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Low-income households face common and chronic housing problems that have known health risks and legal remedies. The Medical Legal Partnership (MLP) program presents a unique opportunity to address housing problems and improve patient health through legal assistance offered in clinical settings. Drawn from in-depth interviews with 72 patients, this study investigated the outcomes of MLP interventions and compares results to similarly disadvantaged participants with no access to MLP services. Results indicate that participants in the MLP group were more likely to achieve adequate, affordable and stable housing than those in the comparison group. Study findings suggest that providing access to legal services in the healthcare setting can effectively address widespread health disparities rooted in problematic housing. Implications for policy and scalability are discussed with the conclusion that MLPs can shift professionals’ consciousness as they work to improve housing and health trajectories for indigent groups using legal approaches.
Housing, health and law are inextricably linked. Many of the endemic housing problems faced by socioeconomically disadvantaged householders place their health at risk even while laws and policies exist to safeguard access to adequate housing as a basic right and social benefit (Bratt, Stone and Hartman, 2006; Cowan, 2011). As such, housing remains a critical health and legal challenge, particularly for the poor (Desmond and Bell, 2015; Gibson et al., 2011; Sandel et al., 2009; Krieger and Higgins, 2002). Laws at the intersection of housing and health are intended to regulate common housing problems related to, for example, living conditions, eligibility for housing subsidies and reasonable accommodations (Schonfeld, 1997). Indeed, many of the housing issues that affect child and family health (i.e. mold and pest infestation and asthma or lead poisoning and developmental delays) may represent the unlawful violation of tenant rights and therefore have legal remedies (Desmond and Bell, 2015; Bashir 2002; Matte and Jacobs, 2000). Thus, legal interventions that address housing, particularly those conditions that pose health risks, may serve to diminish health disparities that plague the poor (Williams et al., 2008; Schulman et al., 2008; Cohen et al., 2010; Zuckerman, 2012).
State and municipal laws ordinarily include sanitary or housing codes governing the construction and conditions of residential properties as well as specific laws focused on certain health threats such as lead paint, asbestos, pests, mold and adequate heat and injury prevention measures such as smoke and carbon-monoxide detectors (Desmond and Bell, 2015; Cowan, 2011; Rosner and Markowitz, 2012). As an illustration, the stated purpose of Massachusetts’ State Sanitary Code (105 CMR 410) is to:
“Protect the health, safety and well-being of the occupants of housing and of the general public, to facilitate the use of legal remedies available to occupants of substandard housing, to assist boards of health in their enforcement of this code and to provide a method of notifying interested parties of violations of conditions which require immediate attention”
Housing regulations, thus, provide opportunities for legal redress to protect the health and well-being of residents as well as set accountability structures for property owners and managers. Also, while housing is considered a basic right in principle, the right to decent, affordable housing is not a ubiquitous right (Bryson, 2006; Bratt et al., 2006). In addition, despite carrying penalties for violations, enforcement of housing laws and mandates is encumbered by limited oversight (Schill and Wachter, 1995). Furthermore, the lack of civil legal resources for vulnerable populations (i.e. socioeconomically disadvantaged and undocumented immigrant groups) limits options in protecting their rights to decent and affordable housing (Legal Services Corporation, 2009).
The present study explores the processes by which a novel intervention- the Medical Legal Partnership (MLP) program- addresses legal problems to reduce proximal and distal health risks for low income groups. The MLPs program is an integrative program model that brings together doctors, lawyers and patients in a clinical setting to target the root causes of health problems that disproportionately affect low-income patients with limited access to legal services (Pettignano et al., 2014; Cherayil, 2005; Beck et al., 2012; Tyler 2012; Tyler et al, 2012; Zuckerman, 2012; Zuckerman et al., 2008, Zuckerman et al., 2004). In the MLP model, doctors and lawyers are cross-trained to mobilize medical and legal resources so as to more effectively address presenting problems such as housing, immigration, family law, government benefits and other civil justice issues that, if unaddressed, compromise health (see Cohen et al., 2010 and Tyler et al., 2012 for detailed descriptions of the MLP model). Doctors are trained by lawyers to consider the presenting problems of their patients as not just medical in nature but as potentially legal issues that might negatively affect health now or in the future. MLP-trained doctors learn to query and listen for such signs at primary care visits (i.e. annual check-ups) and also when patients present symptoms that may be attributed to certain social or legal issues (i.e. asthma exacerbations, chronic colds, malnutrition, signs of injury or developmental delays). In turn, clinically-based lawyers are provided with medical evidence and guidance to substantiate legal claims and seek appropriate remedies for conditions at odds with both legal rights and health (Paul et al., 2009).
