Teaching Grassroots Health Law, Policy and Advocacy: Service and Collaborative Learning

Abstract

This column describes the history, mission, and work of Saint Louis University School of Law’s service-learning course Health Law, Policy and Advocacy: Grassroots Advocacy. Grassroots Advocacy allows law students to work with advocacy organizations on state and federal health policy initiatives, engaging in legislative and administrative advocacy and public education. The course uses community collaboration, community-led advocacy, and collaborative learning to train the next generation of health policy advocates for Missouri and the nation.

For over a decade, Saint Louis University (SLU) School of Law has offered a service-learning course familiarly called “Grassroots Advocacy,” which is formally titled Health Law, Policy and Advocacy: Grassroots Advocacy.¹ Grassroots Advocacy allows law students to work with advocacy organizations on state and federal health policy initiatives, engaging in legislative and administrative advocacy and public education. Our Grassroots Advocacy course has a long history of community collaboration, community-led advocacy, and collaborative learning. The course was initially designed to serve as a training ground to educate and recruit Missouri’s next generation of health policy advocates, and I am proud to report that our Grassroots Advocacy alums now serve as core members of today’s cadre of health policy advocates in Missouri.

My History

I believe in the need for and power of community-led social justice movements.² I went to law school because the civil rights movement gave me a vision of the role that lawyers can play in helping social activists demand justice and reform the law. As a young legal services lawyer, I worked alongside community organizers and community leaders to give them the legal support they wanted and needed to mobilize low-income communities to demand structural change and try to dismantle institutional racism.³ As a junior health law professor at Mercer University School of Law in Macon, Georgia, I helped local AIDS activists and an organization of parents of medically fragile children, providing them with legal and policy analysis and community education to help them push for better and more equitable access to care.

The Georgia parents group inspired me to jump into community education about Medicaid. The group was advocating for Medicaid coverage for the services their children needed to be at home instead of hospitalized or institutionalized. They asked me to present the Medicaid 101 lecture I gave to my health law students. The event was transformative for me: A sophisticated audience with lived experience with Medicaid asked perceptive, insightful, and tactical questions.⁴ The parents ran with the ball. Using their newfound understanding of Medicaid as an entitlement and the broad scope of Early Periodic Screening, Diagnosis & Treatment (EPSDT) services for children, they developed an advocacy strategy. The parents enlisted the help of their elected state representatives in seeking administrative changes. They also bombarded the state Medicaid agency’s phone and fax lines when officials were slow to respond. In response to a combination of administrative advocacy and public protest, the state removed illegal limits on home-based services for children in Georgia.

When I moved to St. Louis in 2001 to begin teaching at SLU LAW in the Center for Health Law Studies, I brought my newfound enthusiasm for community education about Medicaid with me. I spoke to children’s groups, disabilities groups, Centers for Independent Living, and local funding boards looking for ways to leverage Medicaid funds to increase community-based services. I know, it is hard to believe that a law professor talking about Medicaid might generate audience enthusiasm, but lots of people rely on Medicaid coverage. These audiences knew their lived experiences relying on Medicaid. I explained to them the policy and legal framework that gives Medicaid the flexibility to address lots of different healthcare needs. They, too, ran with the Medicaid ball, advocating for regulatory change, statutory change, and new waivers.

Our Grassroots Advocacy course has a long history of community collaboration, community-led advocacy, and collaborative learning. The course was initially designed to serve as a training ground to educate and recruit Missouri’s next generation of health policy advocates, and I am proud to report that our Grassroots Advocacy alums now serve as core members of today’s cadre of health policy advocates in Missouri.

Through these talks and other community interactions, I got to know the folks working on community mobilization around health access in Missouri. I began attending the monthly meetings of St. Louis (now Missouri) Jobs with Justice, where I met their talented cadre of community leaders and organizers. I served on the policy committees of several Missouri health advocates, including Jobs with Justice, Missouri Health Care for All, and Paraquad, St. Louis’s Center for Independent Living.

In the years leading up to the passage of the Affordable Care Act (ACA), grassroots consumer organizations and safety net providers across Missouri began working together to create a health access coalition to advocate for quality, affordable health care for all. A new foundation, the Missouri Foundation for Health, provided critical funding, training, and organizational support to help this diverse group of stakeholders and community groups learn to work together, including sponsoring an annual Missouri Health Advocate’s Retreat and many other convenings, focus groups, and strategy sessions.

