It is widely accepted in the medical field and elsewhere that social and environmental factors in a person’s life can seriously impact that person’s health and general well-being. These social and physical factors are referred to as “social determinants of health,” and they may cause issues that cannot be prevented with a vaccine or removed by a surgical procedure. Homelessness, food insecurity, poor housing conditions, and domestic violence are all factors that may cause patients to turn and return to urgent care clinics and emergency rooms. Medical care providers are regularly disturbed and frustrated by the issues they have little control over and yet hamper their patients’ ability to get better and remain healthy.
Social and Environmental Factors
Social Determinants of Health
- Availability of resources to meet daily needs, such as educational and job opportunities, living wages, or healthful foods
- Social norms and attitudes, such as discrimination
- Exposure to crime, violence, and social disorder, such as the presence of trash
- Social support and social interactions
- Exposure to mass media and emerging technologies, such as the Internet or cell phones
- Socioeconomic conditions, such as concentrated poverty
- Quality schools
- Transportation options
- Public safety
- Residential segregation
Physical Determinants of Health
- Natural environment, such as plants, weather, or climate change
- Built environment, such as buildings or transportation
- Worksites, schools, and recreational settings
- Housing, homes, and neighborhoods
- Exposure to toxic substances and other physical hazards
- Physical barriers, especially for people with disabilities
- Aesthetic elements, such as adequate lighting, trees, or benches
What Is a Medical-Legal Partnership?
From this frustration and a desire to help patients, Dr. Barry Zuckerman, Chief of Pediatrics at Boston Medical Center, developed the first Medical-Legal Partnership (MLP) in 1993. As the name suggests, it is a collaboration between lawyers and medical care providers to assist disadvantaged patients who experience certain barriers to being and staying healthy. Physicians, nurses, case managers, and social workers can refer patients to a lawyer for assistance in tackling these negative social determinants of health. The model has taken off and become a niche field at the intersection of health law, policy, and public interest advocacy. There are more than 450 MLPs across the country, covering 49 states and Washington, DC. Medical-legal partnerships are housed in hospitals, clinics, and specialty healthcare settings, such as children’s hospitals and veterans affairs hospitals.
The National Center for Medical-Legal Partnership (NCMLP), established in 2006 within the Milken Institute School of Public Health at George Washington University, serves as a clearinghouse for education, research, and technical assistance. NCMLP hosts a summit each year for attorneys, physicians, nurses, and social workers to share best practices and train new participants.
How Does an MLP Work?
MLPs can fit into existing medical care programs of any size, from large hospitals to remote clinics. NCMLP created the acronym I-HELP to identify the common health-related social and legal needs: Income, Housing and Utilities, Education and Employment, Legal Status, and Personal and Family Stability. A medical-legal partnership may offer legal assistance in one particular area, such as immigration status, or provide a broad range of services. After conducting an intake and assessing the client’s legal issues, an MLP may refer cases to appropriate legal aid providers, provide full representation through staff attorneys, or rely on a pro bono network to take cases.
At Boston Children’s Hospital (BCH), the MLP program has assisted more than 1,200 individual cases since its creation in 2015. BCH’s MLP is led by a legal fellow hired for a two-year grant who operates out of the hospital’s office of general counsel, making it a unique in-house position. Fellows are responsible for screening referred patients, completing intakes, sharing resources, and connecting families to pro bono assistance. Referrals to the fellow can come from any of the dozens of hospital departments, some of which are satellite locations. Referrals typically come from BCH’s primary care clinics, where patients see their pediatrician. BCH attracts people from all over the world who need specialty care, so there is great diversity amongst the families sent to the MLP for assistance. Some of the children referred are inpatient or very medically fragile.
BCH’s MLP handles various legal issues, including immigration, benefits, special education, and family law, and the largest concentration is landlord-tenant issues, making up more than one-third of the cases. Families must qualify as low-income to be screened formally into the program, though BCH provides basic guidance to families that do not qualify. To avoid a potential conflict of interest, the legal fellow generally does not offer full representation to patient-families. Instead, the fellow provides limited assistance representation and helps families by either making a handoff to a local legal aid office (BCH has a close relationship with Greater Boston Legal Services), a law school clinic, or a pro bono attorney. Some cases can be tough to place, perhaps because of an unusual legal issue or if there is not much capacity for others to help. When that happens, the fellow can be more hands-on, walking the family through self-help options or providing limited assistance representation. The fellow also acts as a resource to hospital staff, particularly to the devoted social workers and resource specialists assigned to the various hospital departments.
Not all medical-legal partnerships operate within the healthcare institution with which they collaborate. MetroWest Legal Services (MWLS) in Framingham, Massachusetts, located 18 miles west of BCH, has had a dedicated MLP attorney on its staff since 2014. This attorney collaborates with the Edward Kennedy Community Health Center, a clinic serving low-income residents from widely diverse backgrounds. The health center serves a very high population of ethnic and racial minorities, and most of the staff attorney’s clients are immigrants from Central and South America. Though MetroWest’s MLP attorney is considered a “generalist” in terms of practice areas she handles, she naturally receives many immigration cases (e.g., asylum, special immigrant juvenile, and other protected status cases) given the patient population she serves. The attorney also frequently helps immigrant clients access benefits and healthcare, a challenging process for immigrant families to navigate. Like the BCH Fellow, the MWLS staff attorney provides technical support and training to clinical staff on relevant legal issues that patients experience.
Communication and regular feedback are crucial elements for every successful medical-legal partnership. First, the frontline healthcare providers act as screeners, asking medical patients if they are affected by social and environmental determinants of health. Then, the legal side must be responsive and provide advice, referrals, or representation. Finally, medical and legal partners must give feedback to one another about additional questions to be asked. That way, more patients can be screened in and receive assistance promptly.
