Wednesday, October 22, 2014

Affordable Care Act: Opening Doors to MLP Expansion in Safety Net, Primary Care Settings

By Rebecca Whitaker* and Madlyn Morreale**

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.
The combined findings of these surveys are encouraging. While FQHC patients have significant unmet legal needs, the surveys showed patients are willing to discuss those needs with their primary care providers, and those same providers would be willing to screen and refer patients if free legal services were available. This is an ideal foundation for exploring how to expand MLPs among North Carolina’s community health centers.

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.

Wednesday, October 15, 2014

Preparing Civil Legal Aid to Partner with a Transforming Health Care System

By Camille Holmes, Director, Leadership & Racial Equity, National Legal Aid and Defender Association

One of my roles in the civil legal aid community has been to encourage innovative, systemic, collaborative, and community-based solutions to the structural problems facing low income communities, particularly those disproportionately impacting low income people of color. At the National Legal Aid & Defender Association (NLADA), that has meant sharing cutting edge research and best practices that help civil legal aid programs prioritize “upstream” activities – those that are more likely to interrupt the stream of problems faced by low income people and build infrastructure for strong healthy communities. I have been privileged to help lead the charge in the civil legal aid community to break out of our silo and build new partnerships in service to community-defined need.

After the passage of the Affordable Care Act, NLADA partnered with the National Health Law Program to hold a National Health Law Training for the civil legal aid community. Health has not been one of the “core” areas of civil legal aid representation, but that is beginning to change. At close to 19% of American GDP, health care touches every aspect of our lives. And while civil legal aid is now paying closer attention to the depth and breadth of health care challenges faced by our low income clients, we must also prepare to partner differently with a health care sector experiencing significant growth and transformation.  

The “Where Health Meets Justice” Fellowship Program was established in fall 2013 with support from Public Welfare Foundation specifically to provide senior civil legal aid leaders with the knowledge, skills and insights to leverage the significant opportunities for partnership and change in the health care landscape in the wake of the Affordable Care Act. NLADA is proud to co-sponsor this Fellowship with the National Center for Medical-Legal Partnership, and I have been delighted to participate as a facilitator and program design partner.  

Where Health Meets Justice was designed to unpack the health care sector for executive level legal aid leaders and build their capacity to partner with hospitals and health centers. The organization and financing of health care institutions – like hospitals and community health centers – Is new territory for many in civil legal aid. Doctors, nurses and hospital administrators use different terminology from ours. They have, as we do, their own alphabet soup of acronyms that can make communication and partnership challenging at the outset, unless we prepare ourselves.

The benefits of partnership are obvious, but we do not take them for granted.  A foundational topic in the Fellowship has been the alignment between civil legal aid mission and that of health care as it relates to the “social determinants of health.” As our Fellows craft effective working relationships with health care institutional leaders, our industries can join the expertise of legal advocates with that of medical professionals to address the deep-seated injustices and structural failures that sustain so much illness in our society. The Where Health Meets Justice Fellowship provides leadership coaching, substantive training and networking to advance our common vision of healthy communities. That’s real impact. And impact is what it is all about.

Applications are now being accepted for the second year of the Fellowship. Click here for more information and to apply. The deadline is November 20, 2014. 

Thursday, October 2, 2014

Combining Extreme Case Management with Legal Care to Prevent Elder Homelessness

By JoHanna Flacks, Legal Director, Medical-Legal Partnership | Boston

Case Manager:      Knock knock.  Knock knock.
                               Knock knock. Knock knock. 
                               Knock knock. Knock knock.
                               Knock knock. Knock knock.
                               Knock knock. Knock knock. 
                               Knock knock. Knock knock.
                               Knock knock. Knock knock.
                               Knock Knock . . .

Client:                    What!?

Case Manager:      Mr. D, it’s Roger.  I’m here to help again.  I’ll keep knocking until you’re ready.