I attended the health advocates’ meetings and retreats. I studied and learned alongside them as we found the language and the messages that connected with voters in Missouri and elsewhere to pass the ACA. I also continued to speak frequently to lay audiences, educating them about Medicaid, ACA, and many other legislative and policy initiatives. At the request of health advocates and elected officials, I testified several times before Missouri House and Senate committees and the Department of Insurance on various access to care issues, including Medicaid and the ACA’s private insurance reforms. I shared their passion for community mobilization, social reform, and social change and was honored to figure out a way I could contribute to the effort. We celebrated together as the grassroots health care for all movement played a crucial role in the passage of the ACA. Many health law professors, including me, analyzed the complicated policy issues embedded in the ACA. But what excited me most was being part of the grassroots social movement for health care for all.

Grassroots Advocacy’s History

The early summer of 2012 marked several important milestones in the implementation of the ACA and the beginning of SLU’s Grassroots Advocacy class. States were beginning to debate whether to implement the state-based Health Insurance Exchanges slated to begin operation in 2014. HHS had begun the federal rulemaking process to implement the ACA’s private insurance reforms, and states were to play a key role in that process. In June 2012, in a move that surprised almost everyone, the Supreme Court held in NFIB v Sebelius ⁵ that the ACA’s Medicaid expansion for low-income adults was voluntary. States now had another big health policy decision to make before January 2014.

The summer of 2012 was also a time of transition for the Missouri health advocates. Several organizations lost their key policy experts to opportunities in DC and elsewhere. At a critical time for health policy in Missouri, the health advocates coalition was facing a policy expertise deficit. The Missouri Foundation for Health stepped in to fill the breach by providing funding for SLU law students and me to become health policy advisors to the state’s health advocates, birthing the Grassroots Advocacy course. This was an opportunity for me and students to become partners in the grassroots movement.

Our new Missouri Foundation for Health funded Grassroots Advocacy project had two goals: (1) to provide policy and legal analysis to support the work of the Missouri health advocates coalition and (2) to train the next generation of health policy advocates for Missouri. The Center for Health Law Studies has long been among the country’s top-ranked health law programs. Many of our health law students come to law school interested in health policy, and many of our graduates work in health policy. However, especially with the passage of the ACA, the lure of DC and excitement of federal health reform implementation enticed our graduates to jobs in the DC area. We hoped that our new Grassroots Advocacy course would not only expose students to state-level health policy advocacy in Missouri but encourage them to remain in Missouri after graduation and become part of our state-level health advocacy work.

The Foundation’s support funded release time from teaching and other obligations so I could devote time to sustained and ongoing policy and legal analysis for the coalition’s members. It also funded a full-time research professor to expand the Center’s work on behalf of the health advocates.⁶ The contract also provided financial support, through travel and research stipends, for our SLU law students to become part of the Center’s collaborative work with the statewide coalition of health policy advocates. We also had the great good fortune in the first few years of the course to have Margaret Donnelly, a Practitioner-in-Residence at the law school, join us to co-teach the course. Judge Donnelly is a former state representative who brought her many years of experience as a lawmaker to the course, helping the students and me.

Our Work

We called the new project and law school course Health, Law, Policy and Advocacy: Grassroots Advocacy to honor the role that grassroots advocacy played in the passage of the ACA, the work of the statewide coalition, and the role we intended to play. The name acknowledges that our work in Grassroots Advocacy is community-led. We do not pick issues or projects based primarily on their interest to faculty or students; instead we do the work that our community partners prioritize for us, through a structure that we have developed to ensure pedagogical value for our students.

For the first decade of the course, much of our work supported mobilization and advocacy efforts to expand Medicaid in Missouri. For over five years, these efforts focused on trying to garner bi-partisan support in a Republican controlled legislature for Medicaid expansion. When legislative efforts stalled, the health advocates coalition switched gears, and we did too, participating in the large coalition that developed the successful strategy to pass a ballot initiative enshrining Medicaid expansion as a constitutional right in Missouri. In 2021-2022, when Missouri began enrolling people in Medicaid expansion, the class partnered with St. Louis Regional Health Commission and Legal Services of Eastern Missouri to create and staff a Medicaid Expansion HelpLine to help people get signed up.⁷

Our law students interviewed hundreds of Missourians, gathering stories about people’s experiences trying to access the healthcare system. They heard first-hand accounts about the financial, physical, and psychological toll that comes from lack of access to care. They listened to the joyful stories of people who could access needed health care because of the new private insurance subsidies included in the ACA. They also heard heartbreaking stories from people stuck in the Medicaid gap as the Missouri legislature failed to pass Medicaid expansion.

In the first year of the course, three Missouri health advocacy coalition members, Missouri Jobs with Justice, Missouri Health Care for All, and Missouri Rural Crisis Center, worked with us to identify five key activities that the coalition members needed and the students, research fellow, and I could provide: community education, story banking, plain-language legal and policy analysis, strategic policy and advocacy planning, and testimony at legislative and administrative hearings. Over the years, our work expanded to include drafting legislation, research projects to support legislative and administrative reform, and creating and staffing the Medicaid HelpLine to help low-income adults enroll in Medicaid expansion.

