to the increases in enrolled children. The large differences in the proportion of Hispanics in the child and adult samples probably suggests that many Hispanic adult caregivers were Medicaid ineligible, perhaps because they were born in Latin America and or had undocumented status. These population data provide circumstantial evidence that many of the Hispanic children enrolled in Medicaid and the adults responding for them reflected cultures that differ from the dominant U.S. culture. In contrast, much of the low-income non-Hispanic Black population in North Carolina has a long family history in the state and similar nearby states.

Language data gathered by the survey provided direct evidence that these presumptive recent North Carolina Hispanic residents were grounded in a foreign language and culture, unlike the bulk of children and respondents for non-Hispanic Backs and Whites. With respondents identifying their child as Hispanic in 35.5% of the cases, 29.3% of respondents reported that they mainly spoke Spanish at home, but 22.6% of the children mainly spoke Spanish at home. Presumably, those figures show the classic process of acculturation as immigrant populations are led to understand American culture through their children’s absorption into it. Some of the difficulty that respondents and their Hispanic children experience communicating with North Carolina health providers is revealed by responses to the question “What language do you mainly speak when talking with your child’s doctor or health provider?” Only 20.4% of respondents—less even than the child’s home use of Spanish—tried to talk with their child’s provider in Spanish (Brandon et al., Reference Brandon, Smith, Carnes, Hampton and Tripp2014). Thus, the survey establishes the differences in language between Hispanic adult caregiver respondents and non-Hispanic respondents. Because language is a major carrier of culture, the data again provide support for a strong presumption that less acculturation can explain much of the gap between the levels of trust among the Hispanic minority and trust expressed by the non-Hispanic Black minority.

Our review of the literature revealed a paucity of studies showing a direct relationship between lower levels of acculturation to the mores and norms of the dominant culture and lower trust scores. Instead, the literature examined the association of citizenship status, English-language proficiency and health literacy with measures of access and utilization. Strangely, one study of a small low-income Spanish-speaking Hispanic population suffering from diabetes that did examine the association of health literacy and trust found that greater health literacy was significantly associated with lower levels of trust in physician and worse treatment compliance; acculturation was not statistically significant, perhaps because there was little variation on this dimension among study subjects, according to the authors (White et al., Reference White, Osborn, Gebretsadik, Kripalani and Rothman2013).

Neither our study nor the ones we examined included a variable for acculturation, a complex relational concept that is difficult and perhaps impossible to study empirically in a direct way (Schumann et al., Reference Schumann, Bug, Kajikhina, Koscholiek, Bartig, Lampert and Santos-Hövener2020). Instead, we were forced to use several proxy variables that can indicate differences in acculturation. In addition to proficiency with the language of the dominant culture, a relevant proxy measure is education, because of its relation to literacy and the more specialized focus on health literacy. Education, which was measured by completion of high school or GED, study beyond high school, and less than high school diploma, proved to be statistically significant in the multivariable regression and to be negatively associated, thereby associating less education with lower trust (lower education presumed to indicate lower literacy, lower probability of high trust scale scores). If our assumption that formal education can be a valid proxy for literacy is accepted, then our finding that lower literacy was associated with lower trust contradicts that of White et al. (Reference White, Osborn, Gebretsadik, Kripalani and Rothman2013), whose focused study dealt narrowly with diabetes and its care.

Our multivariable regression also demonstrated that satisfaction was significantly associated with the level of trust in the way that one would expect (higher satisfaction scale score, higher trust score). This finding may reflect the connection between language proficiency and measures of access and utilization because the scale variable measuring satisfaction in our study was constructed from several survey items relating to talking and listening as explained in the discussion of methods section. Only one of four survey questions—an item about the adequacy of the amount of time spent with the child by the personal health provider—is not closely related to communication. Thus, our satisfaction variable may reflect the literature’s emphasis on the importance of language proficiency for acculturation by capturing the difficulties faced by patients or children’s caregivers who are grounded in a culture different from the dominant society.