The doctor-lawyer team collaborates to protect proximal and distal patient health by treating pressing health issues while also preventing future health risks by tackling the legal infractions that contribute to poor health. The MLP program is structured to capitalize on a convenient and regular point of service at community health centers and in a city-hospital where many indigent patients seek regular and acute medical care. As with referrals to other medical specialists, patients are referred to the MLP program by a physician, social worker, or other clinical personnel, that have identified a legal need and an actual or potential health risk to their patient. The MLP team, which includes lawyers, paralegals, case workers and medical staff, meet on a weekly basis to consult on cases and strategize about the appropriate course of action. In some cases, a letter written by the lawyer and sent by the doctor will suffice to address presenting problems (i.e housing conditions violations or utility service interruptions due to non-payment). In other cases, legal representation in court is necessary (i.e. eviction proceedings). In most instances, the MLP program also links patients to additional supportive resources for which they may be eligible including food and utilities assistance to reduce affordability hardships and budget tradeoffs by increasing household income (Weinstraub et al., 2010). Together, MLP doctors and lawyers work collaboratively to address the upstream determinants of health and provide a unique opportunity to address the civil legal needs of indigent group members that might otherwise be disregarded (Williams et al., 2008; Legal Services Corporation, 2009; Zuckerman 2012).
Previous empirical research on the MLP model is limited but existing studies demonstrate encouraging results in the pairing of doctors and lawyers for patient health (Pettignano et al., 2013; Beeson et al., 2013; Ryan et al., 2012; Beck et al., 2012; Sandel et al., 2010; Hernández, 2010; Cohen et al., 2010; Weintraub et al., 2010; Zuckerman, 2012; Zuckerman et al., 2008, Teufel et al., 2008; Zuckerman et al., 2004). Weintruab and colleagues reported improved child health outcomes and greater utilization of food and income supports on the part of parents. Beck et al., (2012) showed that an MLP intervention was effective in identifying and treating substandard housing conditions in a housing complex with pest infestation, lead and other housing risks. The results of this study suggest that MLPs can effectively target complex and multifaceted housing problems that affect asthma, developmental delays and lead in children. An earlier analysis of the present study data found that inclusion of a lawyer on a patient’s healthcare team increased the patient’s legal consciousness and perceptions about how the legal process might remedy housing and other civil legal issues (Hernández, 2010). Results indicated that MLP participants improved their sense of “legal entitlement” by learning, legitimizing and leveraging the law to address pertinent issues. Still, critical gaps in the evidence base regarding MLPs persist thereby limiting our understanding of the model’s impact particularly in one of it’s largest impact areas: housing (Beeson, 2013; Pilnik, 2008).
The present study unpacks the mechanisms by which MLP interventions address housing problems for program participants and features a community sample of comparable households to demonstrate the alternative trajectories to housing problem resolution outcomes when MLP services are not available. As such, this article addresses a set of key questions that have yet to be explored as it pertains to MLP program participation: 1) How do MLP participants compare to others facing similar housing situations? 2) How does the MLP approach work to resolve housing problems? 3) What are the benefits and missed opportunities associated with the MLP program? The following section of this article describes the research design and methods followed by a detailed presentation of study findings.
This project surfaced in response to requests by Medical Legal Partnership | Boston (MLP | Boston) program administrators and funders to explore process-level factors that contributed to improved health and other outcomes of interest that clients experienced upon receiving MLP services. Housing was the most common problem presented by MLP participants (68%) when this study was initiated. Furthermore, most of the cases were drawn from one particular neighborhood- Dorchester, an inner-city community in Boston. Given its prominence in the program and the known connections between housing and health, we limited the study to MLP housing cases among Dorchester residents. To strengthen the study design we employed a comparative sample comprised of 72 study respondents, half of whom were in the MLP program and a comparable community sample who did not have access to MLP services.
This study was approved by several Institutional Review Boards including those at Cornell University, Boston University Medical Center, and Beth Israel Deaconess Medical Center. It also followed internal review procedures at participating community health centers not affiliated with academic institutions including Harvard Street Neighborhood Health Center and Neponset Health Center. Each of these bodies approved the study protocol, interview guides and consent procedures. Participants provided written and verbal consent to participate in the study. Consent forms were signed by both the participant and the author and each kept one copy for their respective records. Participants were given a $25 cash incentive at the time of the interview. Pseudonyms are used to refer to participants and other identifiable information was altered throughout the article to protect the anonymity of participants.
The study sample was comprised of a “treatment” group (MLP group) and a “comparison” group (non-MLP group) with a total of 72 participants. Of the seven community health centers (CHC) in the Dorchester neighborhood, 3 offered MLP services, while four did not. Each MLP-CHC was paired with a CHC that was geographically adjacent but did not offer MLP services. The sampling strategies for recruiting the MLP group and non-MLP group differed in that MLP participants were identified through administrative records while non-MLP respondents were directly recruited in health care facilities. MLP study participants with a closed housing case were recruited from a case list of pediatric patients enlisted in the program within the previous two years. Selection was based on the nature of the case (having presented a housing issue) regardless of the reason for the doctor’s visit as participants may have been identified for a housing-specific health reason (i.e. an asthma attack due to housing conditions) or during a routine visit. Cases were deemed closed by virtue of their having met one of three conditions: a) the housing aspect of the case was resolved; b) the program could do no more to help the case; or c) there was sustained loss of contact with the client. Special measures were taken to include client-families for whom loss of contact was the primary reason for closing the case; such measures included searching for updated information through medical records and contacting emergency contacts via phone and mail correspondence. The closed case approach provided an opportunity to assess the post-intervention impact of services on the housing and health conditions of participating families. Eligible clients were identified by program administrators and invited to participate in the study first by letter and then by phone calls placed by the principal investigator. Non-MLP participants were recruited directly from the waiting areas of pediatric departments in three selected CHCs over the course of a month at each site. Potential participants were asked to complete a short screening questionnaire administered by the principal investigator that asked about specific housing problems, household income and residence in Dorchester. Eligible participants included Dorchester residents who reported at least one housing problem and were at or below 150 percent of the federal poverty line.
