Moving Upstream To Address SDOH and Health Equity At a Policy Level - April 6, 2021 1:00PM-2:30PM EST
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Moving Upstream To Address SDOH
and Health Equity At a Policy Level
April 6, 2021 1:00PM-2:30PM EST
Bethany Hamilton, JD
Co-Director, National Center for Medical Legal Partnerships
April 6, 2021
Housekeeping
• By default, everyone joins on mute
• Type questions into the Chat Box
• This session will be recorded
• Email aprildaniels@gwu.edu for help.
Acknowledgements This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $625,000 with 0 percent financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
Health Center MLP Toolkit: Information and resources to start, strengthen, and sustain a medical-legal partnership (MLP). Can be used by health centers new to MLP and those actively providing legal services. Much of the guidance and resources will be applicable to teams in other health care settings.
Today’s Learning Objectives Participants will learn more about: • How MLPs are well-poised to identify opportunities to advance health policy solutions for entire communities • Examples of the types of policies that result in persistent health inequities and widening gaps in access to justice • Opportunities for MLPs to engage in policy-driven initiatives that leverage myriad disciplines and stakeholders in bold efforts to remove systemic barriers and amplify the impact of legal interventions
MLPs embed lawyers as members of the health care team, creating: • Healthier patients • A stronger health center workforce • Improved health equity
FROM PATIENTS-TO-POLICY The MLP at Erie Health Center built a multi-state coalition that got HUD to update its public housing lead regulations. Now, they are working to pass a federal bill that will require lead inspections of all federally assisted housing units before families move in. Available at: medical-legalpartnership.org/resources
FROM PATIENTS-TO-POLICY
Whitman-Walker Health’s MLP helped prevent platinum insurance plans
that were widely used by patients with chronic illnesses from being
eliminated in the D.C. Marketplace, ensuring thousands of patients
maintained access to care.
Available at: medical-legalpartnership.org/resources
$154 can buy 48-60 days of formula
FROM PATIENTS-TO-POLICY
Cincinnati Children’s MLP worked
with the agency that administers
food benefits in the county to
eliminate administrative barriers
to women enrolling newborns in
benefits. Hundreds of newborns
now get benefits months earlier
than before, which means an
average of $154 more per family
for child nutrition.
Available at: medical-legalpartnership.org/resources
Moving Upstream To
Address SDOH
and Health Equity At A
Policy Level
PANELISTSAnn C. Mangiameli
Attorney at Law
Managing Attorney, Health, Education & Law Project
Legal Aid of Nebraska
amangiameli@legalaidofnebraska.orgHome and Community–Based Waiver Services for Aged Persons, Adults, or Children (480 NAC 5–000) The criteria for waiver services eligibility are described in 480 NAC 5–000. To be eligible for support through the “Aged and Disabled Waiver” program, a potential client must meet three general requirements: 1. Have care needs equal to those of Medicaid-funded residents in Nursing Facilities; 2. Be eligible for Medicaid; and 3. Work with the services coordinator to develop an outcome-based, cost effective service plan. 480 Neb. Admin. Code, Ch. 5, § 001.A.
How The Problem Began….. Merie B. ex rel. Brayden O. v. State “Children who had profound disabilities requiring constant supervision were not eligible for waiver services if they had no immediate medical treatment necessity and could walk, transfer, see, and hear. ” Merie B. ex rel. Brayden O. v. State, 863 N.W.2d 171, 186 (Neb. 2015) “DHHS …….arbitrarily placed a far greater burden on disabled children than similarly situated disabled aged persons and adults. ” Merie B. ex rel. Brayden O. v. State, 863 N.W.2d 171, 186 (Neb. 2015)
Action taken by Legal Aid of Nebraska’s Health, Education & Law Project (HELP) 1. Families being denied Medicaid waiver services were identified and referred by HELP’s Medical Legal Partnership with Children’s Hospital and Medical Center. 2. HELP successfully appealed five Medicaid waiver denial cases. 3. Additionally, HELP strategized with other advocacy groups to publicize the affect of the regulation changes on children with severe disabilities.