Over the years, our law students presented hundreds (maybe more than a thousand) presentations about the ACA’s new private insurance reforms and Medicaid expansion, helping to educate community members, healthcare professionals, social services agencies, students, and lawmakers. When the Trump Administration sought to pass federal legislation that would block grant Medicaid, the students shifted focus, creating and giving presentations about the many roles Medicaid plays in providing access and care and the harm the bills would cause. Each year, the students worked together to create a 15-20 minute PowerPoint slide presentation, which they and members of the statewide health advocates coalition used to reach people across the state. Every presentation ended with a call to action, giving people concrete ways to advocate for better access to quality, affordable health care.

Our law students interviewed hundreds of Missourians, gathering stories about people’s experiences trying to access the healthcare system. They heard first-hand accounts about the financial, physical, and psychological toll that comes from lack of access to care. They listened to the joyful stories of people who could access needed health care because of the new private insurance subsidies included in the ACA. They also heard heartbreaking stories from people stuck in the Medicaid gap as the Missouri legislature failed to pass Medicaid expansion.

Research confirms the power of personal stories to help policymakers and the public understand complex policy issues (and the stories certainly impacted our law students’ understanding of health access in ways that a classroom discussion never could). The students shared people’s stories as part of their community presentations, as one-pagers written for Missouri legislators, and on social media. They also helped people tell their stories to elected officials and the press.

The legal and policy analysis work focused primarily on “plain language” one-and two-page fact sheets, short briefs, email alerts, and Op-Eds.⁸ Students learned to explain the complicated health law and policy concepts they learn in their health law (and other) classes into language accessible to non-experts and “real people.” Some fact sheets and briefs were intended for lawmakers and the general public. Others were designed to promote coalition building among health advocates and safety net providers. Some of these materials were produced under the SLU Center for Health Law Studies logo; others were created for coalition members to disseminate under their names.

The students also spent hours and hours in the state Capitol meeting with legislators and their staff, helping people tell their stories, and presenting testimony before House and Senate Committees. Our state Capitol is a two-hour drive from St. Louis. Days in the Capitol often began at 5:00 or 6:00 a.m. as we piled in the car to “go to Jeff City” for a full day of meetings. The students were present in the Capitol for key votes on Medicaid expansion (that failed). They stood by as observers on the day sixteen religious leaders were arrested for an act of civil disobedience that disrupted the Missouri Senate. During lobby days, the students served as policy advisors and guides for small groups of community members as they met with their legislators. The students’ role was not to speak for these voters, but to help them find their voice, tell their stories, and serve as a resource if complicated policy questions came up.

If we ever have a Grassroots reunion, many of our war stories will recount the madcap adventures that were inevitable during our long days in the Capitol. One of my favorites is how our students responded with less than 24 hours’ notice when asked to testify before a House Committee on a bill that would have imposed a one-year state residency requirement for Medicaid eligibility. The students had studied the issue in their constitutional law class the week before and were raring to go. Over the course of a long afternoon and evening, they met with their con law teacher, and then drafted and redrafted their testimony. The next morning, they headed to the Capitol to testify. The committee heard a lot of confusing testimony. Our law student was the last witness. She had to throw out her prepared testimony and focus on the questions that had arisen during the hearing. She was cool, calm, and clear. Her testimony killed the bill, which she explained was unconstitutional under Supreme Court precedents. The committee chair thanked her and told her he would hire her on the spot, if she were not still in school.⁹

Service Learning

Many law schools would designate Grassroots Advocacy as a clinical course. However, at SLU LAW Grassroots Advocacy is a service learning course. This teaching methodology reflects the course’s history, its roots in community-led advocacy, and SLU’s Catholic Jesuit identity.¹⁰

Across the SLU campus, service learning courses integrate service into academic courses while fostering a consciousness of social justice that promotes the common good.¹¹ By engaging in service experiences, SLU students and faculty gain wisdom and knowledge from a community partner who serves as a co-teacher. The community partner, in turn, benefits from the work the students and faculty provide, creating a reciprocal relationship. Guided reflection, a key component in service learning, allows the faculty and students to integrate the service experience into the course’s learning goals and the student’s personal and professional development as men and women in service to others.

