Abstract

Health justice as a movement incorporates research about how to more effectively leverage law, policy, and institutions to dismantle inequitable power distributions and accompanying patterns of marginalization that are root causes of health inequity. Legal advocacy is key to health justice because it addresses patients’ health-harming legal needs in housing, public benefits, employment, education, immigration, domestic violence, and other areas of law. In medical-legal partnerships, lawyers and clinicians are uniquely positioned to jointly identify and remove legal barriers to patients’ health, advocate for structural reform, and build community power.

Case

JM is 29 years of age and presents in distress to a municipal emergency department with an acute asthma exacerbation for the third time this month. JM is admitted and seen by a hospitalist, Dr H, who learns from JM that he is living in an apartment with mold and fears being evicted after falling behind on rent. Dr H is concerned that JM will continue to experience severe asthma exacerbations and overall poor health if he remains in substandard and unstable housing.

Commentary

Dr H is rightfully concerned about JM’s health. Exposure to mold in homes has been linked to increased incidence and severity of asthma.^1,2,3 If JM were to be evicted, his health would be further at risk, as eviction has been linked to myriad health conditions.⁴ Indeed, even the threat of eviction has been shown to harm health.⁵ On her own, Dr H lacks the tools in her toolbox to address JM’s substandard housing conditions or prevent his eviction. JM is experiencing health-harming legal needs and requires legal advocacy both to ensure that his landlord remediates the mold in his home in accordance with the local housing code and to prevent his eviction.^6,7

Each year, millions of Americans—and disproportionately people with low-income and people of color—have unmet legal needs related to housing and many other areas of law, such as public benefits, employment, education, immigration, child custody, domestic violence, and disability discrimination.^8,9,10 Legal problems in all of these areas harm health and are associated with socioeconomic and racial health disparities.^8,11,12 For example, illegal substandard housing conditions, like those experienced by JM, are a root cause of asthma prevalence and severity,^2,3 and high asthma rates disproportionately burden people of color and households with low income.¹³ Despite the urgency of such issues, many people with low income fail to obtain legal assistance because they do not recognize their problems as legal in nature and face barriers to accessing legal services.^14,15 Without legal help, the health of patients like JM can worsen.^8,14

Health justice as a movement incorporates research on how to effectively leverage law, policy, and institutions to dismantle inequitable power distributions and the accompanying patterns of marginalization that serve as root causes of health disparities.^16,17 While health equity has been defined as all people having a fair and equal opportunity to achieve health and well-being, the term justice centers the potential for law to facilitate health equity.¹⁸ Because many unmet socio-legal needs harm health and drive inequity, access to justice—or access to adequate legal information, advice, and advocacy—is therefore foundational to health justice. Medical-legal partnerships (MLPs) embed lawyers in health care settings to train health care partners to screen patients for social needs and refer them for legal services.^12,18 This article argues that MLPs offer a promising approach for effectuating health justice by bringing lawyers onto the treatment team to remove legal barriers to health, advocate for structural reform, and build community power.

Health Justice and Medical-Legal Partnerships

Health justice begins with an examination of how law and policy have created and perpetuated health inequity, including how broader patterns of discrimination and marginalization, such as structural racism, impact health.^6,16,19 The health justice framework recognizes that the disproportionate burden of health problems experienced by certain populations is “made, not born.”²⁰ Indeed, a growing body of research recognizes that “[m]edical care is estimated to account for only 10-20 percent of the modifiable contributors to healthy outcomes for a population,” and the other 80% to 90% are known as the social determinants of health, or the conditions in which people live, eat, work, learn, and age.²¹ Health justice underscores that these conditions are not just social but political and structural determinants of health, with roots in law and policy that drive health disparities.^22,23