Results: Given the concerns that had been raised by parents, state lawmakers and advocacy groups, the state hired a consultant to study the new standards and the tool used to measure children’s level of disability. New, less restrictive, regulations were enacted by DHHS effective December 2020 See 471 NAC 43
Population Health Advocacy via
Amicus Curiae Brief
Tuesday, April 6, 2021Keegan Warren-Clem, JD, LLM
Adjunct Professor | The University of Texas at Austin
School of Law and McCombs School of Business
Director | TLSC Medical-Legal Partnerships (formerly Austin MLP)
kwarren-clem@law.utexas.eduARGUMENT
I. Qualifying Individuals Already Face Substantial Administrative Obstacles to
Accessing Medicaid Benefits for Which They Are Eligible
A. Medicaid’s Target Population Is Particularly Ill-Equipped to Navigate Complex and
Ongoing Administrative Requirements
B. The Medicaid Application Process Presents Multiple Obstacles to Accessing Care
C. The Appeals Process Presents Another Set of Administrative Obstacles to Coverage
D. Once Applicants Qualify for Medicaid, They Must Continue Clearing Administrative
Hurdles to Maintain Benefits
II. The Life Experiences of Medicaid Patients and The MLP Clinicians and
Attorneys Who Assist Them Illustrate How Administrative Hurdles Impede
Access to Coverage
III. Work Programs’ Reporting Requirements Add Administrative Obstacles to
Coverage That May Disqualify Otherwise-Eligible, Working Recipients And
Undermine Holistic Efforts To Ameliorate Health DisparitiesAmicus Tips for MLP Organizational Partners
Restrictions Resources
Medical • Brennan Ctr. for Justice, “The Restriction
• No known categorical prohibition on Barring LSC-Funded Lawyers from Bringing
participation in the filing of an amicus brief Class Actions” (Sept. 26, 2003),
https://www.brennancenter.org/our-
work/research-reports/fact-sheet-restriction-
barring-lsc-funded-lawyers-bringing-class-
Legal actions
• No categorical prohibition on participation in • Permissibility of Using LSC Funds to File an
the filing of an amicus brief in a litigated case Amicus Curiae Brief (Mar. 5, 2010), available
without representing a client at
• Recorded as a “matter” and not a “case https://www.lsc.gov/sites/default/files/LSC/ls
cgov4/AO_2010_001.pdf
• But may not undertake an amicus curiae class
action • LSC Act § 1006(d)(5)
• Always consider state requirements • 45 CFR § 1617.2(b)(1)DISCUSSION WITH ANN AND KEEGAN
The
Access to
Justice
Gap and
The Utah
Sandbox
Rebecca Sandefur, PhD
James Teufel, MPH, PhD
April 6, 2021
23MLP version • Legal organizations establish formal
agreements with medicine
1.0 • Acceptance that lawyers can supplement
medicine
• Payment for attorney services through
MLP version insurance or federal health programs
• Lawyers an integral part of the medical team
2.0 • Increasing demand for reactive legal services
as health services
• Policy and regulatory reform for health AND
MLP version legal
3.0 • Legal services are health services
• Increasing supply of proactive legal services>Number of Attorneys in the U.S. More Attorneys
Fewer Specializing in Public Service
1,600,000 I. Public defender or legal aid
attorneys remained 1% of all
1,400,000
attorneys (ABA Lawyer Statistical Reports)
1,200,000
II. Estimates of legal aid
1,000,000
attorneys has also remained
800,000 similar across time (5000-
7000 attorneys)
600,000 Less than 1%
Twice as likely to be female
400,000
200,000 III. Attorneys have increased by
about 60%, but the number of
0
public service attorneys has
1993
1996
1999
2002
2005
2008
2011
2014
2017
2020
not shifted much, if at allInflation Adjusted LSC Funding ($) Inflation Adjusted Funding ($)
LSC Funding Dropping or Stagnating Non-LSC Legal Aid & Pet Costumes
700,000,000 900,000,000
800,000,000
600,000,000
700,000,000
500,000,000 600,000,000
500,000,000
400,000,000
400,000,000
300,000,000 300,000,000
200,000,000
200,000,000
100,000,000
100,000,000 0
2012 2019
0 LSC
1993
1996
1999
2002
2005
2008
2011
2014
2017
2020
Non-LSC
Halloween Pet CostumesNationally, 2018 estimates supported that…
I. Majority in U.S. experience 25,000,000
at least one justice problem 20,000,000 19,500,000
in last two years 18,000,000
II. Large portions of life 15,000,000 13,500,000
dealing with justice issues
I. Adults can expect to spend 10,000,000
two-fifths of the rest of their 4,700,000
5,000,000
lives experiencing justice
issues
0
II. Young adults (age 18-34) 2019 U.S. WJP Population Poll
