Social determinants of health (SDoH) and health equity hold a place in the public consciousness like they never have before. Driven, in part, by the systemic inequities laid bare by the COVID pandemic, public health agencies, legislators, health systems, community organizations, and others are eager to identify and implement programs to improve health equity and address SDoH. This special issue explores one increasingly salient intervention in the effort to achieve health equity — Medical-Legal Partnerships (MLPs).
MLPs integrate lawyers into health care settings, providing legal services to address issues that create barriers to optimal health and wellbeing in environments that patients often trust more than lawyers’ offices. Interdisciplinary teams from law and health care identify and address patients’ health-harming legal needs, tackling issues as far-ranging as housing conditions, access to public benefits, employment discrimination, physical safety, guardianship and more. MLPs’ holistic approach recognizes that systemic barriers, including structural racism and unequal access to health care and other public benefits, generate unhealthy conditions across the spectrum of life — including in employment, housing, nutrition, and education. And, as the articles in this volume illustrate, the scope of legal services that MLPs provide continues to expand.
The MLP model, as it is recognized today, dates back to 1993,Reference Teitelbaum and Lawton1 and has since inspired a well-established national movement. In recent years, the number of MLPs across the United States has nearly tripled: there are now at least 450 MLPs in 49 states and the District of Columbia, including many that are part of a university or that engage academic partners. Earlier this year, Congress showed unprecedented support for MLP by including funding for an MLP grant program within its annual appropriations bill.2
This special issue and an associated convening held at Yale Law School in early 2023 were a joint effort of three institutions that house nationally-recognized MLP programs — The Solomon Center for Health Law and Policy at Yale Law School, the Georgetown University Health Justice Alliance, and Penn State Dickinson Law. We invited contributors to the special issue and presenters at the convening to consider issues of racial justice and intersectionality, data and outcomes, policy and impact, and the role of academic MLPs. The work coalesced into three foci — equity, evolution, and evaluation.
This special issue and an associated convening held at Yale Law School in early 2023 were a joint effort of three institutions that house nationally-recognized MLP programs — The Solomon Center for Health Law and Policy at Yale Law School, the Georgetown University Health Justice Alliance, and Penn State Dickinson Law. We invited contributors to the special issue and presenters at the convening to consider issues of racial justice and intersectionality, data and outcomes, policy and impact, and the role of academic MLPs. The work coalesced into three foci — equity, evolution, and evaluation.
Nearly all of the authors recognize MLP’s core mission to address health equity. Dayna Bowen Matthew and Emily Benfer refer to the recent U.S. Supreme Court decision on affirmative action3 to constitute a “legal epidemiology to describe the harm of overlooking the structural determinants of health, specifically racial discrimination” and identify the need for MLP to address “underlying structural determinants of health memorialized in U.S. law and policy.” Other articles, including a piece by Alicia Turlington, Jonathan Young, and Dina Shek, as well as a piece by Alice Setrini, critically examine the role of community involvement in MLPs and identify intersectional methodologies to design and operationalize MLPs. Together, these articles articulate how anti-racist approaches to MLP work align with the movement’s guiding principles, and help us situate MLP within the larger movements for racial, social, and economic justice.
Other authors with particular expertise in health care policy and operations grapple with the necessity of finding a place for MLPs within the healthcare delivery and financing system not designed to accommodate the work of MLPs. They also consider opportunities to sustain MLPs — a major challenge — including new pathways for financial support from federal and state governments, as well as peer organizations. Barak D.Richman, Breanna Barrett, Riya Mohan, and Devdutta Sangvai counsel that “in a setting of constrained resources and competing demands,” advocates for MLP expansion must supply “evidence that an MLP will enable the health system to see financial upside.” William B. Sage and Keegan D. Warren chart a path for being “radical within the system” by aligning the way professionals move (clinical alignment); the way data move (informational alignment), and the way money moves (payment alignment). Blake N. Shultz, Carol R. Oladele, Ira L. Leeds, Abbe R. Gluck, and Cary P. Gross make the case for increased federal funding to support and incentivize SDoH interventions.
