Jolene Huey1, Hugo Onghai2, and Jeannie She3, Brooke Ellison4
1University of California Berkeley, CA 94720, 2Earl L. Vandermeulen High School, NY 11777, 3Massachusetts Institute of Technology, MA 02138, 4Center for Compassionate Care, Medical Humanities, and Bioethics, Health Science Center, Stony Brook University, Stony Brook, NY 11794
*Editors: Alyssa Kim, Jacob Han, Jessica Guo
I. Introduction
Even after an individual seeks urgent medical help for a health issue, one can continue to be plagued by ailments. The causes are often household conditions, employment status, and economic stability, which fit under the umbrella term, social determinants of health (SDOH). According to the National Center for Medical-Legal Partnership at George Washington University, “60% of a person’s access to health care is determined by [social determinants of health].”[1]However, the impacts of SDOH are often overlooked when prescribing immediate medical treatment, preventing the roots of many medical issues from being resolved due to non-holistic healthcare. Medical-legal partnerships (MLPs) address this by providing patients with access to lawyers who can help them navigate through legal issues and make them aware of important, beneficial services. Survey data from cancer patients who obtained care from a LegalHealth NYC MLP reveals that 75% of them felt that legal assistance reduced stress during their care.[2] MLPs curtail the perpetuation of certain health conditions in three ways: 1) direct, on-site medical, and legal care; 2) active training for professionals to recognize and address legal issues; and 3) outspoken advocacy for beneficial health policies on the local and national scale.
However, the workflow of MLPs has been interrupted with international quarantines and social distancing restrictions induced by the COVID-19 pandemic. As Kerlann Flowers, Legal Director for the New York Northwell/Hofstra Medical-Legal Partnership, stated in an interview, distributions of COVID-19 infections have largely unveiled underlying issues of healthcare. For example, minorities, the homeless, the immunocompromised, and other groups are getting infected at disproportionate rates due to SDOH.[3] An increasing number of patients must deal with new issues of eviction, unemployment, and interrupted access to care, which is why MLPs must be equipped to bridge the gaps between patients and legal advice. Despite this urgency, MLPs must grapple with a lack of funding and the absence of a streamlined, virtual operating system.
II. COVID-19 Related Obstacles: MLP-Focused
A. Transitioning to Telehealth
In order to best serve the community, hospitals and legal services must be adequately equipped to respond during crises. As hospitals adapt to the pandemic and ever-changing social-distancing guidelines, some have adopted telehealth strategies, which use telecommunication technologies to deliver health-related services and information that support patient care, administrative activities, and health education.[4] As a result of these protocols, MLP work has been compromised. Legal aid offices and MLPs have been forced to deliver their services remotely. Many MLPs experience the difficulties of telehealth and tele-legal work especially, including collaborating with partners at a distance, communicating with patient-clients who have limited access to technology, dealing with court and agency closures, signing and notarizing documents electronically, and planning for the medium- and long-term legal consequences of the pandemic.[5]
Some solutions to these common problems can be found in MLPs that have transitioned to remote services pre-pandemic. They have taken advantage of resources such as the FCC’s Lifeline Program, which offers low-income community members and patients affordable communication services, such as Internet service and telephone service.[6] LegalHealth, the MLP aspect of New York Legal Assistance Group (NYLAG), has implemented a centralized intake system, where all legal needs from 37 hospitals and community-based partners are directed towards one phone number.[7] On the other hand, the Hofstra-Northwell MLP in Long Island has kept up with their heavier influx of patients and legal needs by implementing a streamlined telehealth system where patients can get in direct contact with a lawyer via video call immediately after a doctor’s appointment. Still, other hospitals, like those in New York City, have become complete emergency and COVID-19 care hospitals, where all other medical needs are placed on lower priority. The removal of elective cases limits doctors’ ability to screen their patients for legal reasons. Thus, they have resorted to directing lawyers to only contact the hospital when there is something of immediate help to suggest.
B. Receiving Referrals
This brings up the problem of maintaining referrals while patients continue to see doctors remotely. Before the pandemic, doctors could gain a better understanding of patients’ SDOH by checking physical symptoms and having conversations in trusted environments.[3] Although this connection has become lost as services became remote, MLPs have taken advantage of this situation by offering services to a wider range of clients. Normally, low-income individuals affected by SDOH may not have access to health clinics to get referrals to an MLP, especially if that individual does not have insurance.[8] As MLPs in Los Angeles chose to receive referrals through an online portal, telephones often malfunctioned.5 These remote services can be used by doctors who refer patients, but pure legal services can also be vital for the greater community who may not have access to healthcare. MLPs can also use training and support services that already have a footing in the community. LSNTAP (Legal Services National Technology Assistance Project) provides free remote work and legal service training, while the Asylum Seeker Advocacy Project is experienced with building rapport and trust with clients online.
