Symposium on Building Academic Agenda for MLPs

On March 3, 2017, the Solomon Center for Health Law and Policy at Yale Law School held a one-day symposium on building an academic agenda to enhance the practice of Medical Legal-Partnerships (MLPs). This event was co-sponsored by the Yale Journal of Health Policy, Law and Ethics, which is publishing an upcoming special issue focused on MLPs; the Yale Health Law and Policy Society; and Yale’s US Health Justice Collaborative and supported by the Oscar M. Ruebhausen Fund at Yale Law School.

MLPs integrate legal services into health care settings to enable more holistic care addressing social determinants of health, increase access to justice, and “treat” legal issues early avoiding crisis. The symposium was structured around three main panels on MLP interactions with health policy, meeting the needs of marginalized communities, and measuring the impacts of legal services on health. Additionally, the symposium presented an opportunity to grapple with the role of MLPs with the likely demise of the Affordable Care Act. Tweets on the symposium are available at #MLPSymposium, and additional information and videos from the various sessions are available.

The Solomon Center supports student work in five MLPs across the continuum of care and life experiences. These MLPs serve five distinct populations: immigrants, veterans, children, former prisoners transitioning back into the community, and palliative care patients.

Tamar Ezer, the Executive Director of the Solomon Center for Health Law and Policy, welcomed participants to the symposium and introduced the speaker for the day’s opening remarks: Bill Aseltyne, the Senior Vice President and General Counsel and Chief of Staff to the CEO at Yale New Haven Health.

Aseltyne set the scene for the symposium by describing the breadth of the Yale New Haven Hospital System’s (YNHHS) medical care. The system is composed of five hospitals, employs more than 24,000 individuals, and recorded 129,000 patient discharges and two million outpatient encounters last year. Aseltyne described how YNHHS continuously strives to improve the quality of the care delivered, control its medical costs, and enhance access to care within the hospital.

To fulfill this last goal, YNHHS has engaged in numerous efforts to help patients who are particularly vulnerable due to their income or citizenship status. To help address the social and legal conditions that threaten patients’ health, the hospital system has set-up MLPs with a pediatric care clinic, palliative care clinic, transitions clinic for recently incarcerated patients, and clinic for the undocumented and uninsured. Aseltyne also noted that the hospital is engaged in ongoing efforts to address the concerns of undocumented and immigrant patients in light of the November election.

Aseltyne concluded his remarks by describing a powerful personal story that motivated him to pursue a legal career that would allow him to advocate on behalf of patients. Before law school, while volunteering for a clinic that treated patients with HIV/AIDS, Aseltyne witnessed firsthand how discrimination and prejudice caused a patient he worked with to endure enormous personal suffering. The story he told gave a voice to the core mission of MLPs and to the motivation behind this conference: to understand how law and medicine can be used together to better the lives of vulnerable patients and mitigate disparities in health care.

Moderator Samantha Morton set the scene for the discussion on MLPs and Health Policy by asking the following questions: as medical and legal professionals, how can we ensure that people get the care they need? How do we respond with solutions and shape policies that are responsive to the barriers patients face?

Professor Joel Teitelbaum began his remarks by identifying three reasons MLPS should be tools used by social justice advocates in health care moving forward. These included: (1) lawyers and medical practitioners have a rich history of working together; (2) law is the most important social determinant of health (for example, consider the enforcement of housing codes, the litigation concerning Medicaid expansion, and disparate sentencing of crack versus powder cocaine); and (3) MLPs get to the heart of issues of equity in health care. To this third point, Teitelbaum emphasized that controlling costs and emphasizing value over volume in care will be critical to ensuring health equality in the future. Now that the Affordable Care Act is on the chopping block, advocates will need to think hard about how to keep pushing the system in the right direction.

Professor Emily Benfer discussed her MLP’s efforts to combat widespread lead exposure that disproportionately affects low-income communities of color in Chicago and nationwide. She used this example to define the MLP policy framework and show how MLPs have a distinctly inter-professional lens between public health, science, social work, law, and medicine, among others. At the center of this work, Professor Benfer explained, is the patient. Medical and legal partners should consider whether they take a patient-centered or population-centered approach when seeking health equity. Benfer provided a case study about a Health Justice Project case in which an entire household reported chronic lead poisoning. She and Professor Allyson Gold represented the family to end the family’s exposure to a lead hazard. Professor Benfer further determined that the client represented 2.5 million additional families across the country at risk of lead poisoning in federally-assisted housing. Following the MLP policy approach, she convened a “big tent” coalition of diverse professions and non-profits, and they developed a policy strategy that included a petition for rulemaking to the U.S. Department of Housing and Urban Development, digital media, grassroots organizing, and congressional advocacy. In less than a year, the federal government changed its definition of lead poisoning and amended related regulations, leading to safer standards and a shift towards primary prevention in federally assisted housing. 