The largest collection of articles offer case studies or describe models to push the field forward. Georgetown’s interprofessional team of authors examine the unique potential that academic partners have to leverage their service, education, and research resources to train the next generation of lawyers, physicians, and other professionals to advance health justice (Vicki W. Girard, Yael Z. Cannon, Deborah F. Perry, and Eileen S. Moore). Others question the practice in some partnerships of categorically limiting representation and call for expanding MLP services to include representation in child welfare (Kara Finck and Susanna Greenberg) and criminal proceedings (Nicolas Streltzov, Ella van Deventer, Rahul Vanjani, and Elizabeth Tobin-Tyler). They also highlight the potential of expanding to new populations, including patient-clients with opioid use disorder, (Jeremy S. Spiegel, Matthew S. Salzman, Iris Jones, and Landon Hacker), palliative care patients (Rebecca Iannantuoni, Emily B. Rock, and Abbe R. Gluck), and complex care patients (Megha Garg, Jenifer Oliva, Alice Lu, Marlene Martin, and Sarah Hooper). L. Kate Mitchell and Debra Chopp characterize MLP as a paradigm for upstream interventions addressing SDoH. Susan McLaren, Lisa Radtke Bliss, Christina Scott, Pam Kraidler, and Robert Pettignano examine the social-ecological model as a valuable framework for MLPs.
Collectively, the authors highlight the variety of ways MLPs operate and the common challenges they face in achieving their goals. They capture the importance of tailoring MLP design to meet the needs of particular client populations. This diversity presents challenges for scholars and practitioners who seek to develop a theoretical framework around MLPs and share best practices.
Finally, a number of articles take on what may be the holy grail of MLP work — studying their impact. Benjamin Lu, Kathryn Thomas, Solomon Feder, James Bhandary-Alexander, Jenerius Aminawung, and Lisa B. Puglisi analyze longitudinal data to determine the impact of civil legal needs on the health of formerly incarcerated individuals. Griffin Jones and Latisha Goulland use qualitative and quantitative methods, interview patients, and track indicators of patients’ health before and after MLP interventions. Co-authors Andrew F. Beck, Adrienne W. Henize, Melissa D. Klein, Alexandra M.S. Corley, Elaine E. Fink, and Robert S. Khan present a methodology for using data to inform systemic advocacy. Erika L. Silverman, Danielle K. Sandsmark, and Robert I. Field explore how patient health outcomes may improve when providers feel confident that screening for SDoH results in effective legal services referrals. Together, these articles show that MLPs are, in fact, making a positive impact in the lives of their patients through stronger clinical and community partnerships and improved health outcomes, but also point to the need for continued research and funding support.
Our takeaways from the convening and the articles in this special issue are as follows: First, as practitioners engage in deeper and more sophisticated health equity work on behalf of, and alongside, their clients, they must submit that work to rigorous scholarly analysis and evaluation by, to the extent ethically possible, “opening the books” and being transparent in their goals and outcomes. Likewise, as scholars sharpen and deploy their analytic tools and critiques, they must remain informed about the latest practices and trends among the interdisciplinary teams that are doing the work on the ground, and produce research that is relevant to practitioners, healthcare administrators and policymakers, and to the general public. This special issue is, appropriately enough, a collaborative effort of MLP practitioners, scholars, and health care experts and advocates. Second, as reflected in some of the articles in this issue and in other voices from the convening, all of the partners engaged in this work must remain cognizant that to the extent MLPs operate within well-established legal and health systems, they may unintentionally contribute to the very systems that perpetuate health inequities. Third, although case studies included in this volume poignantly illustrate the power of MLP to reduce inequality and improve health and the quality of life, rigorous research studies establishing the effectiveness of MLPs and identifying best practices to maximize impact are critical to the development of the movement.
MLPs have already proved to be a critical intervention in addressing the legal and structural bases of health inequity and injustice; it is up to all stakeholders in the system to chart the success of MLPs’ future.
Acknowledgments
The authors would like to thank the Oscar M. Ruebhausen Fund at Yale Law School for its support and Yale Law School students Meghanlata Gupta and Elena Sokoloski for their tremendous assistance. The authors also thank Yale Law School, Georgetown University Law Center, and Penn State Dickinson Law for their co-sponsorship of the convening “Medical-Legal Partnerships: Equity, Evaluation and Evolution” at Yale Law School in March 2023, at which the authors in this JLME issue and other medical-legal partnership advocates gathered for a robust exchange of ideas.
Note
The authors have no conflicts to disclose.
