By Hena Mehta, Sheehan Scholar
Medical-legal partnerships (MLPs) are collaborations of attorneys and healthcare professionals to provide patients and clients with results that address their social needs. The premise behind an MLP is simple: healthcare workers provide their patients with effective treatment for their medical illnesses while attorneys address clients’ legal problems that negatively interfere with their health. By strengthening the connection between healthcare and law, MLPs create a streamlined method for clients and patients experiencing legal barriers in their complex medical treatment or related independent issues to have on-site attorneys and expert health professionals involved in their care plan. MLPs represent the teamwork of medical and legal staff, who in actuality, share more commonalities than may appear at first glance. Both are tasked with the responsibility of performing their professional responsibilities to patients or clients, which include upholding their fiduciary duty to them and their ethical obligations to low-income communities.[1]
The first MLP was established at Boston in 1993 (MLPB) by Dr. Barry Zuckerman.[2] This MLP was based in the pediatrics department.[3] Dr. Zuckerman was disturbed by social issues his patients were experiencing, including “unsafe housing conditions leading to lead paint poisoning, asthma and injury; lack of sustainable income affecting childhood nutrition; and poor access to educational and social services for children with special needs.”[4] To address this situation, Dr. Zuckerman decided to hire legal staff for the purpose of working with medical staff and provide competent legal representation to protect his patients’ rights.[5] MLPB equipped on-call attorneys who addressed a client or patient’s legal dilemmas real-time using a pager.[6] As of 2008, Dr. Zuckerman’s founding MLP served at least 1,500 families annually.[7] From 2010-2012, MLPB conducted a pilot study called Developmental Understanding and Legal Collaboration for Everyone (DULCE), which focused on providing families with infants up to six months with medical and legal support.[8] This pilot study generated fantastic results, one explanation being because of the “high dose of Family Specialist and low dose of legal support.”[9] By offering legal education to the DUCLE Family Specialists and broader healthcare team, only a small portion of families required legal representation.[10] In 2012, MLPB became independent of Boston Medical Center and now has partnership ties all across the country.[11]
Today, MLPs have widely spread in the U.S. and have become pillars in the healthcare law industry.
The Impact of MLPs
Aside from fostering a mutually beneficial relationship between healthcare and legal staff, research has found that MLPs serve a host of benefits in bridging the gap between underrepresented communities and access to justice. Some have recognized the impact to be three-fold: financial, health, and social.[12] Financially, for example, hospitals and health centers experience return on investments from the legal services attorneys provide in delivering a client’s recovery of benefits.[13] With respect to individual health, MLP programs have significantly contributed to improved patient medicals including reductions in patient stress, number of emergency room visits, and rates of abuse and neglect.[14]Socially, both medical and healthcare professionals engage in training to provide first-class legal and medical care to their patients and clients, and both patients and clients benefit from learning about the medical and legal implications tethered to their care.[15] These three-fold MLP impacts are passed along to patients and clients on the individual level, institutionally on a professional level, and more generally for the community’s benefit.[16]
To illustrate how an attorney’s legal services makes a direct impact on an individual’s ability to receive medical care, let’s look at a relatively common case that can happen with any individual looking to receive medical care. Patient X (X), who lacks insurance coverage, is invoiced many bills from hospital treatment, procedures, and medications.[17] This subsequently causes X to cancel all recommended medical treatment, which deteriorates X’s health.[18] Because the hospital X was treating at is affiliated with a MLP, an attorney reviewed X’s case and was able to reduce X’s medical debt while also recovering Social Security Benefits that were unlawfully garnished.[19] As a result of this legal representation through a MLP, X was able to continue medical treatment (thus improving X’s health), pay those corresponding bills, and allocate expenses for necessities such as shelter and housing.[20]
On a community-wide front, MLPs have been catalysts in public policy initiatives that enhance healthcare for low-income families, including “improved disability eligibility requirements, housing a fuel assistance program, and immigration relief visas.”[21] MLPs encourage a collaborative environment where eclectic minds come together to propose public policy recommendations that improve lifestyle conditions across communities.
The Presence of MLPs in the U.S.