These conditions often present in patients as health-harming legal needs. Housing codes requiring that rental housing be free of hazards like mold and landlord-tenant laws protecting renters from unjust evictions are examples of laws that can impact health.¹ Problems with the substance, implementation, and enforcement of such laws can drive health disparities when they result in people from racially minoritized and socioeconomically marginalized populations, such as JM, disproportionately experiencing unhealthy and unstable housing.¹ For instance, redlining and restrictive covenants relegated many people of color across the country to neighborhoods with substandard housing conditions, reinforcing racialized poverty and making stable and affordable housing inaccessible for many people of color.¹⁰ When landlords do not adhere to housing codes designed to ensure tenants’ safe and habitable conditions, the health of tenants from those minoritized and marginalized communities is harmed.¹ Indeed, “health justice is … economic justice, racial justice, housing justice, and other forms of justice that necessitate access to legal resources to address unmet legal needs.”¹⁴ Health justice requires radical action by cross-sector partners to address these inequities; it requires resolving health-harming legal needs facing individuals, transforming systems that drive health disparities, and building the power of affected communities to drive the health justice agenda.^20,24

By embedding lawyers in health care teams, medical-legal partnerships offer a different model of health care that leverages interprofessional collaborations to tackle the social and structural determinants at the root of health injustice and thereby offer a different and promising model of access to justice. In a traditional legal services model, a person may not realize they have a legal issue with a legal remedy until there is a crisis, such as receipt of an eviction notice. That person must then seek out and obtain legal assistance. Many individuals do not identify their problems as legal in nature, face barriers to locating and accessing legal services, perceive the process as overwhelming and time intensive, and lack comfort with legal services.^12,14,15

Many individuals do not identify their problems as legal in nature. 

MLPs lower such barriers to legal assistance by capitalizing on patients’ presence in the health care setting and their relationships with their health care practitioners to engender trust in the legal team.¹⁴ In MLPs, clinicians proactively screen for and help patients recognize potential legal needs, refer patients to a legal team, and advocate collaboratively with attorneys and legal navigators to address health-harming legal needs.^11,12,14 A 2020 study found that MLPs reduce obstacles to legal assistance by creating a straightforward, affordable, and trustworthy access point.¹⁵ These partnerships can also facilitate more transformative change, as they offer opportunities for interprofessional teams to engage in structural reform efforts through patients-to-policy advocacy and community power building.^14,15

Identifying and Addressing Health-Harming Legal Needs

In an MLP, Dr H would be trained by a lawyer to screen for and identify legal needs so that she could recognize JM’s substandard housing conditions and eviction concern as potential legal issues and refer JM to an attorney.^12,25,26 That attorney could advocate for mold remediation through a letter to the landlord or litigation, and Dr H could assist by providing medical records or court testimony documenting the impacts of mold on JM’s respiratory health and the urgent need for mold remediation.^12,27 Moreover, JM’s MLP attorney could advocate for emergency rental assistance or rent abatement and assert his rights under landlord-tenant laws, such as those requiring landlords to provide safe and habitable housing free of mold, in order to prevent his eviction, avoid the resulting health harms, and ensure he has stable and healthy housing.^28,29 Such collaborative MLP advocacy to remedy substandard housing conditions has been directly linked to improved asthma and respiratory health.³⁰

Access to justice is critical in many other types of matters implicating health besides housing. For example, lawyers can assist patients in asserting their rights to family and sick leave and workplace accommodations,³¹ which can help people remain employed and prevent health harms—and racial disparities—associated with unemployment, including increased risk of hospitalization.^32,33 For pediatric patients, attorneys can advocate for necessary special education services and fight illegal exclusionary discipline,^34,35,36 keeping students in school and reducing their risk of health outcomes associated with low educational attainment, such as chronic disease and lower life expectancy.^37,38,39 For survivors of intimate partner violence, lawyers can obtain divorce, custody, and protective orders.⁴⁰ Data indicate that legal representation reduces recurrence of domestic violence, protecting the safety and health of survivors.⁴¹ Similarly, immigrants with legal representation experience greater likelihood of success at all stages of immigration proceedings,^42,43 with numerous health-promoting benefits, such as greater access to health care and employment.^44,45,46 MLPs therefore provide an innovative approach for effectuating health justice that goes well beyond traditional health law.