This is not an existential joke, but rather an illustrative example of one way I've seen "Extreme Case Management" (ECM) reach some of the most isolated residents of Boston, older adults on the margins of society due to poverty, trauma history, mental illness, and addiction, among other risk factors. ECM -- an approach to elder homelessness prevention and advocacy innovated by the Elders Living at Home Program (ELAHP) based at Boston Medical Center (BMC) – describes a "high-touch" method of case management. It emphasizes not only meeting people where they are in the figurative sense, but actually going to people, like Mr. D, where they are and engaging with them actively in the process of averting threats to their housing stability – even when this means knocking on the door for a full 30 minutes because it will take Mr. D that long to muster the focus to work with his ELAHP case manager. 

Thanks to funding from the London-based Oak Foundation, Medical-Legal Partnership | Boston has had the privilege of partnering with ELAHP and its extreme case managers for the last year on a project called Aging Right in the Community. This experience has taught me a lot, both as a lawyer and as a human being. The bottom line? I can’t imagine attempting legal advocacy for this complex population without partners who practice ECM.

Answering the door is the first step in the process of tackling the herd of elephants in the room: including the hoarding of elephant-sized piles of miscellany that completely filled Mr. D's bathroom floor to ceiling. Other elephant-sized health conditions, like PTSD, alcoholism and progressive dementia often underlie the symptom of hoarding, and can interfere, tragically, with a tenant's ability to avoid institutionalization.

From my legal perspective, ECM advantages tenants when negotiating with landlords at their wits' end. It makes it possible to break the problem down into approachable pieces, including (1) arranging home-based health care, (2) engaging housekeeping services, and (3) assuring that the tenants are not alone in their struggle to remain housed, frequently in the only community they've ever known.

Many ELAHP clients I've met seem more aged than their years. This is not surprising when at least one research study cited by the CDC estimates the average life expectancy for homeless people is 45. ELAHP clients who have a history of homelessness have battle scars to show for it, on top of the visible and invisible battle scars borne by the woefully high number of homeless and at-risk veterans. Those who have a history of homelessness and still reach the AARP's eligibility age (ELAHP primarily serves people over 60) very often need help both to get housing and to keep it. 

Protecting existing tenancies is a core ECM focus side-by-side with ELAHP’s policy advocacy to increase appropriate emergency shelter options and permanent deeply-subsidized housing stock that meets elders’ needs. While there is encouraging movement toward a right to housing, (See the D.C. Right to Housing Initiative and the National Law Center on Homelessness and Poverty’s work), for the time being existing deeply subsidized housing stock meets only half the need for it, and the statistics are worse for people with disabilities that require accessibility features. This is a health equity issue of monumental proportions. Against this backdrop, helping tenants hold tight to the affordable housing they have clearly is critical.

Extreme Case Management doesn't end with the dismissal of an eviction action. The door to the office Roger Arrendol, ELAHP’s senior Case Manager, shares with another case manager and a stabilization worker is always open. New and long-time ELAHP clients often drop in at ELAHP's modest offices tucked in the back of BMC's Massachusetts Avenue overpass. From the East-facing windows, you can see the line queue up outside the Wood's Mullen shelter in the afternoon – a line in which many ELAHP clients have a history of waiting, a fear of waiting again, and a high risk of waiting again were it not for their relationship with ELAHP.

One of the first things I noticed about ELAHP's ECM practice is that it's not exactly an empowerment model.  ELAHP serves people who need hands-on support and who are likely on a trajectory to needing more.  It's not about targeted coaching, an advocacy gestalt that is crucial for many people on other legs of their life course. Those of us in the medical-legal partnership community and allied disciplines are increasingly pursuing a strengths-based approach to advocacy, identifying protective factors that boost an interpersonal violence survivor, a down-sized older worker, or a young family's capacity to build a stable life free from abuse and discrimination, and provide an enriched growing and learning environment for children. I love this model. It makes an important point Elmer Freeman, MSW, Director of the Office of Urban Health Programs and Policy at Northeastern University’s BouvĂ© College of Health Sciences, often emphasizes: most of the problems confronted by disempowered people are not “in their heads.” Maybe they could benefit from clinical therapy, but what would be really therapeutic is justice. And justice is most therapeutic when the aggrieved party defines it, designs it, and helps build it.  