Clearly, there is no universal emergency response that encompasses appropriate actions MLPs can take. To remedy this, we believe that enacting a streamlined telehealth service would be a more viable and accommodating reaction to emergency healthcare responses for hospitals that can still balance MLPs on their plate. For hospitals that have switched to purely emergency care, it would be unrealistic to expect healthcare professionals to expend extra time and effort to address legal needs in their emergency COVID-19 response. In general, every hospital has its own resources that may give way to more effective MLP maintenance during emergency care, such as the presence of social workers, funding for PPE, and access to telehealth.
C. Acquiring Funding
Current MLPs also encounter obstacles when sourcing for necessary funding. While most funding comes from the government-affiliated Legal Services Corporation or health care and legal partners, another significant portion is attributed to a varying, unstable stream of philanthropic donations.[9] One solution for the services to indirectly fund themselves is through helping patients obtain insurance—if insurance is paying for doctor visits rather than the hospitals covering uninsured patients, then lawyers are paying for themselves.[3] Lawyers can also coordinate with social funding organizations to familiarize them with MLPs’ impact and their financial needs. These plans can help fuel the up-scaling of MLP establishments in other vulnerable populations and secure reliable funding.
III. COVID-19 Related Obstacles: Patient-Focused
A. Assisting Unemployed Disabled Workers
Another result of the pandemic is that the disabled workforce has been hit hard. According to Bloomberg Law, “During the peak of the pandemic-induced job losses, 18.9% of disabled Americans were unemployed, compared to 14.3% of the rest of the population. In June, the jobless rate for the disabled fell to 16.5%, while the rate for everyone else dropped to 11%, signaling a faster recovery for the general population.”[10] While the Americans with Disabilities Act has helped ensure employment opportunities and steady incomes for handicapped workers, more can be done. MLPs can help disabled patients receive their public benefits and alleviate any disability-related problems.[11]
Instead of making patients seek out their own lawyers to fill out paperwork, MLPs could integrate this process right into the hospital setting. For example, MLPs can help patients apply for disability benefits such as Supplemental Security Income, and if needed, guide patients through complex legal rules that come with reapplying after an unfair denial of benefits.[11] During the ongoing COVID-19 pandemic, when an increased number of disabled workers lost their jobs—possibly previously guaranteed to them—these benefits would be crucial. Even if a patient is aware of all the advantages they are entitled to, they may lack the knowledge to “navigate this system.”[12]
In workplaces where employment prejudice against disabled workers occurs, MLPs can help victims of discrimination file complaints to the Equal Employment Opportunity Commission (EEOC). The EEOC can file suits against private employers, and the Department can file suits against state and local government employers.[13] Discrimination against qualified individuals with disabilities is especially potent today in the form of layoffs due to COVID-19. MLPs can work with disabled patients to fill out complaints and secure a steady income for their families.
B. Addressing Eviction Moratoria
Stay-at-home orders and other housing-related COVID-19 guidelines are only effective if individuals have a reliable location to live.[14] The pandemic, however, has disrupted many homeowners and renters’ previously steady incomes—so much so that rent budgeting has become a serious monthly burden.
In this crisis, evictions not only impact individuals’ housing/shelter stability, but statistics also show that “patients who lack homes are more challenging and expensive to treat.”[8] A 2016 study found that “stable housing reduced Medicaid spending by 12% — and not because members stopped going to the doctor. Primary care use increased 20%, while more expensive emergency room visits dropped by 18%.”[15] Even though the US government has now initiated several national moratoria on evictions to aid tenants during this tough time, a divide between tenants and landowners remains, oftentimes due to landowners having the upper hand in financial support and legal expertise.
MLPs can step in to address this issue similar to how the Legal Aid Society of Mid-New York and Cornell Law School did in September 2020: creating housing hotlines that connect local tenants to legal advice from private attorney volunteers and law students.[16] Later, these institutions expanded the hotline to a pro-bono Tenants Advocacy Practicum, with ultimate intentions of leveling “the playing field in landlord/tenant disputes.” With an organized group of lawyers like this one, they can also aid tenants in public policy advocacy: these same institutions in New York advocated for the Ithaca Mayor and the New York State Department of Health to forgive 3 months of rent.[17]
C. Accessing Section 8 Housing Vouchers
In situations of evictions or homelessness, the US Department of Housing and Urban Development’s (HUD) “Section 8” program provides Housing Choice Vouchers. Public Housing Agencies (PHA) vet these applicants through their income and citizenship status, which they verify with “local agencies, employer and bank.” If they are deemed eligible for aid, the PHA places their name on a waiting list. Only when the PHA follows up with these individuals are they finally given a housing voucher.[18] During COVID-19, alterations were made to the system. The CARES Act allocated both funding and authority to adequately address the current crisis. The HUD in particular was given the broad authority to “waive statutes and regulations (except for requirements related to fair housing, nondiscrimination, labor standards, and the environment) for Housing Choice Voucher programs.” The HUD in general encourages PHAs to implement alternative procedures to “provide stable housing for some of our country’s most vulnerable families.” These alternatives can include “electronic transmission of information to families, conducting briefings online, conducting conference calls, or using self-service features on the PHA’s website if available, and providing business-reply envelopes or secure drop-box apparatuses for document for assisted families that do not have access to the Internet.” However, if situations do arise where tenant-hopefuls fail to pass the PHA verification, then pro-bono MLP assistance could also be of enormous help.