In March 2015, The National Center for Medical Legal Partnerships (The Center) identified MLPs in 276 hospitals and health centers and 90 legal aid agencies across 38 states.[22] As of July 2023, The Center has identified MLPs in 450 hospital and health centers, 170 legal aid agencies, and 58 law schools across 49 states and the District of Columbia.[23]South Dakota is the only state that does not have an MLP.[24]
According to The Center, the top 5 states with the largest number of MLPs (in order from greatest to least) are: California (65), New York (47), Illinois (25), Ohio (21), and Florida (20).[25] Please see The Center’s interactive map, which provides a jurisdictional breakdown of MLPs in each state.
MLPs in Action
MLPs are unique in their construction because no MLP is exactly identical. Each MLP developed in the U.S. deserves its own spotlight to illustrate the exceptional work it has done for patients and clients throughout the nation. Below are a few of the many examples of MLPs in the U.S., along with a brief description of how these MLPs provide opportunities for attorneys and staff to participate in the initiative through pro bono work.
The Public Law Center (PLC) in Orange County, CA, is a pro bono law firm that has MLPs with various community partners, including: Children’s Hospital of Orange County, St. Joseph Hoag Health, and Laguna Beach Community Clinic.[26] PLC attorneys provide legal services to clients in a host of legal areas including “conservatorships, guardianships, representation in civil and probate litigation, wills, advance health care directives, powers of attorney, select immigration services, employment, landlord-tenant representation, representation in credit disputes and in bankruptcy, disability rights representation, and special education.”[27] PLC also advertises opportunities for volunteers to coordinate annual pro-bono activities in Orange County.[28] PLC invites law firms and corporate legal departments to become “Pro Bono Coordinators,” who coordinate the pro bono activities of their lawyers, and also seeks pro bono attorneys to join the initiative.[29] Additionally, PLC encourages pro bono volunteers in the form of law students, paralegals, and college students to gain on-site experience of how the MLP operates while working alongside attorneys to learn about their role in the partnership.[30] PLC also provides a case list with available cases for pro bono representation for attorneys to review.[31]
The MedLaw Partnership of WNY is a MLP with legal services provided by the Center for Elder Law & Justice and medical services provided by Erie County Medical Center, Kaleida Health, and Western New York Breast Health.[32]Common legal services provided Center for Elder Law & Justice attorneys involve public benefits/income, health insurance coverage and denials, housing and utilities, income maintenance, employment rights, immigration status, elder financial and physical abuse, healthcare proxy or power of attorney, wills, and mortgage foreclosure.[33] This New-York based MLP seeks pro bono attorneys, law graduates, law students, undergraduate students, other student volunteers, and members of the community to participate in the initiative. As a bonus, attorneys in New York looking to satisfy their CLE obligations can earn credit for their pro bono work![34]
In October 2022, Pro Bono Institute (PBI) recognized the ground-breaking work of a Richmond-based MLP. This pro bono MLP was formed in February 2020 with Dominion Energy and McGuire Woods, in partnership with VCU Health. VCU Health medical professionals and social workers refer patients to McGuire Woods and Dominion Energy lawyers to assist with their legal barriers.[35] Legal services delivered to clients included: educational advocacy for pediatric treatment, family law, immigration law, housing law, and estate law. Since the MLP’s existence, over 100 McGuireWoods and Dominion Energy attorneys have dedicated their legal expertise towards this initiative.[36] For more information on the exceptional work this MLP has accomplished, please see PBI’s article honoring this partnership.
Complications in MLP Operation
As with any governing entity, structure, and strategic planning are important considerations to facilitate smooth operation. Because MLPs are subject to the highly regulated professions of law and medicine, internal conflicts about the execution or delegation of tasks can present barriers to the partnership’s function. Internal conflicts among the board of directors or leadership of an MLP can lead medical and legal staff to feel uncertain in how to properly serve their patients or clients.[37] Such disagreement in the delegation of responsibility or instruction of tasks can cause unnecessary tension across the workplace. For example, research has identified that healthcare professionals view the legal system with doubt, due to the possibility of arising malpractice lawsuits and the constant concern of preserving their ethical obligations when discussing patient or client medical records.[38] A way to reconcile such tensions is to ensure proper messaging between medical and legal staff, which enumerates how legal and healthcare services are required to co-exist to administer their respective services to patients and clients.[39] That way, services are executed with the utmost care and respect as to a patient or client’s individual situation and errors are minimized. Once healthcare providers and attorneys are able to understand each other’s professional boundaries better, all parties–attorneys, healthcare professionals, and patients/clients–will be better appraised of the collaboration needed for MLP success. Proper training to medical and legal staff timely addresses any management concerns early on in the process.