The argument so far has built a plausible case based on language use, lower education, and satisfaction with communication: (1) when compared with the non-Hispanic Black minority, the new immigrants to North Carolina are less acculturated to the mores and norms of the dominant society; therefore, (2) this implied deficit in acculturation can go a long way toward explaining the lower trust registered by respondents for Hispanic Medicaid children. Because no standard battery of questions is normally used in health care surveys to measure acculturation (Schumann et al., Reference Schumann, Bug, Kajikhina, Koscholiek, Bartig, Lampert and Santos-Hövener2020), a slippery concept, the case has rested on the finding of statistical significance of both education as a proxy for literacy and the satisfaction/communication variable as a functional equivalent for language in the multivariable analysis. The argument is buttressed—strongly, we believe—by the empirical data about the role of Spanish in the lives of these new Hispanic immigrants to North Carolina.

The skeptical positivist would not be illogical in suggesting that previous experience with Medicaid—perhaps associated with anti-Hispanic prejudice experienced in Medicaid offices or just bad health care—are just as likely to explain lower Hispanic trust as acculturation. Fortunately, this counterargument can be evaluated with reference to time markers contained in the survey instrument. Most of the questions in the lengthy survey explicitly asked respondents to consider only the last six months. That limited lookback is typical of high-quality health surveys because research has determined that six months is about the limit of respondents’ reliable memory of details of their health care (Bhandari & Wagner, Reference Bhandari and Wagner2006; Hargraves et al., Reference Hargraves, Cosenza, Elliott and Cleary2019; Mathiowetz & Dipko, Reference Mathiowetz and Dipko2000). Given the recent influx of Hispanics into North Carolina and their recent appearance on child Medicaid rolls compared with the long familiarity of non-Hispanic low-income Whites and Blacks with Medicaid, it is unlikely that significant bad experiences with North Carolina Medicaid would explain the low levels of trust: adult Hispanic respondents have had much less experience with Medicaid than the well-established non-Hispanic Black population. This observation is further supported by literature that finds Hispanics use less health care than non-Hispanics (Keller et al., Reference Keller, Silberberg, Hartmann and Michener2010; Marton et al., Reference Marton, Yelowitz, Shores and Talbert2016). If earlier experiences of allopathic medicine either in Latin America or after immigrating to the United States constitute the basis for lower trust of Hispanics, those experiences simply become part of the problem of acculturation experienced by this population to a greater degree than by other races or ethnicities in Medicaid.

Our argument against an alternative explanation follows a persuasive positive case for thinking that lower acculturation of respondents for Hispanic children enrolled in Medicaid is how best to understand their lower levels of trust. Together, the positive case and the refutation of an alternative constitute an interpretation of our results that can claim to be explanatory. Following recent trends in interpreting quantitative research, our results transcend mere “association” and such timid euphemisms as “correlation,” “pattern,” “link,” and so on (Hernán, Reference Hernán2018, p. 616). Glymour and Hamad (Reference Glymour and Hamad2018) and Hernán (Reference Hernán2018) challenge conventional wisdom by maintaining that science is fundamentally an explanatory enterprise. Admittedly, observational studies are useful when they call attention to “association” of phenomena that otherwise would be overlooked—like the much lower trust in provider expressed by responders for Hispanic children in successive CAHPS Medicaid surveys that our analysis discovered. But unexpected findings should goad us to look for explanation, in order to advance appropriate policy responses. Even more recently, two of the leading health journals—Health Affairs and JAMA—have attacked the notion that health services researchers have finished their task when they have conclusively demonstrated the existence of some racial/ethnic disparity (Boyd et al., Reference Boyd, Lindo, Weeks and McLemore2020; Rivara et al., Reference Rivara, Bradley, Catenacci, Desai, Ganguli, Haneuse, Inouye, Jacobs, Kan, Kim, Morris, Ogedegbe, Perencevich, Perlis, Powell, Rubenfeld, Shulman, Trueger and Fihn2021; Zambrana & Williams, Reference Zambrana and Williams2022). The danger of such research is that it may invite the reader to think of biological, often genetic, grounding for the putatively “objective” findings of the empirical research, when in truth race is only a socially constructed variable (Boyd et al., Reference Boyd, Lindo, Weeks and McLemore2020). Boyd et al. (Reference Boyd, Lindo, Weeks and McLemore2020) urge investigators to consider racism, a sociopolitical concept, as the explanation for many observed racial disparities. Although distinct concepts, both racism and acculturation are explanations. In our research, racism might well explain the comparatively narrow gap between non-Hispanic Black’s trust in physicians and that of non-Hispanic Whites, but it is not as convincing as differing levels of acculturation in explaining the gap between Hispanics and non-Hispanic Blacks.