Professor Yael Cannon and Dr. Andrew Hsi next spoke about their work in New Mexico on education, prevention, and treatment around adverse childhood events and traumatic experiences connected to poor health and justice outcomes. Their presentation stressed the importance of designing advocacy efforts that include research since many issues faced by vulnerable patients lack data. Cannon and Hsi joined a legislative taskforce in New Mexico and commenced a study on incarcerated minors and their experiences with trauma. Their investigation revealed that many of these children had eight to nine traumatic adverse childhood experiences, were far more likely to have adverse health conditions, and were more likely to attempt suicide and struggle with substance abuse disorders. After partnering with the state child welfare agency and the New Mexico Sentencing Commission to publish their findings, Cannon and Hsi used this information to raise awareness of the effects of childhood trauma with the local judiciary and advocate for policy changes at the county and state levels. Hsi then received a grant from Bernalillo County to develop a comprehensive legal and medical model of care for youth in the juvenile justice system, the ADOBE Project. Hsi and the ADOBE team will start a clinic as part of the University of New Mexico’s Medical Legal Alliance to serve the needs of youth in the juvenile justice system that will include law students and faculty. Cannon is in the process of launching the Georgetown University Health Justice Alliance, which will deploy Georgetown law and medical students and faculty to collaborate through an MLP partnership to address the needs of children and families affected by trauma.

To close the panel, Jay Sicklick’s remarks focused on how the Center for Children’s Advocacy has treated health as a civil right. Like Benfer, he emphasized the importance of MLPs as a tool that brings patients at the center of legal advocacy. By working with patients, advocates can create better solutions for system-wide change. Sicklick emphasized that lawyers have two key tools in health settings: (1) the ability to enforce current legal protections for patients and (2) the ability to advocate for new legislation that promotes health equity. As an example, the Center for Children’s Advocacy lobbied the Connecticut legislature to encourage providers to supply more behavioral health screenings.

During the Q&A, audience members asked about the opioid epidemic, the involvement of universities and the American Bar Association in educating future lawyers about social determinants of health, the existence of international MLPs, the use of MLPs in predatory gambling contexts, and the future of Medicaid.

The second panel shifted from a broader policy perspective to a more direct, frontline orientation on MLPS and Communities. Randye Retkin moderated this panel as a conversation exploring how best to meet the needs of particular marginalized communities, including former prisoners, people with HIV, palliative care patients, immigrants, and transgender youth and lessons from this work. Panelists provided both medical and legal perspectives on the value of integrating legal services into medical care. In working with recently incarcerated patients, Dr. Lisa Puglisi related, “All the medical help can be sidelined if someone does not have their social security benefits or social needs met.” Dr. Christy Olezeski shared that it was “empowering” for parents to have a contact to discuss legal and social concerns regarding their trans children. Professor Medha Makhlouf described how, in her experience, immigrant clients are less likely to access health care services due to confusion about eligibility for benefits, concerns about immigration enforcement, and language considerations resulting in difficulties communicating and completing basic forms. She explained how MLPs can help immigrants overcome these barriers and, in turn, makes them more likely to obtain the medical services they need. She further shared that for an educator, MLPs provide “an excellent platform for teaching students how social determinants of health are the root cause of health disparities and how structures of poverty and inequality are the root causes of social determinants of health.” She hopes to create a pipeline of lawyers who focus on social justice, health, and law.

Panelists also discussed the importance of communication between medical and legal professionals and with patients. Communication can be particularly difficult with different professional ethics on issues like confidentiality. Moreover, lawyers and physicians sometimes speak a different language. Dr. Susan Cohen recommended coordination through co-location and pre-meetings. Puglisi urged the use of language by medical and legal professionals that “puts the power back in the hands of patients, who can be members of systematically disenfranchised classes.” MLPs should be constructed around patient needs, and patients should be the ones determining their needs.

Panelists additionally discussed the challenges involved in serving marginalized communities in the current political climate. Puglisi recommended looking beyond the medical center and reaching back into communities and connecting with community organizations and networks with the help of community health workers. Makhlouf suggested that MLPs and other advocates for immigrants prioritize organizing Know Your Rights Trainings and assisting with safety planning over direct representation. She also discussed her plans to help create a pipeline of medical professionals to conduct forensic evaluations of immigrants who have experienced torture or trauma; these evaluations can improve a client’s chance of success in humanitarian immigration claims. Cohen discussed how current political policies can become public health crises—such as if undocumented patients develop a higher rate of no-shows for medical appointments due to fear of immigration enforcement—and urged data collection and advocacy. Alice Rosenthal likewise emphasized the advocacy prong of MLPs and stressed the power of the health establishment and health professionals on the frontlines, with the support of lawyers, to issue public statements against injustice, sign on to amicus briefs, and attend government hearings. Geoff Wertime reminded participants that communities have survived tough political times before. In fact, Housing Works emerged from the HIV crisis and the weak government response in the 1980s when community members came together and creatively addressed issues. Currently, there are opportunities for change and progress at the state and city levels.