MLPs and COVID-19
The COVID-19 pandemic had a lasting impact on all, from businesses to individuals. MLPs were impacted significantly by the pandemic and pivoted from their initial plans to a business plan in accordance with the “new normal” the pandemic brought about. The operations of MLPs, which previously relied on in-person care, had to change to survive the pandemic. The MLP for Children in Hawai’i (MLPCH), a project of the William D. Richardson School of Law, has its primary site at the Medical-Legal Partnership for Children with Kōkua Kalihi Valley Comprehensive Family Services (KKV).[40] This Hawai’i-based MLP is a case study for how an MLP adapted as a result of the pandemic.[41]
MLPCH encompasses three tenets: (1) “neighbors being neighborly to neighbors,” (2) “expanding the role of ‘client’: from ‘learned helplessness’ to ‘power,’” and (3) “expanding the role of ‘lawyer’: broadening the idea of ‘legal needs’ and ‘legal work.’”[42]Although the COVID-19 pandemic threatened each of these tenets, the MLP identified practical solutions to maintain these tenets.
With respect to the first tenet, pre-pandemic, clients accessed legal services by meeting with attorneys at health centers, which were one block away from the public housing complex where the clients resided.[43] But once the fear of contracting the COVID-19 infection and social distancing rules went into effect, such accessibility was no longer available.[44] During the pandemic, legal and medical appointments were combined and handled online.[45] However, it was not the virtual platforms that “saved” MLPCH, but rather the trust patients and clients had with their medical care team, lawyers, and supporting staff that made them comfortable to share sensitive personal information through a technology medium.[46]
MLPCH also implemented changes to uphold the second and third tenets, concerning the roles of the client and the lawyer. First, the partnership held weekly remote meetings with both medical and legal providers for enhanced communication and collaboration.[47] Second, recognizing that they needed more helping hands, MLPCH hired an interpreter, who was a member of the community advocating for the MLP, to assist with language barriers between existing and incoming patients and MLP staff.[48] Third, MLPCH focused its efforts on updating their website and implementing technology that their clients were familiar with to better facilitate communication with them.[49] Fourth, MLPCH strengthened relationships with their community partners by responding to requests for community trainings at local centers and reached out to work with other attorneys in the area to seek legal representation for their clients’ needs.[50] These changes helped the MLPCH sustain their presence as an MLP and address their client/patient’s social needs despite the unfavorable conditions the pandemic imposed.
Although the pandemic suspended in-person interactions for quite some time, virtual platforms were able to address the main services of MLPs without major disruption. MLPs are now able to plan better and prepare their staff for sudden operational shifts that be necessary to adapt to the changing social conditions. Fortunately, the increases in MLP numbers and participating states reflect the willingness to sustain MLPs despite the debilitating limitations the pandemic presented.
Conclusion
MLPs are distinct–there is “no one size fits all” when determining how MLPs should be created. Each MLP is subject to the legal and medical leadership of the operations team, who decide the degree of integration of the two sectors. Nonetheless, collaboration between the two entities is important to ensure the success of the patient and the client’s needs being met. MLPs can also be “specialized” to cater to disadvantaged communities and connect them with stellar healthcare and legal services. Youth, the LGBTQIA+ community[51], and other vulnerable groups that may have experienced difficulty in receiving individualized medical treatment and/or legal services directly flowing from their illnesses can benefit from MLPs.
The possibilities for MLPs are endless. With a greater presence of such partnerships being implemented in the U.S. today, the potential for improving both legal services and healthcare for various communities is promising. MLPs are a vehicle for increased access to justice, and research continues to report on areas of improvement as well as areas of continued success.