We do not want to claim too much for our explanation. The lack of trust may be particular to the Hispanic population that has immigrated to North Carolina; other immigrant populations with low levels of acculturation may display higher trust in the medical providers who treat them. If the Hispanic population follows the path of most previous immigrant groups (e.g., Irish, Italians, Vietnamese), acculturation will increase, and over time, trust may be expected to resemble that of the general population. Of course, such evolution is not inevitable, as the plight of the Romani people in Europe and North America demonstrates (Kingsley & Dzhambazova, Reference Kingsley and Dzhambazova2020) or the choice of the Hassidim in New York (Shapiro, Reference Shapiro2022).

Limitations

Several factors may limit the utility of our study’s findings. Foremost among these is that the subjects surveyed included only Medicaid enrollees in North Carolina, which makes generalizing study findings to other populations potentially problematic. A second limitation is that the study employed a cross-sectional, observational design, which in the past has often been regarded as incompatible with causal explanations. Additionally, Hispanic children were underrepresented in the truncated data set that was used in our analysis. The proportion of Hispanic children represented in the truncated data set (20.4%) was considerably smaller than that observed among all subjects who responded to the survey in the untruncated data set (35.5%). On the other hand, the proportion of Hispanic children reported in the truncated data set (20.4%) may more closely align with the proportion of 23% reported for the state’s entire Medicaid population as cited by Miles et al. (Reference Miles, Sexton, Margolis and Sanderson2010). Our very conservative methodology excluded many Hispanic cases with low trust scores, thereby making a very compelling argument for the robustness of our findings of differences in trust. Striking statistically significant differences between Hispanic respondents and the other racial/ethnic groups survived our erosion of those differences by the application of our exclusion criterion.

Another possible limitation is that the survey response rate was 36.6% as measured by American Association for Public Opinion Research (2011) standards. At first glance, this appears to be a liability. However, it should be noted that this response rate approaches what some deem an acceptable threshold for participation by Medicaid recipients (U.S. Department of Health and Human Services, 2002). It is also worth noting that the responses offered by survey respondents were self-reported responses, susceptible to possible recall bias and not verified by claims data. In terms of explained variance of the dependent variable (i.e., the trust scale), the absence of interaction variables as predictors may have suppressed the value of the model’s R ². Finally, the Cronbach’s alpha reliability measure scores for the scale measures (trust, satisfaction, and health status) were approximately 0.75, falling short of the ideal threshold of 0.8 or greater.

Partially offsetting these limitations are two strengths of our study. Because our geographically stratified random sample was drawn from selected programs of the noninstitutionalized Medicaid population, the study only includes children in low-income families. The sample was drawn before implementation of the Affordable Care Act (ACA), which allowed Medicaid enrollment of children in families with somewhat higher incomes in many states. (Children in North Carolina’s child health insurance program, which covers children in families with higher incomes, were not included.) The other strength of our study lies in the unusually large number of telephone interviews that were conducted and the relatively large number of respondents in both of the minority groups and in the non-Hispanic White majority.

Policy implications

Our diagnosis that lower levels of acculturation among adult respondents for Hispanic children enrolled in North Carolina Medicaid accounts for much of their low trust in providers makes it incumbent upon us to suggest policy interventions to improve their acculturation and reduce their distrust. Both individual and structural factors are important, but major systemic changes in the U.S. health care system might go a long way toward improving the structural constraints that too often doom local initiatives to alter specific individual experiences and behaviors. Therefore, this subsection will suggest a number of ideas for reducing the gap between what low-income Hispanic residents in the United States receive and the health care experienced by patients belonging to other, more established population groups.