Table 1 shows the demographic and socioeconomic characteristics of the study sample. The two samples were comparable with regard to gender, age, education, income, marital status and race/ethnicity. The MLP group consisted of all women, most between the ages of 25–44, with a high school diploma or equivalent, at or below the federal poverty level, single, Black or Hispanic with about an even split between immigrants and native-born participants. The non-MLP group included mostly women and 2 men, most between the ages of 25–44 with a high school diploma or come college, a household income of less than $30,000, representation across all major racial/ethnic groups but most were Black or Hispanic and native-born.
One notable difference is that MLP participants were more likely to be recipients of housing benefits than the non-MLP group (69% versus 53% respectively), Another important difference in the samples pertains to the higher proportion of undocumented immigrants and non-English speakers in the MLP sample. Undocumented immigrants are particularly vulnerable to health and housing-related risks and are limited in their access to medical services, housing benefits and government-sponsored legal services (U.S. Code of Federal Regulations 45 CFR 1626; Legal Services Corporation, 2009; Portes et al., 2012). Thus, MLP is among very few legal resources available to low-income undocumented immigrants albeit the results were mixed, as reflected in the sections that follow.
All participants were interviewed in their homes, except in three cases where participants chose to meet in a local restaurant. The principal investigator conducted home-based in-depth interviews in English, Spanish on her own and in Vietnamese with the assistance of a translator. The interviews lasted 90 minutes on average. They were conducted using a semi-structured interview guide that focused on the following domains: health, housing conditions, neighborhood issues, coping strategies, perceptions of the legal system and use of legal services. Specific topics discussed included descriptions of the housing and neighborhood environments with a particular emphasis on living conditions and making ends meet; child, parent and family health issues related specifically to housing; a description of a typical clinic experience and patient-physician rapport; the experience in the MLP program and any subsequent changes; the use of legal services outside of the MLP program. The interview guide was piloted with two MLP clients and two comparison group participants and minor refinements were made to the questions. The principal investigator- herself a woman of color from a working class background- built a strong rapport with the participants and found them to be very candid. Participants were assured strict confidentiality and other human subjects protections.
Interviews were transcribed and translated from English, Spanish and Vietnamese by native speakers in preparation for analysis. The principal investigator also wrote summary notes for each interview encounter. Interview transcripts and summary notes, were systematically analyzed using Atlas.ti qualitative data analysis software, which assisted in the processes of categorizing and coding, developing themes, and organizing data segments (Creswell, 2013). Coding and thematic analysis were conducted by the principal investigator and two graduate-level research assistants. A “Multiple Case Study” (MCS) was employed for an in-depth analysis of cases within the bounded system of participation in the MLP program. The MCS approach provided the opportunity to place the issues of interest– housing, health and the nature of MLP interventions– within a broader context and to explore different perspectives on these issues (Yin, 2011; Creswell, 2013). Creswell (2013) explains that in a multiple case study, one issue or concern is selected and the researcher identifies “multiple case studies to illustrate the issue.” He goes on to explain that “the researcher might select for study several programs from several research sites or multiple programs within a single site. Often the inquirer purposefully selects multiple cases to show different perspectives on the issue” (p. 74). For this study, each participant was taken as a case to be analyzed independently and also collectively in order to better understand the housing, health and law nexus.
A combination of “within-case” and “across-case” comparative approaches were used to uncover patterns in the data and provide contextually grounded results. The MCS approach was especially useful in considering the housing resolution outcome of each case, since the facts around varied substantially on a case by case basis. Each case was reviewed independently to capture the surrounding details and then coded for themes relevant to the individual’s experience with housing, health, the use of legal services and participation in the MLP program. The cases were then analyzed together to explore common themes across the cases and to understand the structure of patterns in the data, with initial emphasis on variations between the two groups and further detailed analysis of the MLP participants. Following this approach, the results section is organized into three subsections: a) housing resolution outcomes across the sample; b) housing resolution without MLP services; and c) housing resolution outcomes with MLP services.