All this notwithstanding, I've become increasingly convinced that not everyone gets what they need from an empowerment model, at least at first; but this doesn't necessarily mean they're not "advocacy ready." All too often even younger adults and parents with clinical depression get stuck in a cycle of needing public benefits in order to engage with clinical care, and needing clinical care in order to get public benefits, and getting neither because what they really may need as a condition precedent to an empowerment approach is Roger Arrendol knocking at their door, and knocking again; and when that patient is enrolled in MassHealth and has applied for SSI with the benefit of well-developed medical evidence, and that patient learns to manage their depression, an empowerment model of advocacy can work. Meanwhile, ECM may be able to help prevent expensive and inhumane cycles of hospitalization and homelessness.

For Medical-Legal Partnership | Boston, ECM is embodied in the quietly heroic work of ELAHP’s case managers who stabilize tenancies for older adults with multiple complex health conditions, day in and day out. In your community, ECM may be practiced by case managers, care coordinators, resource social workers, navigators, or community health workers. Is your medical-legal partnership working with collaborators who are committed to some version of ECM?  If not, track those colleagues down. And knock loudly when you find them.

Wednesday, October 1, 2014

Transforming Systems for People with Developmental Disabilities: A Patients-to-Policy Story

By Jay Chaudhary, Midtown Medical-Legal Partnership Director, Indiana Legal Services

People with developmental disabilities – conditions that impact their ability to learn, move, use language and care for themselves independently – are eligible in Indiana for special Medicaid waivers that give them and their families access to substantial community supports. These supports help individuals live in the community with dignity and the highest possible level of self-sufficiency. In 2013, when these services started suddenly going away for patients at Eskenazi Health Midtown Community Mental Health Center (Midtown), Indiana’s first community mental health center, it drastically changed patients’ quality of life. And health care team members could not figure out what happened.

Midtown has a Stabilization Treatment and Recovery Services (STARS) team that includes care coordinators, clinicians, and a team psychiatrist, which specializes in helping patients who are “dually-diagnosed” with mental illness and developmental disabilities. This is a population that relies on the services accessible through the Developmental Disabilities Medicaid waivers. It was the STARS team that first noticed patients’ waiver services were being discontinued; some patients had been receiving them for 10 years. STARS contacted the state agency that oversees the waivers, but were not able to get answers. The STARS team then took the problem in-house, to their medical-legal partnership.  Midtown has partnered with Indiana Legal Services since 2010.  

As Midtown’s lead medical-legal partnership attorney, I began representing patients at administrative appeal hearings. I found an internal memo in a patient’s file from the agency that oversees the waivers. It said, “[Client’s] problems mainly stem from his behavior issues—behavior is a mental illness issue, not a developmental one.”

After going back and discussing this with my STARS colleagues, we figured out that the agency’s new position was that all behavioral issues were attributed to mental health issues, not the intellectual or developmental disabilities.  This change in policy was accompanied by the adoption of a new screening instrument for waiver eligibility which eliminated all consideration of behavioral issues.

From the perspective of my clinical colleagues, this new policy was untenable – behavioral problems are some of the most common and devastating symptoms of developmental and intellectual disabilities.  Furthermore, with dually diagnosed patients, it is virtually impossible to determine the cause of a particular symptom or behavior.  In fact, the co-morbidity and co-occurrence of so many symptoms is the precise issue that makes caring for these individuals so challenging.

This knowledge changed our team’s approach to the problem – it was no longer about applications that had been wrongly denied; it was about a poorly informed policy that needed to change.  When I went to client’s administrative hearings, instead of focusing on the specifics of the particular client’s re-certification process, I called STARS therapists and the team physician to testify about the fallacy of the agency’s stance—and individual client victories soon followed.