I. A fifth (21%) of remaining (Hardships count)
life will include justice- Health
linked hardships Income, Employment, Housing
Relationships
Sources: Calculations from the World Justice Project and US Census Data; Sandefur and
Teufel , UC Irvine Law Review, 2021 Alcohol, DrugsAccessing Justice in Utah
Each Year 16 15
14
• Small
12
businesses=1,061,446
justice issues unserved 10
• Low Income 8
households=944,854 6
justice issues unserved 4 3
• Legal aid assistance= 2 2
64,080 problems
0
• Middle class households= Minimum Within Context "Business As Usual"
Multipliers to Bridge the Justice Gap
409,290 unserved issues Low Income Middle Class Small BusinessMost Civil Justice Issues
Do Not Make It to Legal Services
What courts and
lawyers see
Real people with real legal problems
Civil justice problems of the public
USA: 14 to 24% of
people’s
actual justice
problems
What courts
and lawyers
don’t see
USA: 76 to 86% of
people’s
actual justice
problemsEnabling Innovation in Legal Services
in Utah
• Re-Imaging Regulation • Sandbox
• Rule 5.4 “prohibits a lawyer or • Supreme Court Authorized
law firm from sharing legal Legal Service Innovation
fees with a nonlawyer or • Ownership, fee sharing, non-
forming a partnership with a lawyers (human and computer)
nonlawyer if any of the • Alternative Business Structures
activities of the partnership
consist of the practice of law.” • Data-Driven Regulation
• Positive Risk (opportunity)
• Re-Imaging Legal Services • Negative Risk (harm)
• Advice to representation
• Results, Rights, Payments
• Ownership and feesResearch consistently demonstrates that specialized
non-lawyer providers preforms as well or better than
traditional attorneys in providing legal services.
Learning from the United Kingdom:
Solicitors
Nonlawyer advisors
0% 20% 40% 60% 80% 100%
Below Threshold Compentence Competent to Good Excellent
Areas of practice: benefits, housing, debt, personal injury, immigration, employment, other civilUtah Office of Legal Services Innovation’s “Sandbox”
A policy tool through which new models or services can be offered and
tested to assess marketability and impact and inform future policy-
making.
Office Recommends Court Authorizes or
Denies Applying Entity Collects and
Entity Applies to to Utah Supreme
Entity Submits Periodic
the Office Court along with Recommendation (in Data to the Office
Risk Categorization whole or part)
Licensed Legal Office Monitors and
Utah Supreme
Services Entity Entity Applies to Responds to Risk
Court Authorizes
Ongoing Reporting Exit the Sandbox (harm or data
or Denies Exit
to the Office quality)If legal service inequities are health inequities, we need to
better resolve legal services deserts (Statz and Termuhlen, 2020)
I. No state currently meets
the original LSC vision of 2020 ABA Profile of the Legal Service Profession
2 lawyers for every
10,000 peopleRe-Imagine Systems to Overcome Structural Chasms in Legal Services • The United States ranks 109th out of 128 countries in access to and affordability of civil justice, between Honduras and Bangladesh. • The United States also ranks 115th out of 128 countries in discrimination in the civil justice system (rank below India) World Justice Project, 2020 Rule of Law Index
Contact •Rebecca Sandefur, PhD • Arizona State University •James Teufel, MPH, PhD • Utah Office of Legal Services Innovation, an Office of the Utah Supreme Court • Moravian College World Justice Project, 2020 Rule of Law Index
Lots of problems of people
Few legal services for people
• 1970s • Driving Demand
• 50%-- lawyers for large • Translating justiciable events
organizations into legal needs or cases
• 50%-- lawyers for small • Driving Supply
business or people
• Increasing legal services to
• Today better assist people
• >90%-- lawyers for large • Restructuring legal service
organizations delivery systems
•DISCUSSION WITH REBECCA AND JAMES
QUESTIONS AND ANSWERS
Housing as a Key Social Determinant of Population
Health and Health Equity
HRSA 2019-2020 Health Equity
Report: Special Feature on Housing
and Health Inequalities
Source: U.S. Department of Health and Human Services, Health Resources and Services
Administration, Office of Health Equity. Health Equity Report 2019-2020: Special
Feature on Housing and Health Inequalities. 2020. Rockville, Maryland.Thank You Don’t forget to complete the survey!
Contact Information
Bethany Hamilton, JD
bhamilton1@gwu.edu
www.medical-legalpartnership.orgYou can also read