The initial phase of data analysis began with an assessment of housing resolution outcomes of MLP participants compared to non-MLP study respondents. In this process, several patterns were observed regarding the nature of the respondents’ housing situations and related outcomes. Figure 1. describes the housing problems and resolution outcomes for MLP and non-MLP study participants. The primary housing problems generally fell into three main categories: affordability, adequacy and stability. Affordability cases included housing and utilities hardship and housing subsidies that pertained to the household income to expenses ratio. Adequacy cases referred to substandard conditions and reasonable accommodations regarding the habitability of housing units. Stability cases dealt with homelessness, evictions, doubling-up and other forms of instability. MLP and non-MLP participants were relatively comparable in the scope of housing problems though MLP participants were more likely to describe housing and utilities hardships, while non-MLP participants were more likely to be doubled-up or homeless. For both groups adequacy was the primary problem, non-MLP participants reported adequacy concerns more than MLP participants (61% versus 53%). The groups also differed with respect to affordability and stability, where MLP participants reported affordability issues more often than non-MLP participants (33% versus 11%). Non-MLP participants were less likely to be stably housed (28% compared to 14% of MLP participants). Both groups were almost equally likely to experience two or more of these housing problems simultaneously (MLP 72% versus non-MLP 80%).
In terms of housing resolution outcomes, participants described three common experiences: a) in-place improvements, b) relocation and c) status quo. In-place improvements correspond to changes and improvements that occurred while the participant remained in his/her original place of residence. Relocation refers to a residential mobility in response to the circumstances and conditions of the previous problematic dwelling. Status quo reflects little or no change in the presenting housing problem. Findings reveal that MLP families were more likely than non-MLP families to improve their housing conditions while staying in-place (39%) through, for example, addressing utilities hardships, negotiating rent payments to avoid eviction or retaining housing subsidies. Nearly half of MLP families relocated, often moving to better housing circumstances and averting substandard conditions through transfers on the basis of condition violations or the need for reasonable accommodations. Only 17% of MLP participants experienced no change in their housing circumstances (status quo). In contrast, two-thirds of non-MLP respondents acknowledged housing problems that went unresolved and either continued living under the same conditions or handled their housing hardships by moving more frequently (28%) oftentimes to equally problematic housing units. Therefore, non-MLP families were more susceptible to the negative consequences of housing instability and substandard living conditions.
What follows are representative cases that reflect housing resolution with and without MLP services. The results illustrate common housing issues and include descriptive quotes to demonstrate how non-MLP participants coped with housing problems and how the MLP program worked to resolve similar presenting problems.
Participants in the non-MLP group described facing significant barriers and limitations to utilizing legal services in addressing housing problems. When asked about using legal remedies, most non-MLP participants conveyed that they seldom used legal approaches to rectify housing problems. At times, they reported “never thinking about the law.” In other instances, they considered getting legal representation to confront their housing challenges but cited “money” as a prohibitive factor and the complicated legal processes as a “hassle.” Eileen summed up this sentiment when she said:
“I think that it would be difficult for me because lawyers are too expensive now. If you don’t have the money and pay them on the spot, there’s plenty lawyers that don’t take your case… Not only that, I don’t trust lawyers. Finding a good lawyer, a truly good one that will help you without expecting anything in return is very hard to find.”
Darlene, another non-MLP participant, experienced housing and utilities hardships. She worried about her precarious situation with the utility company and housing stability stating:
“‘Geez, my lights are gonna get shut off.’ Even though I know they won’t. But even if I’m behind a few days, I worry. I worry about a lot of things… It adds stress.”
When asked how she might benefit from getting legal help, Darlene replied:
“I’d probably be able to hold onto my apartment … Even if they moved me that would be fine too. But they’ll probably keep me from losing my apartment ‘cause as far as I’m concerned, I don’t know what to say on the defensive side. But if someone was to help me with that, better able to speak about the situation- that would definitely be of help.”
Darlene recognized the stress-related effects of housing hardship and the deep sense of instability she faced. She also understood the potential that legal advocacy has in defending her right to decent, affordable housing. This was a common feeling among low-income householders in this study, though many also suggested that trying to find legal representation would involve confronting an inefficient bureaucratic process compounded by a lack of free or low-cost legal services (Ewick and Silbey, 1998; Marshall and Barclay, 2003). This begs the question: in what ways are the housing problems of the poor remedied through legal services offered within the context of their healthcare facilities?
Following the initial phase of analysis, a more in-depth approach was taken using the multiple case study methodology to better understand the association between receipt of MLP services and housing resolution outcomes. Table 2 demonstrates housing problem presented by each MLP client and the nature of the resolution.
MLP interventions helped to ensure adequate, affordable and stable housing options for participants through a variety of housing resolution options. The goals of providing adequate housing were largely met through relocation as a resolution. Affordability was accomplished mostly through housing subsidies and referrals to fuel assistance. Stability was accomplished through shut-off protection and the reinstatement of services, housing placements and eviction protection. MLP services helped to a) secure shut-off protection and the reinstatement of services in utilities cases, b) assist in attaining and retaining housing benefits, and with c) mediation of pending evictions, d) relocation for conditions and reasonable accommodations and e) shelter and permanent housing placements for homeless participants. Some of these cases are described in further detail below with quotes, MLP intervention components and participant assessments of the impact of MLP services.
