By Mary E. Kennelly, JD, MPH, Policy Analyst, Presidential Management Fellow, ODPHP
When most people go to the doctor’s office, they don’t expect to leave with a referral to see a lawyer. This may be changing. At the primary care centers of Cincinnati Children’s Hospital Medical Center, when a patient presents with asthma symptoms and reports living in rental housing with mold, pests, or other substandard conditions, the family will have the opportunity go down the hall and speak with a legal aid attorney.
This arrangement, called a medical-legal partnership, adds public interest lawyers to the health care team in medical practices that serve vulnerable populations. As part of the health care team, these lawyers train their health care colleagues to identify patients where eviction, loss of employment, or any number of other civil legal problems limit the patient’s ability to achieve full health. The patient is then offered a consult with a lawyer, just as a physician would make a recommendation to consult a medical specialist. A growing body of research shows that medical-legal partnership adoption is associated with reduced hospitalizations, lower stress levels, and improved treatment adherence among patients who receive services from a medical-legal partnership lawyer.
Medical-legal partnerships are just one example of a continuum of legal and policy services needed to support communities in addressing social determinants of health — conditions in the environment in which people are born, live, learn, play, work, and age that affect health. Healthy People 2020 sets 10-year national objectives for improving the health of all Americans and approaches the social determinants of health through a place-based framework with five domains: economic stability; education; social and community context; health and health care; and neighborhood and built environment.
During a recent Healthy People 2020 Spotlight on Health Webinar, the Office of Disease Prevention and Health Promotion set out to raise awareness of law as public health tool to improve health outcomes related to social determinants of health. With presentations from ChangeLab Solutions, Cincinnati Child Health-Law Partnership (Child HeLP), the Cincinnati Health Department, and the National Center for Medical-Legal Partnership, the webinar provided listeners with actionable strategies to address social determinants of health in their communities.
During the webinar, Ellen Lawton of the National Center for Medical-Legal Partnership explained that the five domains of Healthy People 2020’s social determinants framework intersect with common civil legal problems. Using the social determinants lens, it becomes clear that many civil legal problems are health problems. Today, nearly one in seven Americans lives in poverty and each one of these low-income individuals has at least one health-harming civil legal problem.
As an example, Child HeLP described their experience with the transformative impact that a medical-legal partnership can have on a health care organization and a community. During its eight years of operation, Child HeLP has assisted 9,000 children and 4,500 adults, recovered more than $300,000 in unpaid public benefits, and trained more than 450 residents and social workers to treat the social determinants of health. Dr. Andrew Beck, a member of the management committee for Child HeLP, attributes this success to continual learning and flexibility in the face of challenges. Routine data sharing, monthly management meetings, and a deep understanding of each other’s roles has allowed Child HeLP to become an exemplary medical-legal partnership.
Numbers don’t adequately capture the positive impact that Child HeLP has had on the community it serves. One hot summer, the Child HeLP providers noticed an uptick in patients with concerns related to housing quality like illegal eviction threats for use of an air conditioner and complaints about pests, mold, and other asthma triggers. Child HeLP providers charted this information and referred these patients for consults with the lawyers. A pattern emerged. The complaints could be traced to a cohort of rental housing units owned by a single developer. The buildings had multiple code violations. Affiliated lawyers from the Legal Aid Society of Greater Cincinnati assisted residents in forming a tenants’ association. Child HeLP and the tenants’ association advocated for, and with support from the City of Cincinnati, catalyzed the repair of the buildings, affecting 677 low-income housing units.
This example illustrates how medical-legal partnerships can support broader community health promotion. In this instance, change was triggered by the presence of lawyers on the health care team. However, lawyers just like physicians cannot act without permission of individuals they serve. In the above example, the residents’ willingness to demand compliance with the law through the tenants’ association ultimately led to improvements in the housing complex. On a very small scale, this anecdote encapsulates the importance of social will to sustaining legal solutions.
Marice Ashe of ChangeLab Solutions explained that for lawyers and legal tools to have the greatest impact on protecting and promoting health, lawyers need to become part of integrated social change movements by engaging with communities and building political will. As social change agents, they must partner with advocates, researchers, clinicians, practitioners, and policy makers to design, enforce, monitor, and evaluate the effectiveness of the law in achieving intended results.
While legal solutions are necessary, they alone are insufficient for addressing social determinants of health. Achieving the national public health goals and objectives outlined in Healthy People 2020 requires people from all walks of life coming together and taking action to support the health of their communities.
Special thanks to Ms. Marice Ashe of ChangeLab Solutions, Dr. Andrew Beck of Cincinnati Children’s Hospital Medical Center, Dr. Camille Jones of the Cincinnati Health Department, and Ms. Ellen Lawton of the National Center for Medical-Legal Partnership who contributed to this blog and the webinar on which it is based.