Abstract

Medical-legal partnerships (MLPs) are well suited to address health-harming legal needs associated with the collateral consequences of mass incarceration in the United States, such as those that limit access to food, housing, employment, and family reunification postrelease. MLP innovations seek to expand the current model to address patients’ criminal, as well as postrelease, civil legal needs by including community health workers and some patients as legal partners and creating coalitions to promote local and state policy change. Overall, this article explains how these MLP innovations can support rights of people returning to communities after incarceration and can be leveraged to mitigate criminal legal system involvement.

Early MLPs in Health Care

Initiated in 1993, medical-legal partnership (MLP) is an innovation in the delivery of health care that interweaves the skills of health and law professionals to tackle structural barriers to health by addressing legal issues, such as those related to poor housing conditions and immigration, which interfere with health and well-being.^1,2,3 In so doing, MLPs aim to create change at the individual, health system, and policy level. Recently, the scope of MLPs has expanded from the civil legal needs of typically minoritized patients to the criminal and civil legal needs of people with histories of incarceration.⁴

On any given day in 2021, the criminal legal system in the United States detained almost 1.9 million people; in that year, almost 7 million people were jailed and close to 4 million were on probation or parole.^5,6,7 Incarceration has a disproportionate impact on Black and Latinx people, with the imprisonment rate for Black men at the end of 2021 being more than 5 times that for White men.⁵ People who are incarcerated also have a high prevalence of many chronic physical and mental health conditions. As of 2016, more than quarter of people in state prisons had been diagnosed with major depressive disorder,⁸ almost half had a substance use disorder,⁹ and almost half reported ever having a chronic health condition.¹⁰ The so-called collateral consequences of criminal legal system involvement, which refers to the system of sanctions that people who have a criminal record face—including barriers to food access, housing, and employment—have been found to contribute to perceived stress after release from incarceration.¹¹ Given that MLPs have been shown to strengthen patients’ financial security by aiding in the procurement of public benefits¹² and stable housing,¹³ MLPs are well-positioned to help tackle the collateral consequences of incarceration that drive poor health.

Based on our experiences over the past decade running an MLP that serves people returning to the community after incarceration, we reflect on lessons learned and on innovations developed to adapt the model to the needs of the people we serve. We will first describe the setting of our practice, and then we will describe innovations with a focus on legal assistance and policy-reforming strategies.

Setting

Serving people returning to their communities from incarceration, the Transitions Clinic program in New Haven (TC-NH), Connecticut, is one of 48 primary care programs in the Transitions Clinic Network that address health needs such as diabetes, hypertension, hepatitis C treatment, and office-based treatment of substance use disorders (eg, alcohol and opioid use disorders).¹⁴ At the crux of each program are community health workers (CHWs) who have themselves been previously incarcerated and are embedded within the primary care teams to build trust with patients, engage them in their primary care, and address their social determinants of health.¹⁵ CHWs undergo a yearlong training developed by the Transitions Clinic Network that covers issues such as the broad range of collateral consequences of incarceration, advocating for patients with law enforcement while maintaining privacy, and conducting effective outreach.

The TC-NH program was started in 2010 and is based at a federally qualified health center. Patients have typically been released from a correctional facility within the preceding 6 months and have at least one chronic health condition or are over the age of 50. Most often patients are referred directly from the prison system or are identified by the CHW through community outreach to local halfway houses and social service providers. The MLP component of TC-NH started in 2014 and is a collaboration between the Transitions Clinic program and the Solomon Center at Yale Law School, which identifies law students interested in the MLP, oversees their training and legal work, and provides credit for their coursework. The law students are directly overseen by a physician while in clinic and by their legal supervisor at the Solomon Center.¹⁶

Legal Assistance

Needs-based innovations. We began our program with a focus on addressing civil legal needs, such as family issues and debt that people face after incarceration. Tackling a targeted need for a specific population is common in MLPs, and doing so can help clinicians match patients’ needs to MLP skill sets. A civil legal needs screener is conducted for all new patients, of which we see on average 4 per week. From an internal survey, initially we found that 62% of people had at least one identifiable civil legal need, with needs related to public benefits (45%), family matters (15%), housing and utilities (13.0%), and employment (9%) being most common. However, over time there was increasing interest from patients in addressing criminal legal needs, such as police interactions and helping to resolve outstanding warrants. They saw these things as sometimes more immediately pressing and as impacting every aspect of their lives, including their health. Thus, by providing space for patients to not only complete a civil legal needs screener, but also ask about other outstanding concerns, we have gleaned data that provided an opportunity for our program to serve the full breadth of patients’ needs. This approach requires some degree of flexibility from the MLP lawyer and a willingness to adapt service delivery to changes in the needs of the patient population, such as by engaging public defenders and judges to advocate for revocation of outstanding warrants, when possible.¹⁷

MLPs are well-positioned to help tackle collateral consequences of incarceration that drive poor health. 