The panel agreed that MLPs are as relevant as ever and can play an important role in both service provision and advocacy for reform. In fact, it would be good to expand MLP services during this time of high need by also engaging the private bar, social workers, and service-extenders, like law and medical students.

The symposium’s final panel focused on how to measure the impact of legal services in the lives and health of MLP patients, critical for advocacy based on MLPs’ value. Moderator Emily Wang, herself a clinician, opened the panel by pointing out that data often drives decision-making in the medical world: data determines what gets resourced and what programs are sustained. MLPs increasingly need to address what data and evidence exist to support advocates’ oft-made assertion that legal interventions add value to patient outcomes—and they face the tricky task of doing so across heterogeneous patient populations, medical conditions, and legal cases.

The four panelists who joined Wang each shared their experiences in measuring MLP value. Ellen Lawton, the Co-Director of the National Center for MLP, noted that “the era of the anecdote is passing” for MLPs. With legal aid funding facing an uncertain future, lawyers need to demonstrate to health care providers how MLPs impact outcomes they consider important. The legal community has not historically been data-driven, and MLPs likewise have not yet developed robust data on legal services as reliable tools to address social determinants of health. For MLP lawyers struggling with measurement, she recommends turning to public health professionals to help bridge the gap between anecdotal value-added (client empowerment, greater interdisciplinary cohesion) and more precisely- defined outcome measurements.

Professor Allyson Gold described a data collection study she conducted with Professor Emily Benfer and partners at Loyola’s Department of Public Health and Erie Family Health Center. Gold and Benfer completed a logic model detailing the different inputs, outputs, and assumptions in the Health Justice Project and worked with partners to design a retrospective study to determine whether patients who received legal interventions later demonstrated decreased blood lead levels, improved asthma or diabetes symptoms, and whether the health effects varied based on the type of legal intervention the patient received.  The study will hopefully inform future legal services provided by MLPs to improve health outcomes. 

Similarly, Margaret Middleton and Dr. Jack Tsai described their efforts to demonstrate to the Veterans Administration the impact of legal serves on veteran mental health and well-being. First and foremost, they found it critical to track the basic who, what, and how of the Connecticut Veterans Legal Services Center’s MLP interventions (and subsequent outcomes) for the veteran population. Both emphasized the need to define legal interventions more specifically when tracking MLP activities and linking them to value outcomes: as with medicine, legal services come in both various types and dosages. They expressed the need for a conceptual framework for how MLPs operate, complete with logical assumptions that can be tested at each level. Their initial study without a control found a reduction in symptoms of hostility, paranoia, and psychosis among clients three months after they received legal representation and improvements in housing and income one year later.

The panel closed in agreement that MLP teams need to affirmatively prioritize services where value can be measured and communicated. Data will help health care partners—whether doctors, hospital administrators, or insurance companies—understand what lawyers do for patients and why addressing social determinants translates into the improved health outcomes invested in by these institutions.

Miriam Becker-Cohen and Claudia Wack, law student directors of the HAVEN MLP, delivered closing remarks from the student perspective.

Becker-Cohen described the work of the HAVEN MLP, which is interdisciplinary and student-run and focuses on issues including immigration, housing, wage theft, and medical debt. She shared that the day was special because it offered a space for reflection and connecting law school experiences to the work students hope to do one day. She valued the opportunity to hear from a wide variety of individuals from different disciplines in the MLP world and found it an empowering reminder of the many people who care about health and health care for all as a human and civil right, regardless of race, ethnicity, citizenship, gender identity, or socioeconomic status. In a time when a lot of MLP and legal services work is focused on keeping afloat clients with urgent needs, it was particularly helpful to hear how to connect direct services, on-the-ground experiences, and client stories with advocacy that has a broader impact.

Wack shared how, at Yale Law School, a seminar component has been integrated into the MLP programs for the first time this year. She described how this has been “a great catalyst” for critical reflection, academic writing based on the MLP experience, and dialogue with others doing this type of work. She expressed appreciation for the MLP Symposium as providing insights into potential ways to be involved in MLP work beyond law school and as an opportunity to connect with leaders and pioneers in the MLP field.

Tamar Ezer, the Executive Director of the Solomon Center for Health Law and Policy, then thanked the various presenters and moderators, as well as all the people working behind the scenes to make the symposium a success, and invited participants to continue conversations over a wine and cheese reception.