Several respondents described housing conditions that were in clear violation of housing codes such as the rodent infestation, mold, holes or cracks in the walls floors or ceiling and electrical or plumbing problems amongst others. These violations were often reflective of poor maintenance on the part of landlords and property managers. Patricia described the home she lived in prior to the MLP intervention, stating:
The landlord did not want to do anything. The ceiling was falling down, the bathroom sink did not work, the house wasn’t de-leaded, the front door lock would not… it locked but I didn’t have a doorknob on and the second lock did not work… It was just so much other things going on in that house. It was just like we were living in, like, an abandoned building pretty much.
The MLP program helped Patricia become more aware of her rights as a tenant. They advised her to withhold her rent and assisted her in filing the paperwork for a transfer to another subsidized housing unit in a different building. In retrospect, she noted the improvement in her housing situation:
DH: Is this home better for you and your family?
PF: Is this better than where I left from, from [Craig] Street? Hell yeah. It’s like I’m in a mansion considered from that. Yes, it is.
The improved living conditions were realized through relocation and a transfer to a more habitable unit within six months of initiating her MLP case. While not exactly a mansion, Patricia’s new dwelling seemed more conducive to health than the one she described prior to the MLP intervention.
Many MLP participants reported utilities hardships related to shut-off protection or the reinstatement of services once the utilities were shut-off. Margaret explained the circumstances of her shut-off protection case:
MS: They were gonna shut my gas off and everything so my therapist told me to talk to a lawyer there… I saw them and I told them. I gave them what I… they had me get my income and I got them that and everything and they said, “We’ll make sure that they don’t shut your lights and your gas off and everything.”
DH: How were they able to help you?
MS: They stopped them from shutting my lights and gas off and everything. I had a $5,000 light bill and they wanted $1,296 so they wouldn’t shut my lights off and um… I told them, I said, “I can’t do that. How can I do that? I won’t have anything.” I have grandchildren, you know. They have to be reasonable.
In a similar case, Latoya explained the following about how MLP intervened when her utility services were disrupted. She said:
LW: Oh, they’re sky-rocket [sic]. My lights are pretty cool. My gas is what gets me. That’s why I went to that program because the services had been shut off and she wrote me a letter.
DH: She wrote the letter in respect to your child’s health?
LW: Yep, to have the lights on… I just say thank god for a letter that says somebody is sick.
By Massachusetts law, utility companies must maintain services in cases where a household member’s vulnerable medical condition that necessitates gas or electric services. Margaret’s psychiatrist referred her to the MLP lawyers noting the stress her patient was encountering due to the pending shut-off. The attorneys were able to write a letter to the utility company to avoid the shut-off and also negotiate a payment plan that was affordable on her limited budget in order to pay down her debt to the utility company. The MLP was able to get Latoya’s services reinstated on the basis of her child’s health condition related to asthma. In these cases, MLP was able to leverage health as a means to address utility hardships. However, as noted by Margaret’s case, in particular, shut-off protection and the reinstatement of services address short term needs but do not approach the larger issue of affordability of household utilities (Bhattacharya et al., 2003; Hernández and Bird, 2010).
The circumstances under which relocation was necessary varied drastically across the sample. At times, people wanted to move to a safer neighborhood; at other times the housing conditions rendered a dwelling uninhabitable or unsuitable to accommodate persons with disabilities. In one of the most extreme cases, Deidra’s son was a victim of gang-related gun violence. She did not want her son to return to the same neighborhood upon being released from the hospital for fear of further violence. She explained:
DG: Actually, what happened was, when Cedric got shot I wanted to move out of that place… She helped me with the emergency transfer. She also got it so the people, some group ended up paying my deposit.
The imperative to move was so urgent that the housing authority approved a transfer to a comparable unit and Deidra was able to relocate to another neighborhood to ensure her family’s safety. MLP also helped her to secure funds for the deposit, which may have otherwise impeded the move.
Often the conditions of the neighborhood were so grave and the options to transfer so limited that finding a market rate apartment in a more secure neighborhood paid off in health dividends. Vivian described the stress derived from her old neighborhood:
VW: I really didn’t like it. I really was stressed out at that point. I had a lot of headaches. I never really wanted to go home ‘cause when I went home just to see those people sitting out there it would just kinda get on my nerves and they would always like, fights and arguments and stuff. Trying to mind your business and they just like nosey neighbors and stuff. I just didn’t like it at all. I wanted to be relocated. I was on their waiting list for like eight years and they never relocated me.
The MLP lawyer was unsuccessful in securing a transfer to a better unit within the housing authority but advised Vivian, a full-time administrator, to consider an affordable market rate apartment in a safer neighborhood. With few alternatives, she conceded and followed the lawyer’s advice:
VW: it just got the point where I said you know, if I have to pay a little more money it’s worth it.
Vivian was more relaxed in her new home and neighborhood and no longer feared for her or her children’s safety, thereby reducing stress and anxiety. Furthermore, the information and social support resources furnished by the MLP lawyer functioned, from a social capital perspective, as a means to achieve “unanticipated gains” through access to more varied social network connections (Small, 2009). Thus, perhaps beyond the lawyer’s advice, the perspective of a professional from higher socioeconomic background might prove beneficial in future instances when confronting other problems that require an expanded social network for health or upward mobility.