IV. Conclusion
Underlying problems of MLPs have been exacerbated by the onset of the pandemic: funding is now even harder to obtain, doctors and lawyers are further disjointed in terms of patient information and communication, and the identification of patients who would benefit from legal help has become more difficult. While the new telehealth format has made contacting new patients more difficult, it has also enabled lawyers to consult with previously contacted patients more frequently by cutting out travel and clinic setup times. Though the pandemic has worsened many aspects of life, it is evident that MLPs serve as a crucial bridge between patients and the necessary legal guidance to achieve healthy and sustainable daily lives.
References
[1] Stieglitz, Brian. “Hofstra University And Northwell Health Form Medical-Legal Partnership.” Herald Community Newspapers, Herald Community Newspapers, 12 July 2018, www.liherald.com/stories/hofstra-university-and-northwell-health-form-medical-legal-partnership,105129.
[2] Paul, Edward et al. “Medical-legal partnerships: addressing competency needs through lawyers.” Journal of graduate medical education, Vol. 1, p. 2, 2009: 304-9. doi: 10.4300/JGME-D-09-00016.1
[3] Flowers, Kerlann. Personal interview. 4 Aug 2020.
[4] “Telehealth Support.” AAP.org, American Academy of Pediatrics, www.aap.org/en-us/professional-resources/practice-transformation/telehealth/Pages/What-is-Telehealth.aspx
[5] “Webinar: Delivering Telelegal Services During COVID-19, An MLP Town Hall – Medical-Legal Partnership.” Medical, 16 June 2020, https://medical-legalpartnership.org/mlp-resources/telelegal-services/.
[6] “Lifeline Support for Affordable Communications.” Federal Communications Commission, 30 June 2021, www.fcc.gov/lifeline-consumers.
[7] Benfer, Emily, et al. Medical-Legal Partnerships COVID-19 Town Hall. 30 March 2020, https://www.youtube.com/watch?v=KpB2ft-omH8.
[8] Almeida, R.A, et al. “Access to Care and Use of Health Services by Low-Income Women.” National Center for Biotechnology Information, Centers for Medicare & Medicaid Services, 2001, www.ncbi.nlm.nih.gov/pmc/articles/PMC4194740/.
[9] Trott, Jennifer et al. Financing Medical-Legal Partnerships: View from the Field. Medical-Legal Partnership Fundamentals, 2019, medical-legalpartnership.org/mlp-resources/financing/.
[10] “Pandemic Exposes Ongoing Job Challenges for Disabled Workers.” Bloomberg Law, news.bloomberglaw.com/daily-labor-report/pandemic-exposes-ongoing-job-challenges-for-disabled-workers.
[11] Shin, P., Byrne, F. R., Jones, E., Teitelbaum, J., Repasch, L., & Rosenbaum, S. (2010). Medical-legal partnerships: Addressing the unmet legal needs of health center patients (Geiger Gibson/RCHN Community Health Foundation Research Collaborative policy research brief no. 18). Washington, D.C.: George Washington University, School of Public Health and Health Services, Department of Health Policy.
[12] The Children’s Hospital of Philadelphia. “Medical Legal Partnership: Camren’s Path to SSI Benefits.” Children’s Hospital of Philadelphia, The Children’s Hospital of Philadelphia, 27 June 2019, www.chop.edu/stories/medical-legal-partnership-camrens-path-ssi-benefits.
[13 “Fighting Discrimination in Employment Under the ADA.” ADA, www.ada.gov/employment.htm.
[14] Lowrey, Kerri McGowan. “Combatting COVID-19 through Law and Policy: Social Distancing Only Works If People Can Stay at Home.” Network for Public Health Law, 18 Mar. 2020, www.networkforphl.org/news-insights/combatting-covid-19-through-law-and-policy-social-distancing-only-works-if-people-can-stay-at-home/.
[15] Sable-Smith, Bram, et al. “Evictions Damage Public Health. The CDC Aims To Curb Them ― For Now.” NPR, NPR, 29 Sept. 2020, www.npr.org/sections/health-shots/2020/09/29/916972891/evictions-damage-public-health-which-is-why-the-cdc-has-banned-them-for-now.
[16] Lamb, Anna. “Cornell Law School Teams up with Tenants Union to Provide Legal Defense for Renters.” The Ithaca Voice, 3 Sept. 2020, ithacavoice.com/2020/09/cornell-law-school-teams-up-with-tenants-union-to-provide-legal-defense-for-renters/.
[17] Lamb, Anna. “Tenants Union Demands Movement on Rent Cancellation during Protest Monday.” The Ithaca Voice, 8 July 2020, ithacavoice.com/2020/07/tenants-union-demands-movement-on-rent-cancellation-during-protest-monday/.
[18] “Housing Choice Vouchers Fact Sheet.” Housing Choice Vouchers Fact Sheet, https://www.hud.gov/program_offices/public_indian_housing/programs/hcv/about/fact_sheet