Having enough nutritious food is important to overall health; it can be especially important when undergoing cancer treatment. Days before going to the hospital for breast cancer surgery, Margaret, a single woman in her early 60s, applied for SNAP benefits (“Food Stamps”). Her application was approved, but she never received her benefits card. Margaret tried to work with the local social services agency to get her card, so did the hospital’s case manager. Neither effort was successful. After her surgery, Margaret followed up with her primary care provider at a community health center who was concerned that Margaret's poor nutritional status could compromise her recovery. The primary care doctor referred Margaret to the health center’s medical-legal partnership (MLP) program and within days, the MLP team persuaded the local social services agency to expedite Margaret’s SNAP benefits, allowing Margaret and her health care providers to focus on all of the other things she needed for her recovery.
Stories like Margaret’s are increasingly common. People need more than medical care alone to be healthy, and because they manage individuals’ care in the community, primary care providers can play an important role in connecting people to these services. Thanks in part to significant investment through the Affordable Care Act (ACA), federally-qualified health centers (FQHCs) represent the largest network of independent primary care providers in the US; 22 million patients, including many with chronic, life-threatening, disabling conditions, rely on FQHCs for their primary care.
In North Carolina, 32 new FQHC clinics have been established in the past four years, bringing the total to 180 clinical sites around the state. These clinics provide comprehensive, primary care services to all patients regardless of ability to pay. Nationally, 35% of FQHC patients are uninsured. In North Carolina, more than half of FQHC patients are uninsured.
Recognizing that health is influenced by complex social and environmental factors, FQHCs have developed a range of “enabling services” that are not clinical in nature, but that facilitate access to care and can improve their patients’ health. These enabling services include things like transportation, interpretation, outreach, and case management. In other words, FQHCs recognize that providing high-quality care for their patients often requires addressing non-medical issues that influence patient and population health. As described recently in a report by The Institute of Alternative Futures, “leveraging the [social determinants of health] is ‘in the DNA’ of CHCs.”
The proliferation of FQHCs in North Carolina combined with the opportunity to expand coverage through the Affordable Care Act, have created exciting opportunities for establishing new, or expanding existing, medical-legal partnerships. To help our organizations better understand the health-related legal needs of FQHC patients and to build a case for expanding MLPs within North Carolina’s community health centers, we conducted a needs assessment of more than 330 patients and more than 200 staff at five North Carolina health centers. Here are some of our findings.
- Over 70% of patients reported experiencing an unmet health-related legal need within the past year.
- Uninsured patients and patients reporting poor health status were significantly more likely to experience an unmet health-related legal need. These same groups were least likely to have sought legal assistance in the past or know where to go for legal help.
- Even though the first two findings are troubling, we were delighted to learn that nearly 80% of health center patients said they would discuss legal/resource problems with their health care providers in the future.
- While staff reported varying levels of comfort screening patients for particular health-related legal needs, 71% of staff reported that they would screen and refer patients for free legal assistance if their health center had an established referral program.
- Staff members with shorter tenures were more comfortable screening for these issues and were more likely to make referrals.
- Lack of knowledge about existing resources was the most commonly reported barrier to addressing health-related legal needs. This barrier is one that certainly can be addressed with training.
Our statewide legal aid organization and primary care association (PCA), in partnership with dozens of others, are committed to helping North Carolina’s residents gain access to health insurance coverage through the Affordable Care Act. As we approach the ACA open enrollment period that begins next month, legal aid agencies and PCAs across the country should reach out to one another to discuss how to combine their outreach and enrollment efforts. In many communities, this may already be happening. And it is a great opportunity to begin the conversation about how medical-legal partnership can address other health-harming legal needs.
*Rebecca Whitaker is the former Director of Health Policy and Governmental Affairs at the North Carolina Community Health Center Association.
**Madlyn Morreale is the Supervising Attorney for the Medical-Legal Partnership Program at Legal Aid of North Carolina, Inc.
Acknowledgements: A special thanks to Alexandra Harris, Grassroots Advocacy Manager for Special Populations at the National Association of Community Health Centers, for her assistance with data analysis on this project. Her efforts have allowed us to make stronger connections between CHC patients and unmet health-related legal needs.