Despite these individual victories, the systemic problem remained.  To address this, STARS clinical manager Meg Kovacs and I collaborated on a letter to the state agency’s leadership outlining the issues and problems that were having such a profound impact on the dually diagnosed population, emphasizing that these waiver services were preventive in nature, and generally ended up saving money in the long run by minimizing burdens on legal and emergency systems caused by patients with inadequate supports.

This letter was a true collaboration of medical and legal partners—invoking federal regulations and medical journal articles in equal measure, and focusing on the true victims of the policy shift: the patient/clients who need these services and cannot function without them.  The letter was supported and signed by Midtown leadership, including the Chief Executive Officer and Medical Director.  It was well-received by the state agency and started a dialogue between Midtown and state leadership on this issue.  While no “official” changes made, STARS staff have not seen the same types of unfavorable notices or denials. 

This was a problem that could only have been addressed by a medical-legal partnership.  Without the clinical insight from the STARS team, I would not have been able to figure out the systemic issues involved.  Without access to an attorney, the STARS team would not have been able to figure out how to address a recurring problem that was harming their patients’ health.  And only by working together could we find the right approach, informed by law and medicine, to addressing this at the systems level.

Eskenazi Health Midtown Community Mental Health Center is one of 127 community health centers across the United States that have integrated lawyers into their care teams.  Click here for resources that help health centers understand and develop medical-legal partnerships.

Thursday, September 4, 2014

Moving the Mountain with a Bulldozer instead of a Spoon: How Medical-Legal Partnership can do Primary Prevention for Populations through Policy Solutions

By Megan Sandel, Medical Director, NCMLP

Each aspect of the medical-legal partnership approach is in some way an act of prevention.  Any time someone has better access to healthy food, safe housing or quality education, they are more likely to have better health outcomes.  But how and when they get access to those basic needs play a big role in their health.

In health care, we approach prevention in three ways: tertiary, secondary and primary prevention. We can help someone manage the symptoms of an existing long-term disease to try and promote the best quality of life possible once they are already sick (tertiary).  We can provide care to help stop the progression or onset of a disease for which they have high risk factors (secondary).  Or we can do something to protect them from ever getting ill in the first place, such as administer a vaccination (primary).  Health care tries to do all three, but primary prevention has hands down the best health outcomes and promotes the best quality of life.  It is also the least expensive for the health care system.  And the more primary prevention we do, the less tertiary and secondary prevention is needed.  I often think about tertiary prevention as like moving the mountain with a spoon; the disease course is pretty set and you can only make small differences.  Primary prevention is like moving the mountain with a bulldozer and there are cascades of benefits for people.

Think about medical-legal partnership in the housing context.  Helping a family who is already homeless get into safe housing is important and absolutely critical to preventing the progression of health problems, but many of the adverse health effects from being homeless may have already started.  However, ensuring that housing subsidies are protected and equally enforced throughout a community so that families do not become homeless in the first place is a vaccination.  This inoculation is cheaper from a health care perspective as well as from a legal aid perspective.

We make a big deal at the National Center for Medical-Legal Partnership about encouraging medical-legal partnerships to move as upstream as possible, to focus on using the direct representation cases they do as “legal hotspotting” to detect and treat laws and policies that affect the health of entire communities, rather than putting all their time and resources into individual cases.  This is not because the direct legal assistance for patients is not important work or because it does not have powerful health outcomes for individual patients.  It is an important form of prevention.  But is it the best kind of prevention we have to offer?  How do we go from the spoon to the bull dozer to move the mountain of social and legal determinants impacting the health of patients?  Policy work.  It increases a medical-legal partnership’s capacity and the number of people it can reach.  Most important, targeting the policies that make people sick has a better chance of preventing the disease and not just treating the symptoms as they develop.