Although CHWs could bolster most MLP programs, they have not specifically been described as core components of MLPs in the literature.¹⁷ Our program CHWs are integral to the functioning of the MLP. The legal team works directly with the CHW to build trust with patients and reach those who don’t have phones or are limited by restrictions imposed by halfway houses. CHWs, who have built relationships with halfway house staff, help patients collect records that the legal team needs, ensure open channels of communication, and identify broader issues that they hear about repeatedly. Given that the CHWs spend roughly half of their time in the community, they extend the reach of the MLP beyond traditional clinic walls and into the community.

Strengths-based innovations. While typical lawyer-client interactions can be passive or transactional, our work has demonstrated opportunities for challenging this conceptualization. Leveling the power dynamic can be especially important and productive when working with clients who are themselves quite knowledgeable about the law and have extensive experience working in law libraries in prison as “jail house lawyers,” advocating for their own release and that of others. In our experience, knowledgeable clients provide an opportunity for lawyers to adapt their role by more actively engaging patients in their legal complaints—identifying and providing necessary documentation, understanding the history of the issue at hand, developing litigation, identifying priorities for legislative advocacy, and designing a more sophisticated advocacy plan. Anecdotally, our patients have shared that they enjoyed working so closely with a lawyer—some have voiced that this was their first positive experience with any agent of the criminal legal system. Additionally, our law students have come to see their clients as partners in addressing their needs. In the case of one patient whose life is severely restricted by being on the sex registry in Connecticut for a crime he took a plea deal on many years before the registry was established, the law students are pursuing his litigation idea of promoting a lack of due process hearing for people with convictions that predate the enactment of the statute that established the registry.

Policy Change Strategies

MLP scholars have conceptualized a “patients-to-policy” approach to advocacy, whereby recurring patient problems presented in the clinic serve as a natural springboard for identifying policy advocacy priorities. We have taken up this approach and built on it. This approach has led us, for example, to identify the lack of proper identification among our patients as a barrier to transitioning to the community. But rather than simply raising this issue to legislators, we used the MLP legal team, which had special experience in state-level advocacy, to build and lead a statewide coalition to advocate for the provision of state identification to all people leaving incarceration. This effort incorporated the personal stories of and relationships between our staff and justice-impacted clients to create a public narrative around patients’ need for identification, which led other organizations that recognized the gravity of the issue to participate. These coalition partners included people who were previously incarcerated and community advocates, faith leaders, and labor unions. In spring 2023, our coalition successfully convinced legislators to pass a bill requiring the Department of Corrections to issue proper state identification to all people leaving incarceration. The governor signed the bill on June 28, 2023,¹⁸ and we continue to intervene in the executive branch conversation regarding its effective implementation.

We also have used the MLP legal team to advocate for the policy priorities of the Transitions Clinic, such as the need for sustainable state funding of the work of CHWs in Connecticut, by participating in traditional advocacy with state officials and by utilizing a “bargaining-for-the-common-good” framework, in which unions that have the right to bargain use contract fights as an opportunity to organize with community partners around a set of demands that benefit not only the bargaining unit, but also the wider community.¹⁹ Using this framework, our coalition allies put the need for Transitions Clinic funding into the state labor negotiating process as a union demand. The coalition organized for state funding of CHWs led to another success, as the legislature passed an amended bill requiring the Connecticut Department of Social Services to apply for a waiver that would allow clinics like Transitions to bill Medicaid for CHW work.²⁰ By engaging in coalitions and using a bargaining-for-the-common-good approach, we are experimenting with moving not just from patients to policy, but from patients to policy to power, thereby building collective capacity to achieve policy goals relevant to patient health through our MLP.

In summary, the legal needs that people experience after incarceration are nuanced, and many intersect with their health. MLPs present an opportunity for health systems to rise to the challenge of meaningfully impacting the life and well-being of people who have often been left out of traditional systems of care. By leveling power differentials and instigating new positive interactions with the medical system and legal system for people who have historically been marginalized by both, they can have a positive impact even beyond the clinic doors.