By: Marley Manjarrez
Imagine you are a pediatric nurse. Today you are treating a child suffering from an acute asthma exacerbation. You know this child because they are often in your office with asthma flare-ups. You do the best you can to help and are working with a parent dedicated to their well-being. However, you also know it is winter and their home has no heat. Their parent told you that the landlord has ignored requests to fix leaking pipes for the last three years. That child’s home now has excess moisture and black mold. You are treating that child knowing they will be back soon.
As law students, we are taught about the justice gap. The justice gap is “the difference between the civil legal needs of low-income Americans and the resources available to meet those needs.”[1] This gap becomes visible through statistics such as in the United States’ 90% of debtors who are without legal representation,[2] or in 2015, 98% of tenants in eviction cases who were pro se.[3] However, the justice gap cannot be siloed. It is one of many gaps created by systemic underinvestment, discrimination, and poverty. Another is the mortality gap.[4]
Low-income people live shorter lives.[5] A 2016 MIT study found that the wealthiest 1% of men have a life expectancy that is 14.6 years longer than the poorest 1%.[6] Additionally, the impact of medical advancement is not equally distributed. From 2001 to 2016 the life expectancy of the top 5% of the wealthiest women increased by 2.91 years.[7] For the women in the lowest 5%, the increase was only 0.32 years.[8] While these statistics look at income extremes, the MIT study found that “as you go up in the income distribution, life expectancy continues to increase, at every point.”[9] The vast difference in life expectancy experienced by high and low-income people is the mortality gap.
Low-income families are at greater risk for chronic disease and mental illness.[10] Research has also found that children who grow up low-income experience greater incidences of “developmental delays, toxic stress, chronic illness, and nutritional deficits”.[11] Social and environmental factors play such a large role in health outcomes that only “40% of an individual’s health is determined by genetics, medical care, and personal choices.”[12] That means that 60% of health outcomes are determined by “income, housing, education, job stability, personal safety and access to health care and adequate food.”[13] Unfortunately, many of the contributing factors to the mortality gap cannot be prescribed away by a doctor. Social and legal factors such as public benefits appeals and Fair Housing Act claims can be beyond the reach of healthcare providers. It is not, however, beyond the reach of many lawyers. In the 1990s a Boston pediatrician considered this and created the country’s first Medical-Legal Partnership.[14]
Medical-Legal Partnerships (MLPs) integrate lawyers into healthcare settings to assist providers, case managers, and social workers in addressing the “structural problems at the root of so many health inequities.”[15] VCU Health’s MLP works with a range of legal partners such as CVLAS, LAJC, CanerLINC, and McGuireWoods.[16] Together this team provides free legal services to qualified participants for a wide range of legal fields including consumer law, elder law, employment law, family law, health law, housing law, immigration law, and public benefits.[17]
Across the country, similar work is being done in 450 hospitals and clinics in 49 states and D.C. The impact is substantial.[18] In 2022 MLPs “helped more than 75,000 patients resolve legal issues” and “trained more than 11,000 health care providers to better understand and screen patients for health-related social needs.”[19] Studies have shown that this legal integration has led to patients reporting less stress, more commonly taking their medication as prescribed, having greater access to financial resources, and receiving more frequent reimbursements.[20]
There is an incredible shared economic benefit to MLPs as well. Despite spending more money on healthcare than any other industrialized country, the United States “ranks 42nd in life expectancy and 169th in low birth weight.”[21] Combined, health, Medicare, and social security expenditures made up 46% of the 2022 Federal Budget.[22] With current conversations around national debt becoming contentious, future funding allocations for health-related public programs remain uncertain.[23] Now, as has always been true, reducing healthcare costs is not just an individual concern, but a national issue.[24]
MLPs offer an effective avenue for reducing medical expenditures. Through demand letters, a New York City MLP compelled landlords to address pests, mold, and other adverse apartment conditions for adult asthma patients.[25] These patients experienced a 90% drop in emergency room visits and hospital admissions costing an average of only $225 per case.[26] Documenting similar financial wins a Nebraska MLP found a 700% return on investment since 2009.[27] These financial outcomes are windfalls for those served and for the medical system broadly.
