My parents, aunts, and uncles learned English. They also can till speak Italian, and when my grandparents were alive, they spoke Italian to them.
However, nobody demanded ballots in Italian, hospital workers to speak Italian, etc. etc.
BINGO!!!
What you actually just hit on is the true problem, government meddling in the language issue. Some people think that more government intervention is the answer.
WRONG!!!
It's the government printing those ballots, they need to stop it.
I would point out that your grandparents most likely used whatever Hospital was near them which had a good number of bilingual staff members.
P.S. Do your parents and their siblings (if they're still alive) still frequent Italian markets, deli's, and restaurants on occasion?