Socioeconomic disparities in health persist despite significant advances in medicine, universal coverage, and quality of care.1,2 Although the relationship between poverty and poor health is complex, access to basic needs such as adequate housing and nutrition, appropriate education, and personal safety is well documented to improve health trajectories.3 The article by Beck et al4 in this issue of Pediatrics represents a special example of how a multidisciplinary approach to social determinants of health initiated from a primary care setting can address poor housing conditions and reduce risk for asthma for individual patients and for a population.
The government has enacted laws and regulations to address the negative health impact of hunger, insufficient income, unsafe housing, and disability. When families do not receive the benefits or protections of these laws, health is undermined. The consequences can be treated medically, but their upstream causes are social and are more effectively addressed by using legal strategies.5,6
The authors of a recent report estimate that 50% to 85% of health clinics for low income people have users, between 10 and 17 million people, who experience unmet legal needs, many of which impact their health.7 Many at-risk individuals may not know that their problems have legal solutions. Medical-legal partnerships, developed at Boston Medical Center in 1993 for children, help parents navigate the complex government and legal systems that often hold solutions to many social determinants of poor health. The health care team’s role is to identify unmet legal needs that cause or exacerbate child health problems. Once these problems are identified, lawyers bring critical skills to complement the expertise of the health care team. Medical-legal partnerships now include adult health services and are practiced in over 220 hospitals and health centers, from primary care to specialty services.6,8,9,10,11
In the Beck article, no single activity is new, but what is new is that lawyers connected to the health care providers can accomplish what neither could accomplish on their own. The health system is effective in diagnosing and treating a patient with asthma and maybe with good social work or visiting nurse staff, etc, can have an impact on asthma triggers in the home. The connection to legal aid programs resulted in identification of poor quality housing in a group of buildings owned by 1 firm. Health care teams would be unlikely to identify the owner of a building or see the pattern of risk linked to other buildings owned by the owner. Not only was treatment of the affected index patients addressed, but 11 of the 19 other buildings received significant repairs that improved the housing quality and likely (but not proven) reduced the risk for asthma and other housing-related illnesses. Second, the involvement of legal aid programs resulted in additional legal needs being identified and addressed, which is likely to reduce the risk of health problems. Finally, legal aid’s action to form and represent a tenant association will hopefully prevent further housing deterioration and subsequent poor health. This article is a special example of the potential impact of a medical or health home when it includes connections to community resources.
The development of Accountable Care Organizations and risk-based contracts provides incentives for prevention and outcome, not service volume. To obtain these incentives, health care providers will likely need to redesign its service delivery beyond social workers, nutritionists, home visitors, etc, to address upstream social factors of low income patients. The description of the accomplishments of a medical-legal partnership in this article4 represents such an innovation by increasing access to the benefits and protections of laws that address selective underlying causes of health disparities. When community legal aid agencies and pro bono private lawyers partner with health care providers, they re-orient the delivery of legal assistance before a cascade of crises occurs from homelessness to hunger, from domestic violence to child abuse, or before mold growth causes an asthma hospitalization. This approach potentially reduces the downstream impact of legal and health crises before they occur. Preventive law becomes preventive medicine.
Medical-legal partnership is an innovation in the delivery of health care to potentially close the gap in health disparities that persist even in universal health care coverage. By reducing the impact of legal determinants that affect health, this creative partnership in clinical settings will complement increased access to health care provided by recent health care reform.
- Accepted August 14, 2012.
- Address correspondence to Barry Zuckerman, MD, 771 Albany St, Dowling 3rd floor, Boston, MA 02118. E-mail:
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: Supported in part by the Kresge Foundation.
COMPANION PAPER: A companion to this article can be found on page 831, and online at www.pediatrics.org/cgi/doi/10.1542/peds.2012-0769.
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- 8.↵Weintraub K. Putting lawyers on the case. Medical-Legal Partnership Boston gives patients support from attorneys. Boston Globe. May 10, 2010. Available at: www.boston.com/business/healthcare/articles/2010/05/10/medical_legal_partnershipboston_gives_patients_support_from_attorneys/. Accessed September 14, 2012.
- 9.↵Eckholm E. When Doctor Visits Lead to Legal Help. New York Times. March 23, 2010. Available at: www.nytimes.com/2010/03/24/us/24legal.html?_r=1. Accessed September 14, 2012.
- 10.↵Gorman A. Sometimes, good legal help is the best medicine. Los Angeles Times. March 12, 2010. Available at: http://articles.latimes.com/2010/mar/12/local/la-me-clinic13-2010mar13. Accessed September 14, 2012.
- 11.↵Sun L. From rats to heaters, doctor-lawyer team fights barriers to family health care. Washington Post. May 26, 2010. Available at: www.washingtonpost.com/wp-dyn/content/article/2010/05/25/AR2010052505245.html. Accessed September 14, 2012.
- Copyright © 2012 by the American Academy of Pediatrics