Medical-Legal Partnership: A Powerful Tool for Public Health and Health Justice

A medical-legal partnership (MLP) is a collaboration between a health care organization and a public interest law organization to address health-harming social needs that have civil law remedies. In August 2018, the Robert Wood Johnson Foundation’s County Health Rankings and Roadmaps program compiled evidence of the effectiveness of MLPs. This compilation indicated that, among other things, MLPs can improve patient health outcomes, improve patient well-being, improve patient mental health and reduce patient stress, improve patient adherence to recommended medical treatment, remove barriers to health care for low-income families by addressing cost and insurance concerns, and increase access for individuals and families to stable housing and other social supports.¹ This impressive, although nonexhaustive, list of potential MLP benefits nonetheless begs an important question: Are MLPs best viewed as a downstream, individual (ie, patient) health care intervention that activates only after physicians, social workers, and case managers have worked to the top of their license to assist a patient in need, or can an MLP also properly be viewed as an upstream, population health intervention able to effect policy change at the institutional, community, and even broader levels?

We contend that MLPs can operate at both the individual and population levels. We begin by providing a brief overview of MLPs and then turn to a discussion of MLPs as a public health law intervention. Finally, we describe opportunities for collaboration among MLPs, public health lawyers, and public health practitioners.

An Overview of MLPs

The health care organization partner in an MLP is often a community health center or a private or public hospital. The legal partner is typically either a lawyer trained in poverty and administrative law who works for a nonprofit legal services organization or a law school clinic that trains law students under the tutelage of a law professor. MLPs stand on the shoulders of earlier alliances between physicians and lawyers²—for example, during the Civil Rights era and in the earliest battles against the HIV/AIDS epidemic—and they aim to build on these earlier successes to make legal expertise and assistance a normative aspect of health promotion and well-being.

Currently, MLPs are active in about 330 hospitals and health centers in 46 states.³ Although MLPs form in various settings, consist of various types of partners, and care for various patient groups, they tend to share 8 core components:

1. A formal agreement that typically outlines the partnership’s goals, respective responsibilities, and patient privacy protections;

2. The designation of a defined patient population to be served, with low-income and otherwise vulnerable populations being the most common;

3. A strategy to screen patients for legal needs that cannot be easily addressed by social workers or case managers;

4. Defined staffing arrangements, which typically include some dedicated health care staffing and 1 or 2 full-time lawyers (and in some cases, additional pro bono assistance from lawyers in private practice);

5. A “lawyer in residence” at the health care setting (ie, on-site legal services) for a defined amount of time every week, which enables attorneys to respond quickly to both patients and clinicians;

6. Training of health care staff members by MLP lawyers to help health clinicians recognize when legal interventions may be advisable;

7. An arrangement for information sharing between partners (some partnerships negotiate fully developed agreements that allow data to flow across organizations, either through parallel systems or directly within protected areas of the health organization’s electronic health record); and

8. Funding expressly devoted to the partnership, often a combination of direct funding by the health care and legal organizations, in-kind resources, external grants, community benefit funds, foundation funding, and charitable donations.⁴

Within this framework, MLPs assist patient populations with a range of health-harming social and legal needs that closely correspond to what are commonly viewed as social determinants of health. For example, it is not uncommon for clinician and lawyer collaborators to address patient needs related to public benefits (eg, access to public health insurance programs and Social Security income), food insecurity, housing (eg, evictions, habitability, wrongful utility shutoffs), special education, employment instability, immigration status, family matters (eg, custody/visitation rights, domestic violence), and other matters that contribute to poor mental, emotional, and physical health. And these health-harming social and legal matters are hardly uncommon. According to a 2017 survey by the Legal Services Corporation (an independent nonprofit organization established by Congress to provide financial support for civil legal aid to low-income Americans), 71% of low-income households had at least 1 civil legal problem in 2017, including problems with health care, housing conditions, disability access, veterans’ benefits, and domestic violence; fully 86% of those problems received inadequate or no legal help because of resource constraints; and low-income Americans approached Legal Services Corporation-funded organizations for support with an estimated 1.7 million problems overall.⁵

Thus, MLPs can help provide enormous downstream health (and financial) benefits to individuals and families. At the same time, they also have value in the quest for improved population health and health equity. The next sections turn to a discussion of MLPs in these contexts.