Repeated experience with specific efforts to improve individual-level interactions in some sustainable and replicable manner has shown that it is almost impossible without attention to structural impediments. Creative administrators and clinicians in our health care system have continually developed and tested specific interventions, pilot projects, demonstration programs, and so on, focused on helping individuals receive high-quality care at reasonable cost in local or even statewide evaluations. Some, perhaps many, have shown positive results. These local health delivery interventions often receive some publicity but then fade from collective memory as attention moves on to the next innovation. Few receive the support necessary to bring them to scale. Thus, these organizational improvements are in stark contrast to successful new clinical therapies that have the weight of federal and professional society regulatory pressure and the clout of insurance company and Medicare “best practices” financing behind them. Critical to scalability is financing. For example, HMOs puttered along for decades in various cities and metro areas as prepaid group practices until the 1970s, when the federal government provided both funding and its preemptory legal power in the Health Maintenance Organization Act of 1973 (P.L. 92-222) to force states and professional medicine to accept this suddenly fashionable union of health delivery and finance (Brown, Reference Brown1983; Kingdon, Reference Kingdon2011).

Thus, it is important to envision changes in the principal health care structures that can help Hispanic families adjust to the U.S. ways of providing health care, starting with Medicaid, the chosen instrument for addressing the health care needs of low-income individuals and families. The ACA was a major step in the evolution of Medicaid, because when fully implemented, it transforms categorical programs into a universal entitlement for low-income persons (Brandon, Reference Brandon2012). (By the end of 2022, only 11 states had failed to accept unrestricted Medicaid eligibility for those in families with incomes less than 138% of the federal poverty level and no other health coverage; see Kaiser Family Foundation, 2022.) To fully realize this mission, Medicaid eligibility needs to include residents of the United States without regard to how long they have resided in the country and perhaps their legal status. One of the authors has argued for cutting Medicaid’s Gordian knot by federalizing Medicaid—making it a single program run by the Centers for Medicare and Medicaid Services (Brandon, Reference Brandon2021a; Brandon, Reference Brandon2021b). Currently, Medicaid is effectively 51 programs (Washington, DC, counts as a state for Medicaid but not self-government!) that maintains some uniformity because the federal government regulates state compliance with federal regulations and laws (when federal attention ought to focus on improving quality of care and efficiency in delivering care to patients). A unitary Medicaid program would simultaneously overcome two injustices and achieve two important policy objectives. First, a federal takeover of Medicaid would end recalcitrant states’ ability to escape the ACA’s intended expansion of Medicaid at federal expense into a universal entitlement for Americans with family incomes at 138% of the federal poverty level or less. Second, it will also end the geographical injustice of a federal program that differs in eligibility, coverage benefits, and provider reimbursement rates depending on where beneficiaries live or health providers practice. (As some states become increasingly aggressive in policing clinical judgment and procedures such as interventions for gender dysphoria, obstetrical issues, and reproductive decision-making, federalized Medicaid might also become a shield for professional medical societies and patients trying to preserve traditional clinical and personal autonomy.) The 51 state Medicaid programs treat Hispanic populations and their health care needs very differently, depending on state political and social cultures. A unified federal structure could provide U.S.-born Hispanic children and federally eligible immigrants financial support and regulatory encouragement that would help creative health care administrators and providers innovate to improve the health care of new immigrants and their understanding of the health care system. With a national Medicaid program administered by the Centers for Medicare and Medicaid Services, coverage could be expanded to all migrants whose status is still being determined (an adjudication that can take years).