Housing affordability hardship is often at the root of housing problems among low-income families (Stone, 2006; Harkness et al., 2005; National Low-Income Housing Coalition, 2012). Lack of housing affordability limits housing options and forces trade-offs in other areas such as food and utilities. At times, a slight change in household expenses can be the difference between having enough to eat, heat the home or meet other basic needs. In Regina’s case, MLP lawyers were able to successfully appeal a rent hike spawned by a short-term increase in her salary. They wrote a letter to the management company explaining her tenuous employment situation and her inability to afford any additional rent. Coming from an authoritative source, the letter of explanation averted the rental increase. Regina’s reaction to the process was as follows:
DH: In general how was the process for you? How did you find it?
RT: The process? How can I tell you? They helped me well, in fact, plenty, in my thinking. That rent thing had me very worried. I could barely sleep, “If they raise my rent. What will I do?” Now I say, thank God and them that it got all fixed up.
Regina expressed gratitude to the MLP program for averting an increase in the rent. She recognized that it would have created significant challenges in meeting other household needs and acknowledged being worried and losing sleep, both of which indicate psychosocial stress that can impact other health issues. While not an immediate health threat, the MLP intervention employed a preventive strategy to protect Regina and her family’s health, allowing her to care for her family absent this additional source of stress.
Securing housing subsidies that furnish access to affordable housing often entails long and complicated application and appeals processes in spite of eligibility and need. Monique was relieved when her housing voucher was issued with the help of MLP:
MW: I got the [housing choice] voucher the end of December so around that time… The process was pretty smooth. Like I said, I had most of the information. I just needed somebody who was in a higher position than me to push ahead, ‘cause like, you know, I’m just a little person. If you can get somebody with a little bit of power that’s willing to help you out [it helps], because there’s some things I can’t do but a lawyer can [do].
Monique acknowledged the role of the attorney in helping move the process along in her housing voucher application process. She noted that in comparison to what she could do on her own, the lawyer had more “power” which enabled results beyond her capability as a “little person.”
Once secured, recipients of housing benefits remain subject to particular eligibility criteria and requirements to report all sources of household income. Failure to comply can result in the loss of benefits. When Cameron first came into contact with MLP, she was on the verge of losing her housing subsidy:
CH: My psychiatrist put me in touch with the lawyers. It was so stressful I couldn’t sleep at night. I was losing mad weight, you know what I’m sayin’. I went into a depression.
DH: So what did they do for you? What did the lawyers help you with?
CH: They helped me with my housing situation. That’s when they was threatening to take my Section-8 [housing subsidy] away from me. I was having a hard time with my housing worker because I didn’t report my income, the SSI [supplemental security income] and everything. She knew my income so she had stopped paying the landlord the part that they had agreed to pay him and was telling me that I had to pay the landlord eight-hundred and somethin’ dollars. How in the f- can I afford eight-hundred and something dollars? I only get like, what? $600. She kept going back and forth with that. That’s why I got involved with the lawyer and everything… They [MLP] was like, ‘Wait a minute. You have to give her a chance.’
Cameron’s case involved appealing to the property management company of the subsidized housing unit in which she lived for a total of two years. The lawyers advocated on her behalf and she was able to retain her housing benefits. Given the intensity of the case, Cameron was asked about acquiring the same results on her own and said:
DH: Now, do you think that you would’ve had the same results if you were doing it by yourself?
CH: No, there ain’t no way. I would’ve lost my Secition-8 voucher.
DH: And what would that have meant for you?
CH: In the shelter, into a depression. I really can’t say. I know I would’ve went back into a depression, wouldn’t want to be bothered with no one.
Citing homelessness and depression as the inevitable result of losing her housing voucher, Cameron makes apparent the connection between housing, legal advocacy and health and the difference that having a lawyer in her case made to avoid losing this vital resource.
Low-income renters are especially susceptible to evictions, particularly in light of the recent real estate and mortgage crisis. Evictions compromise housing stability, induce stress and disrupt school and healthcare routines. Marlene was caught in the web of her landlord’s foreclosure and noted:
MJ: The house went into foreclosure at my past apartment… So that’s the reason I had to move. I was being evicted.
DH: And what did they [MLP] help you with?
MJ: They helped me get a settlement from basically damages that I suffered over in that apartment for the violations and all that.
Kathy also faced eviction due to foreclosure:
KL: The house was foreclosed on and the landlord never told us anything, so we kept on paying the rent but also getting eviction letters.
In both cases, MLP represented these clients in housing court. In Marlene’s case, the MLP lawyer was able to secure compensation related to housing code violations in her previous apartment. Kathy was granted additional time to obtain another apartment in light of being evicted; alternatively the family would have been forced to live with family or in a homeless shelter.