MLP as a Public Health Law Intervention

Increasingly, public health professionals are recognizing law as a powerful tool to advance population health. Typically, when people think of public health laws and policies, they focus on policies that address large-scale public health concerns (eg, environmental protections). In response to ever-growing evidence of multilevel health inequities, however, lawyers, public health professionals, and policy makers are exploring more effective ways to shape, measure, and enforce laws that have the greatest effect on disadvantaged populations. One challenge of using law as a public health intervention is determining its effectiveness for advancing health for a targeted population. Public health law research⁶ and legal epidemiology⁷ have been important mechanisms for measuring the effectiveness of public health laws in achieving their intended outcomes. Collaboration between MLPs and public health offers an additional mechanism to better understand the effects of laws and policies on vulnerable individuals and populations.

Laws that affect the social determinants of health and population health are numerous, and often they are not public health laws, per se. Instead, they encompass various laws and regulations ranging from housing safety codes, to public safety-net entitlements, to employment protections, to immigration laws. Often, these laws serve as the greatest structural barriers to health for vulnerable and disadvantaged populations, because they are not written with the health of these populations in mind, because they are inequitably applied across populations, or because they go unenforced. Indeed, it is particularly important in advancing the health of vulnerable and disenfranchised communities to assess not just the “laws on the books” but also the “laws on the streets”⁸—how laws are implemented and enforced, or, more pointedly, where law and policy failures and enforcement gaps lead to health disparities.

Disparate enforcement of housing safety codes is a prime example of how law plays an important role in racial and economic health disparities. On the books, these laws are intended to ensure the health and safety of tenants, providing standards and obligations for property owners, with the threat of fines for failing to meet those obligations. Yet these laws are woefully underenforced on behalf of low-income tenants, leading to substantial racial and socioeconomic disparities in health, such as higher rates of lead poisoning and asthma in low-income and African American children compared with higher-income and non-Hispanic white children.⁹ Often, this underenforcement goes unnoticed and unaddressed because vulnerable populations are not empowered to challenge complex and inefficient bureaucratic systems that are, theoretically, designed to serve them.

One benefit of MLPs is that they can detect the often-gross injustices that fall into the gap between “laws on the books” and “laws on the street” by working directly with patients and clinical partners in community-based clinics. But the scope of MLP goes beyond clinical settings. MLPs are also important partners to public health lawyers and practitioners, because MLP practitioners can both inform the design of larger-scale laws, policies, and interventions aimed at improving health equity and point to disparate enforcement or unintended consequences of well-meaning laws as implemented. For example, public health departments that are tasked with enforcement of lead safety laws may be unaware of potential downstream effects of the enforcement process on low-income tenants. In some communities, MLPs have witnessed retaliatory evictions of families whose children have been poisoned by lead when property owners are threatened with enforcement of lead safety laws. Thus, enforcing laws that protect families from retaliatory eviction can prevent the double jeopardy of having a child poisoned by lead and becoming homeless if a landlord retaliates against a tenant exercising the right to safe housing. By working in the community with patients and populations, MLPs serve as the eyes and ears of public health law and policy, identifying important gaps leading to disparities.

MLPs also facilitate collaborations beyond clinical care professionals and public interest lawyers. Health care delivery reforms are incentivizing new clinic-to-community partnerships intended to connect patients to social service providers and, thus, better address social needs that drive poor health and increase medical spending. With the progression toward value-based payment and the greater adoption of team-based care models (eg, patient-centered medical homes), community health centers, clinics, and hospitals are investing in a range of professionals to fill out their holistic health teams.¹⁰ These team members (eg, social workers, care coordinators, and community health workers) are often close allies with MLP attorneys in identifying structural and legal barriers to health, helping patients navigate complex and overtaxed social service systems, and helping patients access resources.¹¹ Integration of social care into clinical care is still evolving, but it is an important advancement in linking medicine to public health by recognizing that clinical care is but one (small) part of health and that a patient’s social environment is important to overall well-being.¹²

However, there is a danger that success in this arena will be measured simply by whether a referral from clinical care to social care has been made (ie, a box can be checked) without tracking subsequent patient outcomes and success in accessing the services and care needed to improve health. Given the complexity of government agency bureaucracies, grossly underresourced community-based social service programs, and the realities of overburdened clinicians, many vulnerable patients fall through the cracks. With training in the machinations of social service systems, government bureaucracies, and legal rules and rights, MLP professionals navigate these complex systems to not only assist patients in exercising their rights but also to hold accountable the multiple systems with which disadvantaged populations interact (government bureaucracies, the health care system, the criminal justice system, and others).