Legal advocacy and healthcare are a powerful combination. Justice gaps, health gaps, mortality gaps, and more are symptoms of chronic under-resourcing, under-investment, and systemic injustice. MLPs do not solve those problems but they are effective because they accept and are flexible to the realities of them. Social factors determine 60% of health outcomes.[28] When providers know they have the ability to connect patients to support they are empowered to ask about living conditions, employment, and education. They can say to patients, “You have asthma, your landlord is legally required to remove the mold from your apartment. We have a lawyer down the hall that can help you with this today.” MLPs help practitioners identify potential legal issues and remove the hurdle of finding legal representation. With outcomes such as 90% drops in hospital visits, justice and mortality gaps are slowly filling.[29] While a mountain of work is still needed to eradicate the root causes of poverty, collaborations such as MLPs demonstrate how effective corrective action can be when we consider systemic social barriers.
[1] LSC, The Justice Gap Executive Summary, https://justicegap.lsc.gov/resource/executive-summary/ (last visited Feb. 5, 2023).
[2] Pew Charitable Trusts, How Debt Collectors Are Transforming The Business Of State Courts (2020), https://www.pewtrusts.org/en/research-and-analysis/reports/2020/05/how-debt-collectors-are-transforming-the-business-of-state-courts.
[3] LSC, 2017 Justice Gap Report, https://www.lsc.gov/our-impact/publications/other-publications-and-reports/2017-justice-gap-report#:~:text=This%20%E2%80%9Cjustice%20gap%E2%80%9D%20%E2%80%93%20the,are%20overwhelmed%20with%20unrepresented%20litigants. (last visited Feb. 5, 2023).
[4] Peter Dizikes, New Study Shows Rich, Poor Have Huge Mortality Gap In U.S., MIT News (Apr. 11, 2016), https://news.mit.edu/2016/study-rich-poor-huge-mortality-gap-us-0411.
[5] See id.
[6] Id.
[7] Id.
[8] Id.
[9] Id.
[10] HHS, Poverty, https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/poverty (last visited Feb. 7, 2022).
[11] Id.
[12] Jodi Siegel et al., Benefits of Pediatric Medical-Legal Partnerships, 71 Fla. L. Rev. Forum 145, 145 (2019).
[13] Id.
[14] VCU Health News Center, Medical-Legal Partnerships: How Legal Services Can Improve Your Health (Nov. 23, 2020) https://www.vcuhealth.org/news/medical-legal-partnerships-how-legal-services-can-improve-your-health.
[15] Nat’l Ctr. for Med.- Legal P’ship, Home, https://medical-legalpartnership.org/ (last visited Feb. 5, 2022).
[16] VCU Health News Center, Medical-Legal Partnerships: How Legal Services Can Improve Your Health (Nov. 23, 2020) https://www.vcuhealth.org/news/medical-legal-partnerships-how-legal-services-can-improve-your-health.
[17] Id.
[18] Nat’l Ctr. for Med.- Legal P’ship, The Impact, https://medical-legalpartnership.org/ (last visited Feb. 5, 2022).
[19] Id.
[20] Id.
[21] Nat’l Ctr. for Med.- Legal P’ship, The Need, https://medical-legalpartnership.org/ (last visited Feb. 5, 2022).
[22] Fiscal Data Tresury.gov, How much has the U.S. government spent this year?, https://fiscaldata.treasury.gov/americas-finance-guide/federal-spending/ (last visited Feb. 7, 2022).
[23] See Jim Tankersley, Biden Demands Details on Budget Cuts From McCarthy, N.Y. Times (Jan. 31, 2023), https://www.nytimes.com/2023/01/31/us/politics/biden-mccarthy-budget-debt.html?searchResultPosition=1.
[24] Id.
[25] Tina Rosenberg, When Poverty Makes You Sick, a Lawyer Can Be the Cure, N.Y. Times (July 17, 2014 9:30 PM), https://archive.nytimes.com/opinionator.blogs.nytimes.com/2014/07/17/when-poverty-makes-you-sick-a-lawyer-can-be-the-cure/?searchResultPosition=1
[26] Id.
[27] Id.
[28] Jodi Siegel et al., Benefits of Pediatric Medical-Legal Partnerships, 71 Fla. L. Rev. Forum 145, 145 (2019).
[29] Tina Rosenberg, When Poverty Makes You Sick, a Lawyer Can Be the Cure, N.Y. Times (July 17, 2014 9:30 PM), https://archive.nytimes.com/opinionator.blogs.nytimes.com/2014/07/17/when-poverty-makes-you-sick-a-lawyer-can-be-the-cure/?searchResultPosition=1