Haji Ali was teaching English at a high school in northern Iraq when the United States launched an invasion in 2003.
Like hundreds of other Yazidis living in the region who had been targeted by Saddam Hussein’s regime, Ali became an interpreter for the US military, a service that earned his family a special visa to emigrate to America.
When he arrived on July 25, 2012 – he remembers the exact day – Ali continued to perform, first at the Center for People in Need and in various roles as other Yazidis settled into their new home in Lincoln, the largest religious minority community in the US
“I haven’t done any other work since,” he said in a phone interview in February.
More recently, following a new influx of Yazidi immigrants to Lincoln after the so-called Islamic State launched a genocide in 2014, Ali has taken up more specialized work as an interpreter.
It helps Yazidis who have experienced tragedy and trauma connect with mental and behavioral health professionals, bridge language and cultural gaps, and build trust between doctor and patient.
Meaning can be lost in translation if the wrong words are used, and a patient who is already struggling to navigate daily life amid trauma and grief can begin to spiral.
“It’s important to have someone they feel safe in the room with,” said Mark Hankla, a licensed independent mental health practitioner who often works with members of Lincoln’s Yazidi population.
But since January, Ali’s work has been suspended.
Last fall, Nebraska Optum Behavioral Health, a subsidiary of UnitedHealthCare, informed providers that it no longer reimbursed for in-person language interpretation services through Medicaid, the latest of plans offered by Nebraska Medicaid to do so.
The change has disrupted mental and behavioral health services for dozens of Yazidis, as well as others in Lincoln who have limited English proficiency.
“It came out of nowhere,” said Megan Watson, a licensed psychologist whose caseload includes up to 30 patients requiring interpreting services from a stable of four interpreters, including members of the Yazidi population. of Lincoln.
“No one told us, there was no communication that this was going to happen,” she added.
The service change was discovered in early January when the billing company used by Watson contacted Nebraska Optum Behavioral Health after the interpreters’ billing code – T1013 – was still listed but was not being paid.
“Are you sure that’s correct – that T1013 is not covered?” the billing company wrote to Optum on Jan. 3, according to an email shared with the Journal Star.
“(L) The State of Nebraska informed us in October that the T1013 was not covered,” the vendor relations attorney replied the next day. “So it has been removed from the covered list, the fee schedule you received did not have the code removed yet. It will be removed from the fee schedule so there is no further confusion.
Hankla said reimbursements for interpreters he relied on to work with his clients temporarily stopped in 2021, but were later resolved – what he called a “bureaucratic snafu”.
Then, in October, the claims for reimbursement of the interpreters he used again ceased to be paid.
“Our account manager was calling and trying to find out why they weren’t paying,” Hankla said. “First, they were talking about the codes being wrong. Then, a few weeks ago, he said, “We are not responsible for paying interpreters.”
The explanation Hankla received referred to a 2017 bulletin from the Nebraska Department of Health and Human Services to providers participating in the Nebraska Medicaid program.
The bulletin states that while providers who receive federal funds are required to make language services available to those with low English proficiency, “(n)neither Heritage Health nor Medicaid plans are responsible for providing or reimbursing this service for interaction with the provider”.
“Heritage Health Plans may choose to provide interpretation services for a member to interact with a provider, but this service would be a value-added service offered only at the discretion of the individual health plan,” the bulletin said.
A senior director of external communications for UnitedHealthCare directed questions to the Nebraska Department of Health and Human Services.
In response to questions from the Journal Star, a DHHS spokeswoman said that while Nebraska Medicaid does not pay for requests for interpreting services, managed care plans available through Medicaid do provide those services.
“Each of the plans has different resources available in this area, so we recommend reviewing each if you have specific questions about what a specific health plan covers,” wrote Barb Tyler, marketing and communications specialist at DHHS.
Dr. Les Spry, a kidney specialist and board member of the Nebraska Medical Association, said the US Department of Justice’s Office of Civil Rights requires any contractor receiving federal funds to provide translation services.
There are no federal dollars tied to this requirement, he explained, making it an unfunded mandate.
The federal government is generally willing to share the cost of interpreting reimbursement with states — often a split of 60% federal and 40% state — but has been unwilling to increase that share, Spry said. .
“There are real issues that we feel we have to pay for, but the feds don’t give us any sympathy for that,” he said.
Medicaid reimbursed interpreters until recently, said James Goddard, senior program director at Nebraska Appleseed, a Lincoln-based nonprofit that advocates for affordable health care and immigrant programs.
“The state could, if it wished, cover these services under Medicaid so that they weren’t solely the responsibility of the provider,” Goddard said.
But, the state and DHHS chose not to, he said.
“I think it’s ill-advised not to cover interpretive services for behavioral health because it will further erode access to these services for a population that already has very limited access,” Goddard said. “It would force providers to pay for interpretation or not provide the service to those with poor English skills.”
Providers such as Hankla and Watson say the uncertainty over whether or not interpreting services will be covered has put them – and their patients – in a difficult spot.
Hankla continued to see her patients in need of interpreting services after learning that Medicaid no longer reimbursed the service, believing the problem would be solved again.
The performers he works with racked up thousands of dollars in unpaid bills, until he was forced to suspend his work with them.
“It’s a mess,” he said. “Above all, I feel like the worst part is these people who were brought here and want to function as productive citizens and good neighbors, but who have been so traumatized that they are struggling cope with the stress of everyday life.
“I feel bad, I feel like I’m letting these people down, but we can’t afford to pay an interpreter with what they pay us and keep our lights on.”
Watson said she saw emergency patients and paid for interpreters out of her own pocket.
“It’s very concerning to me,” she said. “Many of my clients, when they don’t get the treatment and medication they need, end up in hospital. It’s just a matter of time.”
Ali said patients he has performed for have called him angry that they cannot access services.
One man in particular, who was held captive by Islamic militants and has since suffered from anxiety and depression, vented his frustration on the interpreter, his only connection to the services he desperately needs.
It’s neither your fault nor our fault, Ali told him. A promise made to the men and women who helped the US military at great risk to themselves and their families has been broken, he said.
“They don’t keep their promise to their friends.”