Mainstreaming Medical Legal Partnerships (MLPs)

Last week, I had the opportunity to speak at the 10th Annual Summit of the National Center for Medical Legal Partnership in McLean, Virginia. The summit brought together more than 400 people working to “mainstream” medical legal partnerships (MLPs). The theory of change is that through these partnerships, the health care sector can begin to more systematically address social, behavioral and environmental determinants of health. Particularly on behalf of patients who are low-income, legal professionals address root causes of illness by working with utilities companies, landlords, social service agencies and the court system.

Concretely, MLPs are programs in which civil legal aid agencies, health care organizations and public health departments cooperate to train their staffs, treat individuals and identify population level problems. Most often, it is civil legal aid agencies that provide expertise in the laws around housing and public benefits, and spend their resources to ensure access to housing subsidies, food benefits, health insurance and employment. Some law firms also contribute pro bono time to the cause, as do some law schools in the form of clinics.

The latest data suggests that more than 140 hospitals and 130 health centers nationwide already have an MLP in place. This diffusion has resulted in more than 15,000 health care providers being trained on how to screen for social determinants of health last year. The organizational models for how these partnerships are established can vary but virtually all research conducted on the impact of MLPs has demonstrated impressive results. In a 2012 paper published in Pediatrics, a team led by Andrew Beck found that an MLP was able to facilitate home improvements in substandard housing in 71% of referred cases. In a 2012 article published in the Journal of health Care for the Poor and Underserved, a team led by James Teufer suggested that a rural MLP was able to generate a 319% return on investment between 2007 and 2009. (For full methods of how that ROI was calculated, see page 707 of the linked article.) Several additional studies, including randomized control trials, are forthcoming.

MLPs currently operate on the basis of a mixed funding base. Many rely on a combination of short-term grant funding from the likes of the Kresge and Robert Wood Johnson Foundations. In some cases, non-profit hospitals may support MLP programs as part of community benefit efforts required to maintain tax exemption. At least one for-profit firm, Walmart, has also become a key investor in the movement.

A key challenge for MLPs is in tracing what institutions and actors accrue what benefit from the work. Health care utilization is likely to go decrease, which may result in savings for a hospital or health center depending on the insurance status of the patients in question. The state may be paying “more” in benefits if MLPs became mainstream and supported client enrollment in programs like Medicaid, Temporary Assistance for Need Families (TANF) and Supplemental Nutritional Assistance Program (SNAP). On the contrary, the state may also recuperate some costs if clients utilize fewer police and emergency services in the short term, or become employed and transition out of welfare programs over the longer term.

These are all positive impacts from a public health perspective – but given this ambiguity, the question of who should provide the initial capital investment to catalyze program development remains contested. As health care aims to move towards a more value-based financing model, MLPs can and should become an attractive tool in creating and maintain health. Thankfully, the attendees of last week’s summit haven’t waited for this seismic shift before getting to work.

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