At times evictions are also brought on by the fact that low-income tenants face competing expenses against limited budgets. Stephanie describes how her difficulties making ends meet affected her housing, she explained:
SH: The reason why I went to them was because I was having an issue with the landlord about the rent and stuff. I told [the landlord] that I can’t give her the rent money, and that she’s gonna have to wait like this month coming up. Like, why I’m a month behind is because school came in and I had to get my children clothes. So that’s what made me fall back behind because I had to get their clothes. Otherwise I would’ve been up to date on my rent.
According to Stephanie, the landlord was “harassing” her for back rent payment, which she was not able to pay immediately due to budget trade-offs. The MLP lawyer was able to mediate the dispute between Stephanie and her landlord and also negotiate a payment arrangement with the landlord, which deescalated the situation and averted eviction and further stress.
The interaction of doctors and lawyers made it possible to address the key pillars of housing- affordability, adequacy and stability- and related socio-legal needs of indigent medical patients. Those that benefited from MLP services described having a doctor-lawyer team as “extra oomph” (Latoya) and as something that “kinda gives you the edge up on what to look for and how to go about it” (Monique). Summarizing the very essence of what the program hopes to accomplish, Patricia noted:
If Boston Medical didn’t have the legal service, in the pediatric department I wouldn’t be where I’m at today. So that’s why I say that they work well together because the doctor’s trying to work and get the best for you just like a they’re trying to heal a person. And the bottom line, her referring me to the lawyer is healing me also because it’s getting me help – not just the baby, but me also. By them healing me I can take care of the kids.
Despite these success stories, there were times when MLP services rendered no change in the presenting housing problem their clients faced.
In the recruitment process, we actively sought out cases that were lost to follow-up and found several MLP participants who were enrolled in the program but did not fully benefit from the intervention. There were several instances when MLP was not effective and lost several participants to follow-up. These cases were deemed status quo, representing 6 of 36 participants (17%). Most of the housing problems (5 of 6) were related to adequacy relating to conditions (3), crowding (1) or utilities (1). Tynetta was referred to the program because the electricity company shut off her services. She recalled,
“Yeah, [the pediatrician] recommended me to them. That was it. We spoke at the [intake] meeting and that was it.”
Tynetta did not receive follow-up services beyond the intake process and resolved the problem by getting a loan from a family member to pay the balance she owed to the utility company.
The other case related to affordability resulted in a passive referral but the participants chose not to follow-up, as was the case with Clara:
DH: So the lawyers weren’t really able to help you.
CM: They were just giving me numbers to call you know, to call and talk about it and stuff like that… It was okay but you know housing, it’s a slow thing. You have to go through so much paper and everything so I didn’t bother to do it.
It is important to note that legal assistance is not likely to be of much or any help getting someone who isn’t already high up on the wait list to obtain housing subsidies (except perhaps for people who have become homeless). On the other hand, the results herein demonstrate that medical-legal services can be of real help in assisting people with housing subsidy address problems with the housing authority/landlord to ensure better housing quality and greater stability.
In other cases, immigration status prohibited some participants from fully engaging with MLP staff. The reasons for this were not stated explicitly by participants but close analysis of comments made during interviews may shed light on this issue. For instance, when asked about her case, Modesta affirmed that she was not helped by MLP:
DH: So they did not help you with anything?
MR: Nothing, nothing…I don’t know why.
However, at one point during the interview, she asked me to confirm that the landlord would not be reprimanded based on her description of the subpar housing conditions in which she and her family lived. Existing literature suggests that the precarious nature of an undocumented immigration status may inadvertently affect willingness to fully participate in programs that might jeopardize elements of family stability regardless of the potential benefits for fear of deportation or other perceived repercussions (Hacker et al., 2011; Portes, Fernández-Kelly and Light, 2012). The missed opportunity here may reflect a gap in communication on the part of MLP staff to provide reassurance to participants and ensure that fear is not the primary cause for lack of engagement. Future studies should investigate cases that are lost to follow-up to provide guidance on improved practice.
This study offers a comprehensive analysis of participants in the MLP program using a multiple case study approach to show the trajectory of their cases noting specific housing problems and resolutions. It also compares program participants to similar families to demonstrate alternate resolution outcomes in the absence of legal services. However, this study is subject to limitations characteristic of qualitative studies, including convenience sampling methods, the varied interpretability of findings and non-generalizable results. The study was designed to capture retrospective accounts on experiences with the MLP program which introduces recall bias. It also did not consider variations in housing type (i.e. public housing, market rate or voucher); therefore results do not pertain directly to any one particular housing type or status. It also focuses on primary housing problems, albeit many respondents reported several simultaneous housing problems. Furthermore, information on the reasons why the participants visited the doctor was not systematically collected, therefore missing an opportunity to further assess the relationships between poor housing and poor health from the lens of the clinical visit. While these limitations cannot be overcome in this study, the results presented reflect a vigorous approach to data collection, analysis and confirmation of results. Future research should build on results presented here in order to systematically investigate the results of MLP interventions in domains beyond housing.