How Can a Legal Answer Help Address a Medical Problem?
Medical-legal partnerships acknowledge the connection between legal barriers, legal injustices, and health outcomes. More than a third of the intakes conducted by BCH’s MLP involve housing issues. The reason for the high number of housing-related referrals is a complicated and multifaceted question to try and answer. At best, Boston has a precarious rental situation, and at worst (and more likely), it is in a full-blown housing crisis. Like many areas in the United States, Boston has a supply-and-demand issue for housing and limited affordable rental stock. Boston is one of the top five most expensive cities to live in in the United States when it comes to housing. The average monthly rent for a two-bedroom apartment is over $3,000 per month, more than double the national average.
Massachusetts has a state-run emergency assistance housing program for some low-income families, and lawyers are often crucial to families who are denied or terminated from the shelter program. Medical-legal partnerships in Boston and Framingham will undoubtedly see these shelter cases. Cases involving poorly maintained housing conditions by landlords are also common, especially from BCH’s asthma program clinicians who feel strongly that mold or pest residue in the apartment is exacerbating the patient’s asthma. It is difficult, if not impossible, to comprehensively treat childhood asthma if the home in which a child is living has conditions that exacerbate the illness. A housing attorney can assess whether there is a landlord-tenant matter that can resolve an underlying barrier to better health. Of course, eviction defense presents itself frequently as well.
MLP in the Time of COVID-19
When Massachusetts’ COVID-19 eviction moratorium was set to expire, BCH social workers were eager to learn how they could assist the many families that would be impacted. Current fellow Leah Porter arranged a well-attended Zoom training session to inform and prepare staff on what to expect and when to direct patient-families to certain eviction-related protections granted by the federal government.
Operation of the fundamental aspects of medical-legal partnership clinics during the COVID-19 pandemic has not changed. The day-to-day work is now remote for many programs, but helping families in crisis is nothing new for MLP attorneys. The types of issues are generally the same, but the level of need and the cause of the hardship are now tied to the pandemic’s economic impact. Government agencies that oversee benefit programs or rental assistance programs are overwhelmed with applications.
Although there are differences in how these various programs provide services, one thing is for sure: to be a medical-legal partnership attorney is to be a poverty law attorney. Further, to be a poverty law attorney means that you will very likely witness troubling racial disparities. Racial gaps in wealth and socioeconomic status are tied to inequalities in life expectancy and chronic disease rates. Statistically, the average low-income client has at least two legal issues happening at once, which can be challenging, but also great for an attorney who likes some variety in their practice. When one domino falls, others are likely to fall with it. If your benefits are mistakenly disrupted, how might that impact your ability to pay rent? The legal issues are not easy, and it can be hard to hear the heartbreaking stories of some families that lay beneath the technical legal analyses. For this reason, the success stories are easy to relish.
The following stories are true; client names have been changed to protect their privacy.
Sonia came to the United States so that her medically complex five-year-old could receive the care he needed. She arrived from the Dominican Republic using a visitor visa, allowing her and her child to stay in the United States for six months. The visitor visa prevented Sonia from working, and even if she was allowed to, she needed to care for her special-needs son. Given the family’s immigration status, they were not eligible for federal affordable housing programs. Affordable state housing (with fewer restrictions) had a waitlist of several months, if not years. Their only option was to double-up with relatives, sleeping together on a mattress placed in the kitchen. Food stamps and welfare benefits were not an option for her either, and Sonia was virtually dependent on her family’s generosity. Sonia sought assistance with her immigration status, but she was swindled by a “notario,” or a person fraudulently posing as an immigration attorney. Notarios are known for accepting a retainer of hundreds of dollars before disappearing. With her visa set to expire, she felt trapped until being referred to BCH’s MLP. Once the MLP assessed her needs, they connected her with a legitimate pro bono attorney who represented her and her child with a Medical Deferred Action application to the US Citizenship and Immigration Services Office (an application that is generally very confusing for laypeople to complete on their own). The application is currently pending, but the family was put in the best legal position possible thanks to the MLP.
Janet was a young mother whose daughter had various medical complexities. They moved to the greater Boston area to receive appropriate treatment at BCH. When she was referred to the MLP, Janet needed a place to stay because her boyfriend had become violent. At the same time, her daughter needed an aide at school, and Janet was having issues with Social Security benefits due to the move. There was so much on her plate, but she was determined. The MLP fellow advocated on her behalf before the Department of Housing and Community Development and secured temporary emergency housing at a motel. With continued advocacy, Janet secured long-term subsidized housing within weeks. With the help from her primary care provider, the MLP fellow was also able to advocate for a 1-to-1 aide at the daughter’s school and to connect Janet with a pro bono attorney for the social security matter.
How Can You Become an MLP Attorney?
MLP attorneys are often full-time attorneys based at a legal aid agency, but they also might be embedded with a medical center or a law school. The ABA Medical-Legal Partnership Pro Bono Project and the National Center for Medical-Legal Partnership offer state-by-state guides that highlight local MLP programs. Many MLPs rely on pro bono attorneys who can take referral cases. They may also provide training and supervision for attorneys who agree to take a case. This is a great way to learn more about your local medical-legal partnership.
Many career paths can lead to working with an MLP. For example, after law school, a family law clerkship can introduce you to topics like child dependency and neglect while also exposing the lawyer to how the healthcare system can combat inequities. Masters of Public Health programs can also expose individuals to topics that form the foundation of the work performed by MLPs. Finally, if you do not have a background in the social determinants of health and healthcare issues but are interested in poverty law, immigration, family law, or other legal aid topics, you can volunteer on a pro bono basis to work with an MLP to take referral cases.