Delivery of Care

The cavalry will not be coming to our rescue

Why we must become our own cavalry in furthering a medical-legal partnership to advocate on behalf of less-resourced people when it comes to accessing health care

Image courtesy of M:PB

The import of the blog post by Samantha Morton, CEO of MLPB, is that the cavalry will not be coming to the rescue and advocates seeking to advance health through justice will have to deploy their own strategic cavalry.

By Samantha Morton
Posted 11/18/19
A new team-facing approach, one that expands legal problem-solving knowledge and strategies beyond lawyers to expand the “army” of legal problem-solvers who can partner with families, is being developed when it comes to accessing health care benefits and protections.
How welcome would the strategy of deploying legal expertise as part of community health teams in Rhode Island? Is there an opportunity for health equity zones in Rhode Island, based on community needs assessment, to consider creating legal advocates as part of their ongoing strategic approach? What can be learned from the efforts led by the Childhood Lead Action Project around enforcement strategies in different municipalities? What kinds of opportunities are there to train and deploy law students at Roger Williams University in projects around housing, health and childcare advocacy?
On Wednesday, Nov. 20, a special legislative commission chaired by Sen. Josh Miller will convene to study the impact of insurer payments on access to health care. The first session will include a presentation by Neil Sarkar, interim president of the Rhode Island Quality Institute and founding director of the Center for Biomedical Informatics at Brown University.
Of particular concern are the low reimbursement rates currently being paid by the R.I. Medicaid office for mental health and behavioral health services and the way that such low reimbursement rates make it difficult for providers to offer such services.

Editor’s Note: In reporting on the delivery of care and the development of community-based solutions to address health social disparities, as well as the development of Health Equity Zones and Neighborhood Health Stations, one missing part of the equation is the role that legal advocacy can play on behalf securing rights and protections in the delivery of health services.

In this story, Samantha Morton, the CEO of MLPB, a legal advocacy organization that seeks to advance health through justice, shares her ideas about how to unlock the barriers that often block a family’s access to health benefits and protections.

At first glance, it may seem to be far afield from much of the current conversations around health care delivery, but it provides a new way to look at how a medical-legal partnership can improve health outcomes at the community level.

BOSTON – The barriers that block families’ access to health promoting benefits, services and legal protections are numerous and complex. While many supportive federal and state laws and entitlements exist, less-resourced people often:

Are unaware of these supports and protections

Are aware, but lack counseling and coaching to enable informed decision-making about their legal options in high-stakes situations [i.e., the kind of legal support accessed by people and businesses of means during tax season, in preparation for a divorce, etc.]

Wish to pursue legal rights, but do not because of system navigation complexity, experiences of discrimination, and other experiences of trauma, intimidation and alienation

Experience unlawful denials of their benefit applications or non-recognition of their legal rights at the hands of both public systems [e.g., agencies administering SNAP, WIC, TANF, subsidized housing, Medicaid, etc.] and private actors [e.g., landlords presiding over unhealthy/unsafe conditions and employers engaged in wage theft]

This gulf between a lower-income family’s legal rights and their ability to vindicate them is outrageous. Not only do these system/enforcement failures contribute to intensified early life stress for young children, but they are an affront to the ideals of our democratic society.

A new approach
Against this backdrop, a new approach to scaling legal problem-solving knowledge and coaching with families is urgent. This “team-facing” legal partnering strategy pioneered by MLPB was recently detailed [in a Sept. 2019 publication of the Center for the Study of Social Policy] and calls for direct embedding of legal resources within systems that serve families – such as early education and family home visiting programs – to equip members of these workforces as legal problem-solving partners to families.

The core components of this capacity-building model need to include:

1.System design support in the planning and implementation of programs, including:

Informing development of screening tools that effectively detect barriers to concrete supports

Identifying role-appropriate responses to positive screens when legal risks are detected [through process mapping and other steps];

Curating a complex – or barren – legal services landscape to enhance the likelihood of successfully connecting families to appropriate advocates.

2.Implementation of workforce training and inter-professional education, including:

Bolstering effective screening and triage of barriers to concrete support that are linked to families’ legal risks, rights, and remedies—as well as identification of scope-of-practice-aligned problem-solving strategies.

3. Creating a system of “continuous consulation” by embedding in regular interdisciplinary team meetings and supplying “rapid response consults” outside meetings. These interventions would include:

“Issue-spotting” potential legal risks, rights, and remedies.

Equipping colleagues with valuable legal information that can (a) then be conveyed to families, and (b) enable implementation of creative, role-appropriate problem-solving strategies when families are informed and can make decisions.

Assuring that families have realistic expectations when no solutions exist under current law or public policy.

The gears of justice are jammed
Why integrate legal problem-solving capacity directly within sectors like early childhood? Because the gears of justice are jammed for too many families.

While the public interest law community has valiantly represented the interests of marginalized families in a range of foundational contexts, that community is radically under-resourced and weakened by structural limitations. For instance:

Efforts to disseminate “know your rights” information to individuals, families, and communities are most often reactive, primarily in response to a legal development such as the proposed public charge rule impacting immigrant households.

This dynamic likely is driven by the sheer density, complexity, and dynamism of laws and policies governing people’s lives – overwhelming and challenging to wrangle and distill for sure.