We can now turn to programmatic innovations—the individual-level interventions that Medicaid, with its entitlement funding, could nourish. An intervention designed to facilitate enrollment in the ACA developed trained “navigators.” Initially intended to help uncovered individuals and families make sound decisions among many options and “doors” within and beyond the ACA health insurance marketplaces (or “insurance exchanges”), navigators constitute an important patient-centered addition to the health delivery system that can serve as coaches to guide patients in utilizing care after enrollment. Research has shown that these individuals and the network of nonprofit corporations that organized them often go beyond helping families enroll in the appropriate health plan by helping newly covered families use their new coverage after enrollment (Tripp, Reference Tripp2015; van Eijk et al., Reference van Eijk, Prueher, Kett, Frogner and Guenther2022). Too often, low-income families who have had little or no experience with health insurance coverage fail to take full advantage of comprehensive coverage such as Medicaid when they first receive it. Recognition of this expanded role for navigators justifies funding to maintain contact with families for the first year after enrollment or until new health care consumption habits are established. As van Eijk and colleagues (Reference van Eijk, Prueher, Kett, Frogner and Guenther2022) demonstrate, assured recurring federal funding is one of the keys to building such a system of health system coaches. Funding tied to the entitlement aspect of Medicaid means that unlike navigator dollars in the ACA annual appropriation is not required. (The Donald Trump administration cut ACA funding for navigators and for public communication; see van Eijk et al., Reference van Eijk, Prueher, Kett, Frogner and Guenther2022.) These needed services should at least be available in areas—many rural—where there are concentrations of newly arrived populations and those with little understanding or even the ability to comprehend the complex, fragmented web of health services and financing that constitutes the U.S. health care system.

The brave efforts at a student-run free clinic at Eastern Virginia Medical School that apparently enjoyed at least temporary success echoes the national attempt to organize effective cadres of knowledgeable guides using ACA funding. The medical students involved in the clinic developed their own system similar to navigators to help many of the patients at their student-run free clinic into a regular source of care once funding for coverage became available to some low-income patients (Taylor-Fishwick et al., Reference Taylor-Fishwick, Patel, Van de Graaf, Adsit, Cronin, Ingram-Thorpe and Britton2021). While admiring the intelligence and energy of these students, from the perspective of a national health care system with its many problems, one must ask whether such ad hoc, voluntary solutions are scalable or even sustainable. Indeed, the many different kinds of free clinics from which this particular innovation emerged often seem precarious, depending as they do principally on volunteers, philanthropy, and local oversupply (often temporary) of medicines, technology, and supplies.

Finally, the issue of language and cultural competency looms large in discussions of immigrant populations. Modern technology and improved connectivity have enabled many medical practices to meet the challenge of securing reliable basic interpretation services and professional standards for interpreters have improved as recognition of the necessity of such services for quality health care has become more widespread. Remote interpretation is usually focused on clinical interactions. Yet with new influxes of immigrants and vetted refugees from Afghanistan, the Middle East, and other non-Spanish-speaking areas, on-the-ground guides to health care provided locally would also help such families in transition. In particular, anecdotes suggest that nonprofits that receive public short-term funding to settle legal refugees granted political asylum and their families need to work more closely with established health providers and patient advocates. Of course, the health care system must also provide care to large numbers of undocumented immigrants. The health care system (with its Medicaid funding and Health Resources and Services Administration grants) and local agencies charged with settling legal immigrants could usefully collaborate to provide English-language instruction that could be infused with health care concepts, which are universally useful to new immigrants. In more rural areas where many Hispanics live, responsibility for providing such courses to facilitate acculturation is likely to fall entirely on institutional health providers (hospitals, nursing homes, managed care organizations, etc.), especially where local government lacks funding or political will to sponsor such programs.

Of course, it goes without saying that providers should be well educated in terms of cultural sensitivity and competency and adhere to best practices or standards (Barr, Reference Barr2019). Recruiting more qualified Hispanic health providers is also an important agenda item. Specifically, health providers serving Medicaid eligible children should engage in participatory decision-making processes with patients and their parents, encourage parents to voice their concerns and ask questions, and then provide additional information and feedback based on those questions and concerns.

Language competency should also be emphasized as part of professional preparation. Fifty years ago, undergraduates at most U.S. colleges took at least one foreign language through the intermediate level (typically four semesters). Even when students failed to achieve proficiency, good language training was accompanied with some degree of enhanced cultural competency. If nothing else, struggling to communicate in a foreign tongue when others seem to jabber on with ease teaches humility and the need to speak slowly, simply, and clearly. In light of our new era of global population exchanges, it may be time to reinstitute the expectation that anyone with a bachelor’s degree—at least anyone aspiring to enter one of the helping professions—should have had exposure to a modern foreign language, a category that includes American Sign Language, through the intermediate level. If medical schools were able to make sure that applicants take organic chemistry, over time, they ought to be able to induce aspiring college students to enroll in a modern non-English language.