AMA Journal of Ethics^®

You are a pediatrician, halfway through a busy morning clinic. You walk into an exam room to see 9-year-old Sarah, whose asthma you have treated for years, and her mother. Initially, Sarah’s health was very unstable, requiring numerous hospitalizations. By working closely with her family, you were able to get her asthma under control.

In the past 6 months, however, Sarah has had three emergency department visits and two hospitalizations for asthma. You are confident that the family is compliant with the treatment plan, and your medical management has been comprehensive: allergy testing, pulmonary function tests, asthma education classes, appropriate medications—and yet, Sarah’s asthma is not controlled. You dig deeper and identify several problems. First, Sarah and her family rent an apartment that is infested with cockroaches. The family keeps their apartment meticulously but there is trash in the hallways, and an often-overfilled dumpster sits against the outside wall. There is also a water leak from the apartment above theirs that has led to mold growth on one wall. Sarah’s mother has tried repeatedly to get the landlord to address these problems, to no avail.

A second problem is that Sarah has lost her Medicaid. Her mother submitted the renewal application 2 months ago but has not heard back. The family is unable to purchase Sarah’s medications. Finally, Sarah’s school has threatened to take her family to court because of excessive school absences this year. In this case, you realize that fixing Sarah’s problems will take a lot more than the latest and best asthma medications. Sarah needs a specialist—not a pulmonologist or allergist, but a lawyer. If you work with a medical-legal partnership (MLP), Sarah and her mother can walk right down your hallway and meet with a lawyer who can address these problems.

The National Center for Medical-Legal Partnership defines MLP as

a health care and legal services delivery model that aims to improve the health and well-being of vulnerable individuals, children and families by integrating legal assistance into the medical setting. MLPs address social determinants of health and seek to eliminate barriers to health care in order to help vulnerable populations meet their basic needs and stay healthy [1].

The first MLP was developed by Barry Zuckerman, MD, at Boston Medical Center in 1993, and the model is used in 225 hospitals and health centers in 38 states. In 2010, more than 13,000 individuals and families received legal assistance through MLPs, and more than 10,000 health care professionals received training on the MLP model. MLP has been endorsed by the American Medical Association and the American Bar Association [2, 3].

MLPs focus on three key activities. First, they provide legal assistance in the health care setting. Legal professionals meet with families to identify and address those circumstances affecting their health that are amenable to legal intervention. Second, MLPs work to transform health care practice by educating health care professionals about the significance of social determinants of health. Third, MLPs work toward policy change by addressing local, state, and federal laws and regulations that can stand in the way of maintaining good health.

As physicians, accurately diagnosing our patients’ problems and providing the latest evidence-based management of their physical problems can seem challenging enough. We must go deeper, however, to better understand the underlying causes of our patients’ illnesses and the reasons why they sometimes do not respond to our medications. Often the answer is found by taking a detailed social history.

Increasing attention is being paid to the social determinants of illness. A 2009 review in Pediatrics emphasized the strong link between problems in the social and physical environments and the risk for childhood asthma [4]. There is also evidence that the origins of adult conditions can be traced back to childhood [5]—researchers have found strong associations between early childhood adverse experiences and environments and adult diseases such as coronary artery disease, chronic lung disease, cancer, alcoholism, depression, and drug abuse. Few physicians make house calls anymore, so we must delve deeper in our history taking to fully understand the circumstances that may be influencing our patients’ health. It is also important for us to develop collaborative relationships with other professionals in our community. Typically, these other professionals will be in the health care field, but sometimes what our patients really need is a lawyer.

According to a 2009 report from the Legal Services Corporation, the average low-income household in the United States had 1.3-3.0 legal needs per year [6]. These needs included problems related to housing, consumer protection, family law, employment, health care, and government benefits. Typically, legal assistance was received for fewer than 20 percent of these problems.

Unsafe housing conditions and inappropriate denials of government benefits are common examples of legal problems that can directly affect the health of our patients. Through direct access to legal advice while in the hospital or clinic, our patients get the assistance they need. Data show that MLPs can increase access to health care and improve the patient’s and family’s sense of well-being [7]. Assistance with benefit denials can also significantly improve reimbursement to health care facilities, which can help defray the cost of the program [8].

So let’s get back to Sarah. Her mother receives legal assistance from the MLP in your clinic. Two telephone calls from the MLP lawyer are enough to get the landlord to address the cockroach and mold problem and to get Sarah’s Medicaid reinstated. The lawyer then goes with the mother to Sarah’s school. School personnel agree to accept Sarah’s medically excused absences and to work with her mother to help Sarah catch up on school work that she missed. Sarah’s mother is ecstatic and Sarah’s asthma management gets back on track.