Though many state-level websites expertly summarize a multitude of priority public interest law topics for lay people, these tools are dormant until accessed by someone who (a) knows they have a problem, (b) understands that resources exist, (c) can access the resources, and (d) possesses sufficient time, energy, and self-confidence to study the material and apply it to their particular problem.

A breakdown at any of these nodes may – and often does – extinguish hope because there is no systematic, proactive approach to educating families with young children about their legal risks, rights, and remedies across the many areas of life impacted by them.

The professional culture of law largely is transactional, focusing on direct service delivery at the individual/household-level. With notable exceptions like class actions, impact litigation, and legislative/regulatory drafting undertaken on behalf of groups/populations, the notion of leveraging, for example, civil rights law as a public health lever is fairly young. Most families in need are not benefiting from legal strategies that operate at a population level.

Government funding of civil legal aid organizations is not only dramatically inadequate, it also limits – formally and informally – the populations they can serve and the strategies they can undertake. For example, Legal Services Corporation-funded organizations cannot sue the federal government in domains such as immigration law and policy and disability benefits administration (SSI and SSDI).

In addition, state funds are generally available through annual state legislature-driven budget allocations, and an organization may opt to not proceed with a lawsuit against a state agency whose practices are harming families for fear of repercussions in the next budgeting cycle.

While many organizations supplement their government funding streams with philanthropy and other dollars, those supplements do not mitigate the primacy of the governmental funding streams. These dynamics can create barriers to zealous advocacy for marginalized people and call for increased alliance-building with independently financed public interest law networks.

Unmet needs
While some communities have innovated access to counsel in eviction cases in exciting ways as well as the consumer-friendliness of court service centers, geared to supporting people who must represent themselves in court proceedings, these exceptions prove the rule.

The pace of progress cannot keep up with the needs of families experiencing unlawful benefit denials, sanitary code violations, evictions, and many more health-harming challenges now. There is an ocean of unmet need, so focusing primarily on increasing the ratio of lawyers to clients will only mean justice delayed and thus justice denied.

We must extend legal problem-solving knowledge and strategies beyond lawyers to expand the “army” of legal problem-solvers who can partner with families. By building capacity in – for instance – the early childhood workforce [which, importantly, is geared to maintaining high-trust, longitudinal relationships with families], we can accelerate and scale conveyance of legal information to families and empower more informed decision-making by them.

Expanding the medical-legal partnership
How is this connected to traditional medical-legal partnerships? “Team-facing” legal partnerships are being driven by a new framework to recognize the levels of impact and professional responsibility boundaries.

While the medical-legal partnership movement has admirably spotlighted the population health dimensions of public interest lawyering, its “open tent” culture has created challenges in discerning (a) which programs [and legal partners] are best-equipped to tackle a range of family health-promoting activities, and (b) how best to manage challenging ethical imperatives of legal partnering.

“[B]uilding teams’ and organizations’ capacity to engage with families in legally informed problem-solving” is the “team-facing” function that MLPB pioneered and committed to organizationally.

Importantly, drawing these boundary lines around intended legal partnering impact also means revisiting key professional responsibility considerations for legal partners.

When legal partners focus on “family-facing” case handling or “community-facing” law reform (the ‘top’ and ‘base’ of the impact pyramid), it is families and communities who are relying on the quality and comprehensiveness of their legal support. In the capacity-building zone, the team/organization/system is relying on the quality and comprehensiveness of the legal partner’s guidance.

Moreover, in the team-facing capacity-building mode, legal partners bear witness to the messiness of systems as those systems endeavor to improve their care for and service to families.

This messiness can involve mandated reporting of families in instances of suspected abuse or neglect, errors in care/service delivery, and even misconduct by rogue ‘bad actors’ – all of which can cause harm to families.

For all of these reasons, “team-facing” legal partnering and “family-facing”/”community-facing” legal partnering should not be conducted by the same legal advocate or organization in a single community. Undertaking both functions ignores the conflict of interest potential inherent in such a dual role.

What comes next?
While envisioning an ideal justice infrastructure, let’s imagine the power of investment in family-centered legal problem-solving partners in sectors outside of law – like early childhood.

By democratizing access to legal problem-solving knowledge and strategies through new capacity-building partnerships, where we recognize that we all must become the cavalry, we will:

Accelerate family and community access to concrete supports like food, income, and housing;

Spread critical knowledge and problem-solving skills across key systems serving families;

Strengthen the efficacy and morale of allied workforce colleagues; and

Advance the cause of an accessible justice system designed less for lawyers plying their trade and more for people asserting their rights.

To get from here to there
In all of these evolutions, we should be guided by the wise words of Chief Justice Ralph Gants, in a recent Massachusetts Supreme Judicial Court opinion:

“In a complex, high-stakes process where the right to counsel is not guaranteed and professional assistance is not universally available, the assistance provided by non-attorneys may be the only way for many litigants to learn about and assert their rights.”

Samantha Morton is the CEO of MLPB, a legal advocacy organization that seeks to advance health through justice. The article is reprinted with permission from “Bridging Divides,” the MLPB Blog, originally published on Oct. 4, 2019.


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