Wednesday, July 23, 2014

Lessons in Not Reinventing the Wheel: What MLP Can Learn from Other Integrated Care Models

By Maggie Eisen*

As someone who recently helped start a medical-legal partnership (MLP) in Philadelphia, I have found that there are important lessons to be learned about integrating services, not just from other MLPs, but from our healthcare partners themselves who already embrace other models of interprofessional, collaborative care.  After working my way through Phase I of the 2014 MLP Toolkit, I wanted to offer two additional pieces of advice to anyone starting an MLP:
  • Mine a potential health care partner’s internal landscape and history for examples of service integration, whether successful or not.  Indeed, advice and technical assistance from the National Center for Medical-Legal Partnership (NCMLP) and from other MLPs will be essential to your planning and implementation processes.  However, it’s critical to dedicate equal attention to unpacking the history and experiences of the place where you plan to integrate legal advocates and learn all you can from their past attempts at service integration.  As Phase I of the MLP Toolkit mentions on page 6, “Addressing psychosocial and care coordination needs have been increasingly accepted as critical to improving health, and both social workers and patient navigators have been integrated into the healthcare team at most healthcare institutions.”  Leveraging these types of experiences, lessons learned, and best practices will likely streamline your integration process, making it more efficient and effective.  They have lessons to teach MLPs, and an individual healthcare institution’s personal history with these types of projects may inform their willingness to partner with legal services.
  • Explore websites and publications authored by thought leaders from organizations in parallel movements like Collaborative Family Healthcare Association (CFHA), which was established around the same time as the first medical-legal partnership at Boston Medical Center.  Just as NCMLP espouses the importance of fostering relationships across disciplines to “build a better healthcare team,” CFHA “envisions seamless collaboration between psychosocial, biomedical, nursing, and other healthcare providers, and views patient, family, community, and provider systems as equal participants in the healthcare process.”  To get started, I recommend reading a recent blog post on interprofessional integration processes by Dan Marlowe, PhD, LMFT on CFHA’s website.
Medical-legal partnership and all other “strains” of integrated care delivery should not be considered as ends in themselves; rather, they are iterative processes, deeply dependent on thoughtful cultivation of trusting, equitable relationships.  These critical relationships should be made horizontally and vertically, within and across organizations and movements, as we strive together to achieve the healthcare Triple Aim.  And making use of existing infrastructure and familiar operational procedures is a strategic way for MLP practitioners to anticipate and answer institutional resistance to integrating legal advocates.

*Maggie Eisen is the Director of Medical-Legal-Community Partnership at Philadelphia Legal Assistance.  Their medical-legal partnership works with the Philadelphia Department of Public Health, Ambulatory Health Services Division.

Wednesday, July 9, 2014

The justice availability gap versus justice accessibility gap: A role for medical-legal partnerships

By: James Teufel, MPH, PhD* and Shannon Mace-Heller, MPH, JD**

Protecting and promoting access to justice has been recognized as a significant value in the United States since our nation’s founding.  Historical events including the Gideon decision affirming the right to an attorney in criminal proceedings in 1963 and the passing of the Economic Opportunity Act in 1964 providing federal funding to support civil legal aid services are only a few examples of efforts to protect and expand access to justice for citizens.  However, in the United States, a right to an attorney is only guaranteed in some criminal matters.  To date efforts to establish a civil Gideon standard have not yet come to fruition, resulting in a remarkable disparity between the economically advantaged and disadvantaged population’s availability of and access to justice in civil legal matters.  Medical-legal partnerships have the potential to transform and expand the current legal aid services system in the United States thereby bridging the existing justice gaps.  Moreover, the MLP model is a viable vehicle to reframe the access to justice debate moving from a solely public social justice-based framework to one that engages a wide variety of private and public stakeholders including health care and political systems.

