Ten years ago, the ABA passed a resolution in support of medical-legal partnerships (MLP), a nationwide movement to provide legal remedies for social conditions that negatively affect individual and population health. The ABA's encouragement of the MLP approach is consistent with its historic interest in access to justice for the most vulnerable individuals, and in line with research about the detrimental effects that social and environmental factors can have on a person's health.
The past ten years have witnessed the spread of MLPs across the country, from just over sixty in 2007 to now nearly three hundred. But perhaps the most important development is that MLPs have evolved from a service almost exclusively funded by legal aid organizations or charitable giving, to one that is included in one-third of the operating budgets of partnering health care organizations, or subsidized by federal health programs. Put simply, health care administrators and leaders are beginning to see that legal services and expertise can improve health and the delivery of health care. The MLP approach should continue to gain ground provided that MLPs document their utility and continue to show their benefit not only to vulnerable patients and populations, but also to those who work within the health care system.
1. The Burden of Unmet Legal Needs on the Poor
Long before the first MLP formed in 1993, civil legal aid attorneys knew that unmet legal needs burdened their low-income clients. Unscrupulous landlords and unsafe working conditions kept people from equal opportunities in housing and employment, and discriminatory practices kept them out of the political process. The ABA's long history of leadership to protect the rights of those underserved by America's justice system has been essential in activating strong legal services programs and actively engaging the resources of the private bar.
2. Social Conditions Affect Health
While any civil legal aid or pro bono attorney can tell you about the difficulties brought on by unaddressed legal problems, an understanding of the connection between social conditions and poor health has emerged only in the last few decades. In the 1980s, health researchers documented the long-lasting, negative health effects of chronic stress and environmental toxins on children, and discovered the association between income and age-adjusted mortality. Health care providers working with low-income patients have also paid more attention in recent decades to the fact that life outside the exam room affects their patient's health at least as much as traditionally diagnosed medical conditions.
3. Justice and Health: Medical-Legal Partnerships
Clinicians treating low-income patients and lawyers working with low-income clients came to understand that many social conditions, like substandard housing or unlawfully denied public benefits, have unmet legal needs at their core. In MLPs, clinicians and social workers, wanting better health outcomes for their patients, and lawyers, seeking to remedy civil wrongs, achieve a joint goal: providing access to justice for low-income people while improving health and well-being. Although they differ in number of employees, organizing structure, and workflow, all MLPs address legal matters that detrimentally affect their patient/client health.
An MLP attorney may advocate on behalf of an elderly person whose heating has been shut off. She may assist a client in appealing the denial of disability benefits. And while these issues may not differ much from those seen in many legal aid offices, MLP attorneys often work on-site at health centers and hospitals, so that a patient whose legal need is identified during a medical appointment can meet with an attorney in the same facility, sometimes during the same visit. MLP attorneys develop strong working relationships with clinicians and social workers, which often prove beneficial when the health care provider must explain to a court the dangerous health effects of living without heating or to document the extent of a patient's disability in order to secure benefits.
4. Growth and Sustainability
In his 1920 book Justice and the Poor, Reginald Heber Smith identified the "greatest weakness of organized legal aid work" as "its lack of funds." As every legal aid attorney knows, even the best-laid plans for serving low-income individuals can go awry because of a lack of funds. MLPs are no exception. MLPs that depend solely on funding from already-stretched legal aid partners, or from philanthropic grants that may not be renewed, often fizzle out.
However, as health care payors and providers increasingly search for ways to improve the health of populations while lowering costs, MLPs have emerged as a sustainable solution and one for which many health care organizations are willing to pay. MLPs are showing their value, not just to the benefit of patients but as a means to reduce costs. For example, MLPs have recovered costs for hospitals by challenging Medicaid coverage denials. They have helped individuals with complex conditions avoid repeated trips to the emergency room by helping to secure housing and affordable medicines. Health care funders have taken note, as the examples below demonstrate.
First, as of 2014, health centers can receive supplemental funding from the federal Health Resources and Services Administration to pay for civil legal services. They are now considered equal to other ancillary but vital services that enable individuals to receive health care or achieve good health, like getting a ride to the health center or having a language interpreter in the exam room.
In addition, the U.S. Department of Veterans Affairs (VA), which provides medical care through its Veterans Health Administration to more than nine million veterans each year, now encourages its VA Medical Centers to provide free space for community legal agencies to provide care on-site. Twenty-two medical centers are now offering fully integrated MLP services. MLPs serving veterans address many of the legal issues they most commonly experience such as child support, homelessness, and preventing eviction and foreclosure. Through its Supportive Services for Veteran Families program, the VA offers funding for organizations that provide legal services to homeless veterans or those at risk.
Exciting new funding opportunities for MLP are also emerging. For example, the federal Substance Abuse and Mental Health Services Administration recently invited state mental health agencies to apply for block grants to fund programs like MLP that address the social determinants of health for patients with mental health or substance use issues. Through its Accountable Health Communities program, Medicaid is experimenting with whether screening for the social determinants of health—and funding community partnerships to address uncovered problems—will save money. In the future, this program could be used to develop MLPs as one approach to treat social conditions affecting health. In the meantime, initiatives like Los Angeles County's Whole Person Care are piloting the integration of legal services for high-risk Medicaid patients.
5. Measuring Value for Long-Term Sustainability
Just as the ABA has thrown its support behind pro bono and legal aid in recognition of the routine denials of justice that take place based on poverty, the ABA understands the value of and promotes MLPs, because it understands that health is negatively affected by poverty and related social factors. MLPs provide opportunities for the private bar, as many MLPs rely upon pro bono attorneys for referral or collaboration, as well as professional development for attorneys who are unused to working across sectors. Critically, MLP also enables lawyers to work upstream in a preventive capacity. As more and more MLPs begin to systematically track their progress, including by measuring improvements to the health and well-being of those served and the financial benefit to health care organizations, the MLP movement is poised to only grow stronger.