Closing Language Access Gaps Is Key to Improving Financial Assistance Awareness: Erin L. Duffy, PhD, MPH

On a recent Managed Care Cast episode, Erin L. Duffy, PhD, MPH, a health policy researcher at the Schaeffer Center for Health Policy & Economics at the University of Southern California, spoke with The American Journal of Managed Care^® (AJMC^®) about her study, "Availability of Hospital Financial Assistance Documents in Non-English Languages," published in the June 2026 issue. The study found that nonprofit and system-affiliated hospitals provide greater access to translated financial assistance information.

During her conversation with AJMC, Duffy discussed what inspired the research, the study’s key findings, and strategies for improving equitable access to financial assistance information, regardless of language.

This transcript has been lightly edited for clarity.

AJMC: Before we get into the study, can you explain what the rule is regarding translated financial documents and how well it is executed in practice?

Duffy: Under the Affordable Care Act, nonprofit hospitals are required to maintain a financial assistance policy and make information about financial assistance widely available. There are also federal tax regulations that require nonprofit hospitals to provide translated documents for language groups that constitute the lesser of 1000 individuals or 5% of the community served by the hospital.

Although those requirements exist, there has been relatively little research on how consistently hospitals are implementing them. So, our study was designed to evaluate how well hospitals are meeting the spirit of these requirements by making information accessible to linguistically diverse communities. The work matters because if translated documents are not available or difficult to find, then patients with limited English proficiency may never realize they qualify for financial assistance.

AJMC: Given this context, what were the primary objectives of your study, and what methods did you use to investigate them?

Duffy: The primary objective of our study was to assess the availability of hospital financial assistance documents in languages other than English and to identify hospital characteristics associated with greater language accessibility. To do this, we conducted a cross-sectional review of hospital websites for nonfederal acute care hospitals located in the 10 most linguistically diverse metropolitan areas in the US.

We searched the hospital websites for 3 key financial assistance documents: a financial assistance policy, the financial assistance application, and a plain language summary, which is meant to be a shorter version of the longer financial assistance policy in more easy-to-understand language. We recorded the number of languages in which each of these documents was available and then examined how availability varied by hospital ownership type, nonprofit status, and system affiliation.

AJMC: Can you summarize the study's main findings? Were there any results that particularly stood out to you?

Duffy: Overall, we found substantial variation in the availability of translated financial assistance documents. Nonprofit hospitals offered significantly more translated documents than for-profit and government-owned hospitals, and system-affiliated hospitals also consistently outperformed other hospitals that were not part of larger health systems.

One of the most striking findings was that even in some of the most linguistically diverse metropolitan areas in the country, many hospitals offered little or no translated financial assistance information online. Given the diversity of the communities these hospitals serve, that gap was surprising and suggests that many patients may face unnecessary barriers when seeking financial assistance.

AJMC: Going off of that, what are the real-world consequences for a patient who speaks a language other than English when they cannot find translated financial assistance information on a hospital's website?

Duffy: The consequences can be significant. Patients may not realize they qualify for financial assistance, may misunderstand eligibility requirements, or may be unable to complete an application successfully. As a result, some individuals may forego applying altogether and face medical bills that could otherwise have been reduced or forgiven.

Beyond the financial impact, language barriers can create confusion, stress, and distress in the health care system. Financial assistance programs are intended to protect patients from excessive medical debt, but those protections are only effective if patients can understand and access them. Additionally, if a financial situation is a barrier to accessing care, there may be patients who are forgoing care because they don't understand that they're able to get financial assistance.

AJMC: With all this in mind, what would you recommend to policymakers or hospital administrators who want to close this language access gap?

Duffy: Hospital administrators could routinely assess whether financial assistance materials reflect the linguistic needs of the communities they serve; translating key documents into commonly spoken languages and ensuring those materials are easy to locate online can significantly improve accessibility.

As for policymakers, the Internal Revenue Service requirements for nonprofit hospitals seem to be yielding more document translations. States have the opportunity to extend translation regulations beyond the nonprofit sector, as some already do for a range of financial assistance requirements. We've also seen some states step in where hospitals may be falling short. In California, for example, patients can send hospital billing and financial documents to a state program for translation into their preferred language. It's an innovative approach that could help make financial assistance information more accessible and could potentially be adopted elsewhere.