[1] See Elizabeth T. Taylor, Allies Not Adversaries: Teaching Collaboration to the Next Generation of Doctors and Lawyers to Address Social Inequality, 11 J. Health Care L. & Pol’y 249, 250 (2008).
[2] Id.
[3] See MLPB Advancing Health Through Justice, Our Story, https://mlpb.health/our-story/.
[4] See Taylor, supra note 1 at 250-251.
[5] Id. at 251.
[6] See MLPB Advancing Health Through Justice, Our Story, https://mlpb.health/our-story/.
[7] See CoGenerate, Purpose Prize: Barry Zuckerman (2008), https://cogenerate.org/purpose-prize/barry-zuckerman/.
[8] See MLPB Advancing Health Through Justice, Our Story, https://mlpb.health/our-story/.
[9] Id.
[10] Id.
[11] Id.
[12] See Bharath Krishnamurthy et al., What We Know and Need to Know About Medical-Legal Partnership, 67 S.C. L. Rev. 377, 383 (2016).
[13] See generally James A. Teufel, Rural Medical Legal Partnerships and Advocacy: A Three-Year Followup Study, 23 J. Healthcare for the Poor & Underdeserved 705 (2012) (discussing the financial success experienced by a MLP of Southern Illinois (“MLPSI”), a rural MLP).
[14] See Krishnamurthy et al., supra note 12.
[15] Id.
[16] See Joel Teitelbaum & Ellen Lawton, Partnership Approach to Health: From Collegiality to Civil Rights to Health Equity, 17 Yale J. Health Pol’y L. & Ethics 343, 367-369 (2017).
[17] See Teitelbaum & Lawton, supra note 16 at 367.
[18] Id.
[19] Id.
[20] Id.
[21] Id. at 369.
[22] See Krishnamurthy et al., supra note 12 at 379.
[23] See The Partnerships., NAT’L CTR. FOR MED. LEGAL P’SHIPS, https://medical-legalpartnership.org/partnerships/ (last visited, Aug. 4, 2023).
[24] Id.
[25] Id.
[26] See Public Law Center, Medical Legal Partnerships, https://www.publiclawcenter.org/medical-legal-partnerships/.
[27] Id.
[28] Id.
[29] Id.
[30] Id.
[31] Id.
[32] See Center For Elder Law & Justice, MedLaw Partnership of WNY, https://www.elderjusticeny.org/medlaw-partnership-of-wny.
[33] Id.
[34] Id.
[35] See VCU Health, VCU Health, McGuireWoods and Dominion Energy Win National Award for Medical-Legal Partnership, (Aug. 2022), https://www.vcuhealth.org/news/vcu-health-mcguirewoods-and-dominion-energy-win-national-award-for-medical-legal-partnership.
[36] See Virginia State Bar, VCU Health, McGuire Woods, And Dominion Energy Lawyers Receive National Pro Bono Award, (Sept. 2022), https://virginialawyer.vsb.org/publication/?i=762571&article_id=4352187&view=articleBrowser.
[37] See Jessica Mantel & Leah Fowler, A Qualitative Study of the Promises and Perils of Medical—Legal Partnerships, 12 Ne. U. L. Rev. 186, 224 (2020).
[38] Id.
[39] Id. at 227-228.
[40] See Siyue et al., Reflections on the Pandemic, Protests, and Political Perils: Developing a Pedagogy of Community Partnership Amidst COVID-19: Medical-Legal Partnership for Children in Hawai’I, 28 Clinical L. rev. 107, 112 (2021).
[41] See generally Siyue et al., supra note 40.
[42] Id. at 121-125.
[43] Id. at 125.
[44] Id.
[45] Id. at 126.
[46] Id. at 126-127.
[47] See Siyue, supra note 40 at 128.
[48] Id.
[49] Id. at 129.
[50] Id. at 128-129.
[51] See generally Amelia Melas, Increasing LGBTQ+ Access to Legal Services via Medical-Legal Partnerships, 48 Am. J. L. and Med. 134 (2022).