The National Center for Medical-Legal Partnership developed the I-HELP^TM framework for helping health care and legal partners identify and understand such health-harming legal needs in the categories of income, housing and utilities, education and employment, legal status, and personal and family stability.²⁵ MLPs are expanding beyond these areas by, for example, engaging physicians with public defenders and law school clinics to advocate for compassionate release from incarceration of people with serious health conditions.^18,47 Research shows the benefits of MLP legal advocacy, including improved health and reduced stress for patients, as well as return on investment for hospitals and health care systems.^26,29

Advocacy for Structural Reform

Health justice requires more than legal advocacy to leverage laws already on the books, such as housing codes; it also requires structural reform of laws, policies, and systems that drive health inequity.¹⁶ MLPs use a “patients-to-policy” approach to pursue this type of transformative change.

Using this approach, MLP partners listen to their patients’ concerns and draw on their patient-focused advocacy to identify broader systemic gaps and problems with the law and engage in policy advocacy to address those problems.^48,49 A patients-to-policy approach allows MLPs to build on their individual-level advocacy by surfacing the health harms that result from current legal structures and pursuing broader reforms to improve community health and health equity. This advocacy can take different forms. For example, attorneys can advocate for law reform by preparing health care team members, as well as patients, to provide written or oral testimony before local, state, and federal lawmakers at legislative hearings in order to share their firsthand knowledge of how the law impacts health and drives disparities.^6,14,49 In JM’s case, beyond protecting JM’s individual rights, Dr H and her MLP partners might employ such a patients-to-policy approach to identify gaps in the city’s housing code and inspections system. They could use that knowledge to advocate with municipal or state legislators for systemic reform, such as housing code changes to require proactive mold screenings in rental units. The MLP could also advocate for other transformative policy changes, such as significant increases to housing voucher programs, a universal basic income program, and homeownership initiatives for low-income tenants, all of which could benefit JM and promote broader health equity.

Community Power Building

Health justice also requires intentionally building power for both individuals and communities experiencing health inequities.^16,50,51 MLPs offer a unique model for fulfilling this important health justice objective.

MLP scholars have called upon MLPs to more vigorously embrace antiracist, intersectional, and power-building approaches^12,52,53 to ensure they “are not merely creating repeat clients but rather increasing the collective power of marginalized communities and dismantling racial injustice that legal (and medical) systems have perpetuated.”¹⁴ Consistent with their holistic and patient-centered orientation, MLP partners can help patients build their power by educating them about their rights and providing them with tools and resources to aid in future self-advocacy.⁵⁴ For example, an MLP could work closely with JM to help him understand his rights to safe, healthy housing and how to document and pursue remediation of substandard housing conditions by his landlord if they recur. MLPs can also build community power by facilitating patient engagement with policy makers in accordance with the patients-to-policy approach, such as by helping JM testify before legislators about his lived experience and the need for stricter housing code enforcement and greater access to affordable housing. Furthermore, MLPs can connect patients like JM with grassroots movements, such as tenant cooperatives, which can provide patients with greater solidarity and power. Attorneys, physicians, and other health professionals can also become resource allies, lending their expertise and support to those organizations and engaging in community-based participatory research and other collaborative efforts to help affected communities identify their needs and lead the development and implementation of the health justice agenda.^55,56

Call to Action

Hospitals, health care systems, and government entities should seek opportunities to develop and expand medical-legal partnerships that can address health-harming legal needs, pursue structural reform, and promote community power, all of which advance health justice. In particular, more universities and teaching hospitals should develop academic MLPs (A-MLPs) that engage students in MLP learning and advocacy and conduct MLP research. Given universities’ research missions, A-MLPs are well-positioned to study both connections among law, health, and equity and the efficacy of MLP approaches to inform best practices. Furthermore, A-MLPs can train the next generation of law, medical, nursing, and other students to practice differently in ways that intentionally promote health justice, thereby contributing to the transformation of the health care and legal systems. Through curated preprofessional interdisciplinary learning environments during their formative years of professional development, students can learn to practice with an understanding of how health and justice intertwine and to intentionally partner across disciplines to foster health equity.⁵⁷ A-MLPs are uniquely positioned to teach future lawyers, doctors, and other health care professionals early in their careers how to advance health justice by collaboratively addressing the health-harming legal needs of individual patients like JM, advocating for structural reform, and building community power. ^57,58,59