In the United States, there is one private practice attorney for every 217 individuals earning more than 200% of the federal poverty level. However, there is only one legal aid attorney for every 14,229 individuals earning 200% of the federal poverty level or below. The difference in these ratios acts as a conservative marker of a justice availability gap in civil law.  This is an availability disparity of 66 times.  The attorney availability gap can be understood through an analogy using the most populated and least populated states in America: California (over 38 million) and Wyoming (approaching 600 thousand).  If we set the number of attorneys available in each state at 2,690 and kept the population of each state at its naturally occurring level, then we can understand the civil law availability gap experienced by the economically poor in the United States.  The 2,690 attorneys in California would need to serve the needs of over 38 million people, whereas the same number of attorneys in Wyoming would serve a little over half million people’s needs.  Based on the justice availability gap, the economically disadvantaged have the California experience, whereas economically advantaged have the Wyoming experience.  In this hypothetical scenario, the answer to the availability gap would be to move to Wyoming.  The justice availability gap, however, oversimplifies the experience of economically disadvantaged in the United States.  The justice availability gap underestimates the justice access gap.   

The justice access gap includes other important factors.  For example, it is more realistic from a relative poverty perspective that a person would likely need to earn at least 400% of the federal poverty level to have adequate access to private attorneys to address new and ongoing legal care needs.  This adjustment would increase the disparity among those with economic advantages and disadvantages, whereas the justice availability gap was 66 times, the justice access gap has an objective basis of 258 times.  In other words, the ratio of people below 400% poverty to legal aid attorneys is 27578:1, and the ratio of people at or above 400% poverty to private practice attorneys is 107:1. 

Beyond population poverty to attorney ratios, many other factors can impact justice access ratios.  For example, from the perspective of individual financial position, safety net income levels underestimate economic inequalities.  Annual income measures do not account for wealth well.  At least a quarter of American families have no or negligible wealth, and the wealth of the next quarter of Americans has shrunk by about 50% in the last 15 years.  The lack of wealth of many American families could further increase the justice access gap.  Beyond cash and credit availability, other issues such as transportation, no paid time off, and trust in the justice system could also further the access to justice gap.  Additionally, research supports that most economically disadvantaged households have at least one civil legal issue that has gone unmet.  From a Machiavellian perspective, the inequity between the availability and access gaps could be decreased through disinterest in engaging the civil legal system among those experiencing economic disadvantage.  This is similar to the situation that occurs when calculating unemployment rates.  For example, unemployment in the United States is calculated as the number of people unemployed but in the labor force divided by all of those in the workforce (unemployed or employed).  Military personnel, people under age 16, institutionalized individuals, and discouraged workers are not considered part of the workforce and therefore cannot be unemployed.  A discouraged worker is a person who has not sought work in the past 30 days.  If all people stopped seeking work, unemployment would decrease dramatically.  The discouraged worker phenomenon applies to arguments related to the gap between justice availability and justice access.  Perceived legal access problems decrease as people become discouraged by and disengage from the legal system. 

It is relatively easy to estimate objective availability and access justice gaps.  However, when we include issues of discouragement, the access gap will shrink mathematically.  This must be the case.  Medical-legal partnerships aim to change systems that have historically discouraged participation of vulnerable populations.  Issues of access include subjective experiences of needing and wanting services.  Not unlike accessing healthcare services, a discouraged person may need services but not want services.  The discouraged community effect helps to explain the slow diffusion of innovations within vulnerable populations.  Medical-legal partnerships have the opportunity to not only provide direct services but also change systems, policies, and environments that impact vulnerable populations in the United States.  The benefit and challenge to MLP that change community culture is that they can objectively help to meet access needs.  However, as the innovation of MLP integrates in community culture, MLPs will experience demand that will necessitate scaling of the supply of legal care in order to meet the needs and wants of communities.

*James Teufel, MPH, PhD, Assistant Professor of Public Health and Associate Director of the Institute for Public Health, Mercyhurst University

**Shannon Mace-Heller, MPH, JD, Director, Office of Policy & Planning, Baltimore City Health Department; Public Health Law Specialist, Health, Education and Legal assistance Project: A Medical -Legal Partnership, Chester, PA.