By embedding legal professionals in clinical care settings and partnering with a host of community-based providers and advocates (eg, housing advocates, community action programs, public health departments), MLPs help improve cross-sector communication and problem solving. They also shine a light on the systemic barriers that drive health disparities and help to identify upstream policy changes that can alleviate some of these barriers. One example of the role of MLPs in the identification and removal of upstream structural barriers to health is the Cincinnati Children’s Medical-Legal Partnership’s work to help low-income mothers enroll their newborns in the Supplemental Nutrition Assistance Program (SNAP). Clinicians identified food insecurity among mothers of newborns as a big problem; mothers were not enrolling their newborns in SNAP or had substantial delays in obtaining benefits because, to do so, they had to jump through multiple administrative hoops. To wit, (1) the new mother had to call the Department of Job and Family Services (JFS); (2) JFS would then send a “baby packet” to the mother, who had to fill out the paperwork and return the packet by mail; and (3) even if the packet was filled out completely and accurately, there were often further delays (eg, JFS’s failure to scan the information into the computer). The Cincinnati Children’s MLP found that the delays caused an average loss of $154 in food benefits when nutrition for the mother and baby were critically important to maternal health and early childhood development. The MLP advocated for changes to the policy and procedure, ultimately leading to a new streamlined process: JFS got rid of the baby packet, now receives birth records directly from the Medicaid program, checks to see if the family already receives SNAP benefits and, if so, automatically enrolls the newborn. The MLP expects that the policy change will help 150 mothers per month access SNAP benefits in a timely manner at a critical time for healthy newborn development.¹³

Opportunities for MLP–Public Health Collaboration to Improve Public Health Laws and Policies

Because MLPs detect policy failures “on the ground,” they can be critically important partners to public health professionals in identifying, targeting, and strategizing about laws and policy changes most likely to advance health justice. One opportunity for this type of collaboration centers on community health needs assessments. Under the Patient Protection and Affordable Care Act, tax-exempt hospitals must engage in a community health needs assessment every 3 years and are obligated to include their local health department, community based-organizations, and community members in identifying community health needs.¹⁴ MLPs can inform health care and public health partners about the legal needs and structural barriers experienced by the target population and provide recommendations for a community-based implementation strategy to address those needs.¹⁵ These strategies also inform how tax-exempt hospitals allocate community benefit funds and often help to focus hospitals on more upstream interventions, rather than pure downstream charity care. In addition to tax-exempt hospitals, community health centers and other safety-net providers regularly engage in health needs assessments and quality improvement studies. MLPs can be key partners in collecting and analyzing data and engaging public health researchers, policy makers, and other stakeholders to identify barriers to health for a community and, because of their legal expertise, strategizing about changes to law, policy, and enforcement mechanisms to improve population health.

While other specific examples of MLP–public health collaboration exist, this type of partnering is also being facilitated at a national level. Together, the Network for Public Health Law (NPHL)¹⁶ and the National Center for Medical-Legal Partnership (NCMLP)³ have begun identifying various avenues for collaboration. Thus far, 3 primary objectives have been discussed:

1. MLPs should help inform NPHL of systemic population health issues amenable to wide-scale policy and legal intervention;

2. NPHL and NCMLP should jointly support the involvement of state and local public health agencies in the work of MLPs;

3. NPHL should provide legal technical assistance to MLP attorneys to support population-level policy work.

The formal partnership between these national organizations, although still in its infancy, has already generated and supported cross-sector collaboration among state public health departments, local MLPs, and NPHL regional offices. For example, a collaboration among several MLPs, called Project HEAL (Health, Education, Advocacy and Law), that involves an MLP in Akron, Ohio; Medical-Legal Partnership for Children in Toledo, Ohio; and Health Forward, an MLP through Chicago’s Legal Aid Foundation,¹⁷ identified high rates of childhood lead poisoning as a substantial problem among the populations they each serve. The MLPs observed that low screening rates made it difficult to understand and respond to the full scope of the problem in their communities. The Network’s Mid-States office produced a memorandum outlining current legal screening requirements and legal and nonlegal strategies to improve lead screening rates, drawing on expertise from NPHL’s Mid-States, Eastern, and Southeastern offices. According to M. Curry of HEAL and C.H. Boufides of NPHL, each MLP has used the Network document to work with their local task forces and community partners to explore legal and nonlegal strategies to approach the problem.

Conclusion

Public health practitioners are increasingly embracing law and policy as important tools for improving public health and promoting health equity. To ensure that laws and policies are effective in reaching their goals, understanding their effects on vulnerable populations is critically important. Through collaborative work with health care, public health, and community partners, and by directly serving individuals and families who are most affected, MLPs detect policy failures, inequitable enforcement, and health injustices that may otherwise be invisible to health care administrators, public health officials, and policy makers. By working in collaboration with public health partners, MLPs are powerful allies in driving more effective upstream policy change to promote health justice.