The present study examines the processes by which a medically-based intervention addresses legal problems related to housing for poor families. This article demonstrates how MLP participant families differed from comparable families in the results they obtained regarding the resolution of common housing problems. The MLP model is premised on the notion that providing legal services in the context of healthcare allows doctors to address the root causes of the symptoms they treat, while at the same time low-income patients are given rare access to legal services to address housing and other socio-legal problems that affect health. In the cases above, the respondents often acknowledged the health toll they experienced due to their housing circumstances. Most often they described feeling stressed, being sleepless and experiencing mental health challenges such as depression associated with the juggling acts of affordability and instability. The cumulative stress literature suggests that these are the pathways to disease and disadvantage for low-income parents and children (Evans, Brooks-Gunn and Klebanov, 2011). A relatively new emphasis on addressing structural factors such as housing has emerged as a way to combat the pertinent of health disparities (Williams et al., 2008). The MLP program is designed to recognize the synergistic effects of poverty, housing insufficiency and health impacts along with the compounding effect of limited access to legal services. Framed within the context of health care, the MLP model has the potential to transform patient-centered care and long-term housing and health prospects for low-income families through the enforcement of rights to decent, affordable housing. The mechanisms by which the MLP intervention facilitated positive results for participants include a) convenience and easy access, b) free services; and c) eligibility for groups such as undocumented immigrants that are not served by traditional legal services channels available to the poor. Doctor’s appointments are part of most families’ health routines and function as an ideal entry point for medical, social and legal intervention. Furthermore, the trust and established relationships with medical providers who then refer patients to MLP lawyers also help participants to feel more comfortable engaging with lawyers. The MLP intervention was facilitated by the fact that the program exists within the context of community health centers or the equivalent of “medical homes” under the Affordable Care Act. Consistent with the objectives of health care reform, programs such as MLP have the potential to not just serve as “band-aids” for medical and legal problems, but to address inadequate enforcement of current laws especially those related to housing. This is especially promising for vulnerable groups who have limited access to legal services since in addition to financial barriers lawyers and other bureaucrats are often perceived with scrutiny and distrust, a perspective that is exemplified in the quote by a non-MLP participant (Eileen on page 7) and otherwise well-established in the literature (Ewick and Silbey, 1998; Marshall and Barclay, 2003).
The present study demonstrates that the impact of MLP services extends beyond the immediate nature of the problem or the resolution strategy employed and shows the value of doctors and lawyers working together to assist patients outside of the health care setting to improve outcomes. This intervention has important implications for the patients and providers alike. For participants, the collaborative relationships formed between doctors and lawyers engender a unique opportunity to draw on their partnership to address problems in the future. Previous work on the impact of medical legal services on legal consciousness suggests a process in which people learn, legitimize and then leverage the law (Hernández, 2010). The shift in legal consciousness for those at the intersection of inequality- race, gender and socioeconomic status- entailed a process in which people become familiar with legal options and rights (learning legality), begin to “integrate the law in interpretations of problems” and viable options for redress in the law (legitimizing legality) and mobilize the law to address problems (leveraging legality) (Hernández 2010, p 111). However, at the provider level there is also a vital shift in consciousness that occurs in the partnership between doctors and lawyers as they co-construct a “medical-legal consciousness.” The cross disciplinary training that instructs the doctor to search for legal lapses to treat health matters and prepares the lawyer to leverage medical conditions to address legal infractions fundamentally alters and broadens the professional lens and toolbox of doctors and lawyers working with indigent groups. Hence, the medical-legal consciousness that is formed through the MLP intervention changes the norms of practice in each field and creates new and exciting prospects for viewing and tackling the problems of poverty more holistically.
Despite this more hopeful assessment of the “extra oomph” that MLPs provide vulnerable households, lawyers and doctors remain limited in their scope of work. MLP lawyers were able to secure particular results in averting crises (i.e. eviction and utility shut-offs) and intervening during urgent times (i.e. homelessness and uninhabitable conditions). Still, the fundamental issues regarding mounting utilities debts, the depraved housing stock available to low-income householders and violence in inner-city communities are beyond a lawyer or doctor’s pay grade. These issues require more systemic approaches to contending with social exclusion and a reevaluation of the extent of human and civil rights afforded to the poor in housing and access to medical and legal services. The MLP intervention is a step in this direction. If brought to scale, MLPs have the potential to decrease medical and legal disparities and intervene in the cycle of limited access to effective alternatives that combat poor housing and poor health.
Dr. Diana Hernández is fully responisble for the study design, data collection, analysis and interpretation of the data and the final write up of the article. I wish to acknowledge the input of Kirk Grisham, Megan Sandel, Emily Suther, Ellen Lawton and Barry Zuckerman on earlier versions of this paper.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this research was made possible through Atlantic Philanthropies, the Law and Social Science Dissertation Writing award sponsored by the National Science Foundation, the American Bar Foundation and the Law and Society Association, and several internal grants at Cornell University including a jointly funded seed grant from the Center for the Study of Inequality and Bronfrenbrenner Life Course Center and the Provost Diversity fellowship.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.