Each year, the Grassroots Advocacy course partners with one or more grassroots organizations, like Missouri Jobs with Justice, Missouri Health Care for All, Missouri Rural Crisis Center, Paraquad, St. Louis Regional Health Coalition, and Missouri Appleseed. The students’ community co-teachers have included organizers, social workers, lobbyists, policy advocates, community activists, and lawyers. Our community co-teachers participate in the classroom component as guest lecturers and full-fledged teachers. They supervise and mentor students when they are in the state Capitol. They involve the law students in their organization’s activities, giving the students the opportunity to be part of strategy meetings, community meetings, meetings with elected officials, coalition meetings, protests, phone banks, and fundraisers.

The class is offered as a full-year course. Students earn two hours of credit in the fall and two to three hours in the spring semester. The fall semester typically involves community education, story banking, and researching and drafting bills and proposals for the Missouri General Assembly, which meets in regular session from January to May. The spring semester involves various activities, including monitoring the legislative session, meeting with legislators, attending committee hearings, preparing and presenting testimony, and doing Op-Ed writing.

As with law school clinical courses, the Grassroots Advocacy service learning class requires three hours of work for each unit of credit. Thus, to earn two hours of credit, students are expected to devote about 6-8 hours per week to class meetings and service learning fieldwork for at least 100 hours per semester. The course’s classroom component meets weekly, typically for 80-120 minutes.

Grassroots is a graded course. Students are evaluated based on class participation and fieldwork, including researching, drafting, oral presentations, story banking, and “being in coalition” with our community partners. Much of the work is done as group projects.

Each student works with me at the beginning of each semester to develop personal goals. I give the students the basic distribution of activities we hope to offer all students during the semester (for example, community legal education, story banking, legislative advocacy in the state Capitol, policy analysis, and being in coalition) and help them identify their personal goals, aspirations, and interests for the semester. At the end of the semester, each student creates a portfolio that includes their final written work products and a diary of the other activities. They also write a reflection paper describing the project or event that was most meaningful to them, the most challenging one, and why. We also ask the students to include recommendations for improving the service learning experience for future students in their reflection papers.

Collaborative Learning

When students sign up for Grassroots Advocacy, the syllabus warns them that it is a collaborative learning experience: the students, community partners, and faculty work as a team. We organize weekly classes as team meetings, discussing the previous week’s events and ongoing projects, strategizing, reviewing drafts, and assigning work. Much of the work is done as group projects.

Students take ownership of their projects. As a group, we help each other develop research plans and strategies. We help each other figure out who to talk to and where to go to get needed information. We review each other’s written drafts and oral presentations and are not shy in giving helpful criticism. We talk through roadblocks and problems. We have lots of templates and samples. We know who the experts are, and who we can consult.

Our Health Law and Policy Fellows deserve most of the credit for developing our approach to collaborative learning. Each year, I invite one or two students who have taken the Grassroots Advocacy course to return to help co-teach the class. Fellows help plan the semester’s syllabus and class meetings. They mentor the students as they work on projects. They accompany students when they give community presentations or go to the state Capitol, providing constructive feedback on what went well and how to improve. The Fellows model self-confidence, enthusiasm, and how to work for and in collaboration with community organizations. They are the glue that holds the team and course together.

Grassroots Advocacy Today and Into the Future

Grassroots Advocacy remains part of the SLU health law curriculum. The Missouri Foundation for Health funded the course for five years and the law school has continued it since.

Since 2018, Grassroots Advocacy has partnered with Missouri Appleseed, a grassroots policy advocacy organization that uses research, advocacy, and education to improve systems and policies at the intersection of public health, criminal justice, and child welfare. The course is now co-taught by Liza Weiss, Missouri Appleseed’s director, and Brandon Hall, a SLU Law graduate and Grassroots Advocacy alum who also served as a Health Law and Policy Fellow for the course.¹² Missouri Appleseed has an extraordinary record of success in building bi-partisan support for legislation. The students have partnered with Missouri Appleseed to help pass several bills, including legislation requiring that feminine hygiene products be free of cost in Missouri’s prisons and jails, Medicaid suspension rather than termination for justice-involved people, and community-based sentences for primary caretakers so children are not separated from their parents. This year, the students’ projects include helping with a pilot project to enroll Missouri jail populations in Medicaid and implementing a bill to establish a Missouri prison nursery.

Grassroots Advocacy alums are now part of Missouri’s health policy and advocacy community. They work for the Missouri Foundation for Health, Legal Services of Eastern Missouri, and Missouri Appleseed.¹³ Others have served as counsel to the minority caucus of the Missouri House, staff to the Missouri Senate, and worked for the Missouri Department of Social Services.¹⁴ Three Grassroots graduates were part of the litigation team that successfully sued to force Missouri to honor the ballot initiative and constitutional amendment by which Missouri adopted Medicaid expansion.¹⁵ Many other alums have gone on to do health policy and advocacy in DC and other states.

The students and I thank our many community partners for trusting us, joining with us, and teaching us about grassroots advocacy.