Law Is a Critical Determinant of Health

Laws constitute the societal building blocks that should enable everyone to lead safe, healthy lives. According to the Centers for Disease Control and Prevention, seven of the ten greatest public health achievements in the United States during the 20th Century — immunizations, motor-vehicle safety, workplace safety, infectious disease control, drinking water fluoridation, tobacco control, and food safety — were grounded in the use of law.³ Furthermore, federal laws and programs such as Medicaid, Medicare, the Public Health Service Act, the Affordable Care Act, the Women, Infants, and Children Supplemental Nutrition Program, and the Ryan White HIV/AIDS program are just a few of the many examples (including numerous state laws) of legal building blocks that, in theory, provide the foundation for a healthy nation.

At the same time, the inequitable design and application of laws and legal policies in sectors as diverse as housing, education, labor, lending, transportation, and criminal justice undermine health. For example, a housing code that goes unenforced in an asthmatic child's apartment often means that the child's health condition worsens, resulting in missed school days, missed work days for her parents, and unnecessary medical bills. On the flip side, the relatively strict enforcement of drug laws against populations of color results in the mass incarceration of African-American males, and associated negative health consequences for incarcerated individuals, their families, and their communities.^{Reference Bailey4}

The unequal application of laws and policies across multiple sectors perverts what should be a more equitable distribution of social benefits, incomes, and punishments, contributing to a raft of health disparities.^{Reference Tobin-Tyler and Teitelbaum5} Furthermore, an old but massive crack in our legal foundation continues to destabilize the nation's health: the racially discriminatory laws that no longer govern but are nonetheless powerful correlates of health in communities of color. Our nation's history of genocide, enslavement, oppression, and “redlining” institutionalized the economic, educational, and social disadvantages that for people of color remain forceful predictors of health and well-being.^{Reference Schwarz6}

Thus, while factors like substandard housing, employment discrimination, and food insecurity are important determinants of health, these factors should not just be understood as having remedies in law; they must be recognized as often being the result of laws or their unjust application. Health professionals must appreciate how laws and legal policy not only can be used to remediate individual health-harming legal issues, but also can act as inputs to poor health at levels far upstream from individual health conditions. Through permanent and robust medical-legal collaboration scaled to achieve population-level health improvements, the unique expertise and approaches of the health care, public health, and legal professions can promote solutions to the nation's ever-worsening health inequity crisis.

Historical Collaboration between the Medical and Legal Professions

There is nothing particularly novel about medical-legal collaboration. While popular understanding of the relationship between the two professions is one of mutual contempt, there is actually an impressive history of effective collaboration when social exigencies push them together.^{Reference Teitelbaum and Lawton7} For example, lawyers helped doctors create some of the medical profession's earliest standards, while lawyers routinely ask doctors to provide expert testimony in lawsuits.^{Reference Jacobson8} Physicians and lawyers have also long collaborated to protect human rights, together documenting abuses and developing legal standards to prosecute human rights violators.⁹

Medical-legal collaboration began to confront racism, poverty, and discrimination at least as early as the Civil Rights Movement, when in the 1960s one of the country's earliest community health centers hired an attorney to “treat” legal problems plaguing patients, including race-based discrimination and poor housing.^{Reference Lawton10} The HIV/AIDS crisis further solidified the interdependency of clinicians and lawyers in addressing health-related social needs, as ground-breaking organizations like Whitman-Walker Health in Washington, D.C. not only provided health care to those afflicted with the disease, but legal services, too, which addressed issues ranging from estate planning to securing disability benefits.¹¹

Formalizing Collaboration for the Benefit of Patients and Communities: Medical-Legal Partnership

Medical-legal partnerships (MLPs), in which lawyers are integrated into health care settings to serve as patient-facing experts in the battle against health-harming legal issues, are the latest example of collaboration between the professions. With roots in the earlier doctor-lawyer alliances, MLPs have spread consistently since the mid-1990s, with some 350 MLPs now in operation around the country. Although MLPs are comprised of different types of partners and care for a variety of populations, they tend to share eight core components: (1) a formal agreement between a health care organization and a (typically) nonprofit or academic legal services provider; (2) a defined patient population to be served; (3) a strategy to screen patients for social needs; (4) legal staffing; (5) a “lawyer in residence” at the health care setting; (6) training of health care staff to recognize legal needs; (7) information sharing between health and legal partners; and (8) funding expressly devoted to the partnership.^{Reference Regenstein, Trott, Williamson and Theiss12}

According to the Legal Services Corporation, 71 percent of low-income families have at least one unmet legal need.¹³ Most of these families experience needs in one of three categories, each of which have direct links to health and well-being: housing, public benefits, and educational supports. As an integrated service of a holistic health care team, MLPs can help provide solutions to individual patients' health-harming legal issues at the point of care, both in moments of crisis and as a matter of prevention (e.g., by preventing an unlawful eviction).

While MLP services aim to improve a single patient's health, they also serve to effectuate health equity at the community level. Two examples illustrate this effect. First, at Whitman-Walker Health, lawyers and health care providers teamed up with community allies and patient advocates to challenge the proposed elimination of a health insurance plan in Washington, D.C.'s health insurance marketplace. By showing how crucial this plan is for many HIV-positive individuals who would otherwise not be able to afford their medications, Whitman-Walker ensured its continuation.^{Reference Marple and Dexter14} Second, when lawyers at the Cincinnati Child Health-Law Partnership repeatedly heard about unsafe housing for pediatric patients — including pest infestation, water damage, and threatened evictions when tenants made complaints — their investigations identified a large cluster of homes owned by the same company. The MLP instigated repairs or nearby relocation, guaranteeing safer housing for an entire community.^{Reference Beck15}

Viewed through a broader lens, MLPs are important partners in upstream efforts to address social determinants of poor health because their frontline perspective provides insight into specific ways in which laws harm or fail particular populations.^{Reference Tobin-Tyler16} From this unique perspective, MLPs can contribute in distinctive ways to each of the five essential public health law services that public health legal experts have identified as necessary to the effective design, implementation, and spread of public health legal interventions.^{Reference Burris17} For example, MLPs are well-situated to gather evidence of implementation and enforcement trends that negatively affect their clients; to guide development of improved laws and implementation strategies; and to identify opportunities for enforcing laws through strategic litigation. Applying a public health perspective to MLP work has enormous potential to channel health care, public health, and legal efforts and resources towards the most widespread and problematic of legal barriers to health while simultaneously assuring that legal interventions are evidence-based and tailored effectively to fix well-defined problems.