Key points

Many social determinants are legal needs with legal remedies

Many of the social determinants of health can be traced back to laws that are unfairly applied or underenforced. Lack of access to public services and benefits constitute legal problems that affect individual and population health. The impact of the denial of benefits and unfair application of the law is especially common in vulnerable populations, including low-income families. For example, pest infestation, which is linked to asthma rates in rental housing, violates local and state sanitary codes. If the sanitary code is not enforced, then asthma rates can worsen. When families are wrongfully denied nutritional benefits like the Supplemental Nutrition Assistance Program (SNAP), they are at risk for malnutrition and other poor health outcomes. Therefore, when these laws are not properly enforced, families risk health consequences.

Studies have shown a significant correlation between legal needs and health. Indeed, the overlap between rates of legal needs for low-income populations and poor health outcomes for low-income populations reinforces the axis between legal needs and poor health. Hardships associated with poverty (including hunger, safety, and substandard housing ) directly influence health. These social determinants of health require some level of legal care/intervention to prevent poor health outcomes. The civil legal problems of low-income families, such as protection from abusive relationships, safe and healthy housing, access to necessary health care benefits and services, and family law issues, such as child support and custody, constitute basic human needs. Emerging practices highlight the proposition that aligning legal and health care through medical-legal partnership (MLP) can help communities/health care institutions lower barriers to basic needs improve access to care.

Prevalence of legal needs in low-income populations

With 1 in 6 people living in poverty, the need for more/new impactful/powerful strategies to address the links between poverty and health is overwhelming. Studies show that most vulnerable individuals have at least one civil legal problem that negatively affects their health; national and state data suggest that most low-income people experience at least 2 legal needs, and most of these needs are not addressed. This translates to more than 50 million Americans who have some sort of legal need, usually derived from the most basic human needs as detailed earlier.

Small-scale/preliminary/pilot studies indicate that legal needs are widely distributed, of long duration, and detrimental to patient health. For example, at a clinic in Tucson, Arizona, providers screened and referred 104 low-income patients for a single legal matter; at the subsequent legal intake, 170 discrete legal matters were identified, ranging from housing concerns to health insurance coverage to finances. Pediatric providers at a Baltimore hospital found similar results when surveying parents about legal concerns, with employment and education being the most prevalent. Like health needs, legal needs occur along a continuum; some problems can be successfully resolved with social resources and referrals that are guided by trained legal experts; but other legal needs can escalate to legal crises if not addressed early by legal experts. For example, families at risk of eviction for nonpayment of rent, perhaps because of job loss, may be able to rely temporarily on community safety-net resources for rental payments. But a family who has longer-term income struggles may require a lawyer to negotiate a payment plan with their landlord or secure other resources or benefits.

Bridging the divide: the legal and health care systems/communities

Legal needs that address social determinants of health have traditionally been addressed by the legal community, with minimal input or feedback from the health care community beyond the provision of basic evidence for people with disabilities seeking public benefits. In 2012, 8100 publicly funded civil legal aid attorneys and paralegals handled legal problems for more than 800,000 low-income and vulnerable people; a significant number of those problems were legal issues linked to health most frequently related to safety and domestic violence; safe housing, including unlawful evictions and landlord-tenant issues; and income maintenance concerns, including obtaining and maintain disability benefits. Despite those linkages between health and legal needs, the impact of legal interventions on individual and family health is not tracked.

Despite legal needs being so common in low-income families and having such a strong impact on health and well-being, information about legal needs and hardships is not considered in most health care practices; access to legal expertise and interventions is not often integrated into practice. This circumstance might be because health care staff do not consider these concerns to be related to health; but given the emerging understanding of social determinants of health, it is more likely that physicians and other clinical staff do not have the time, staff expertise or capacity, or resources needed to respond to legal concerns. Some clinics have staff, whether clinical, paraprofessional, or volunteer, who might try to navigate the legal issues faced by their vulnerable families; but they are not trained to address the underlying legal problems or they risk exacerbating the legal problem. Amid this constellation of emerging awareness of legal needs, alongside confronting the dramatic lack of community legal resources to support vulnerable families, the MLP approach has flourished as a strategy to build capacity inside the 4 walls of the health care clinic while bridging with a community partner who holds singular expertise to address, and eliminate, the social determinants of health.

Accessing legal support

National studies continually document both the inability of low-income people to ascertain when they have a legal need that requires a legal expert as well as the utter lack of sufficient resources for people with legal needs.

Barriers to civil legal aid access include patients not thinking their concerns were a legal issue, being unaware of how to access legal resources, and perceiving legal assistance will not be helpful. With the exception of one family, most of the families who did access legal support found it ineffective.

The medical-legal partnership response

The MLP approach in the clinical settings combines the knowledge, training, and resources of health care, public health, and legal professionals and staff to address and prevent the social determinants of health caused by legal needs.

The partnership between clinical and legal staff established through MLP facilitates the identification and correction of potential legal barriers to individual and family health. Attorneys and paralegals train health care providers to recognize the connections between unmet legal needs and health and develop screening questions for patients. Health and legal team members work together to address the identified legal needs. Effective, sustainable MLPs use shared data and expertise to respond to the social determinants of health in 4 ways:

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  TRAIN health care, public health, and legal teams to work collaboratively and identify legal and social needs upstream

  
  
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  TREAT individual patients’ health-harming social and legal needs with legal care ranging from triage and consultations to legal representation

  
  
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  TRANSFORM clinic practice and institutional policies to better respond to patients’ health-harming social and legal needs

  
  
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  PREVENT health-harming legal needs broadly by detecting patterns and improving policies and regulations that have an impact on population health.

MLP uses the acronym I-HELP (Income, Housing and utilities, Education and employment, Legal status, and Personal stability) to identify the most common social determinants of health impacted by legal need and to identify ways in which an MLP can benefit families facing these concerns ( Table 1 ).