This article is part of State of Health, a series examining integrated care and its potential to improve Michiganders' health. It is made possible with funding from the Michigan Health Endowment Fund.

According to the Justice Gap Report, in 2017, 86% of the civil legal problems reported by low-income Americans received inadequate or no legal help. 41% of those issues related directly to healthcare.

In Michigan, medical-legal partnerships (MLPs) are working to change that by integrating free, professional legal services directly into healthcare settings.

"We have a lot of laws on the books that are meant to protect vulnerable people and kids with disabilities – rules about housing, rules on public benefit," says Debra Chopp, associate dean for experiential education and clinical professor of law at the University of Michigan (U-M) Law School. "Lawyers can help enforce those laws for vulnerable people."

The U-M Law School's Pediatric Advocacy Clinic functions as an MLP focusing on children's health and wellbeing. The clinic provides assistance to patients of U-M's Mott Children's Hospital, Ypsilanti Health Center, School of Social Work, and Medical School, as well as patients of Corner Health Center in Ypsilanti and the Washtenaw County Maternal Infant Health Program. Law students may take the clinic as a seminar, learning lawyering skills and substantive law while representing clients under the supervision of attorneys. Pediatric residents also do a rotation through the clinic.

"We are training future lawyers and doctors on how to go forth into their professions with these interdisciplinary skills," Chopp says. "... On a small scale, we are changing the culture of the profession of lawyering and the healthcare profession."

Debra Chopp.

In collaboration with physicians, the clinic can take Medicaid and private insurers to court when coverage is denied or send a lawyer along to individualized education program (IEP) meetings at school. When a child with a diagnosed condition like ADHD is expelled from school, clinic lawyers can advocate for the child to remain in school to ensure success. MLPs offer family law services that help create family stability, reduce stress, and increase income via child support or public benefits.

"If you have a lawyer as part of the healthcare team, you can better address social determinants of health," Chopp says. "Our medical-legal partnership often deals with families with chronically ill children. Whether or not we win, just being by someone's side while they are going through a stressful situation like a custody hearing, an IEP, or challenging denial of insurance coverage … there is a benefit no matter what the outcome."

Chopp recently represented the mother of a four-year-old girl with a rare genetic disease that resulted in her needing multiple jaw surgeries. Afterward, the girl required speech therapy. But Medicaid refused to cover the therapy, saying the girl could access speech therapy at school. When Chopp filed for a hearing, Medicaid approved the therapy before the case even got to court. Chopp says that's not an uncommon turn of events.

"Parents have their hands full dealing with a chronically ill child. They do not have the time to spend hours fighting with insurance companies, fighting with schools. It really helps to have an ally," Chopp says. "A lot of people who have legal or social issues may not realize that there is a legal solution. When you have a medical-legal partnership, doctors and social workers are trained to flag issues and make a referral. It gives people another point of access to legal services so they don't have to figure it out on their own."

The lawyer is in.

In Southwest Michigan that culture shift is evident in Cherry Health's MLP with Legal Aid of West Michigan (LAWM). Leaders of both organizations had noticed more MLPs popping up across the nation and decided it was time to make one happen in West Michigan. When LAWM executive director Pam Hoekwater and Cherry Health director of psychosocial services Cheryl Tschosik discovered their shared objective, they got together in September 2016 to make it happen.

"When we first met, it went really quickly. We really had the same vision," Hoekwater says.

Pam Hoekwater.

LAWM helps low-income clients who have been denied public benefits, are facing eviction or conflicts with landlords, or are victims of domestic violence. The organization also handles criminal, tax, and many other legal issues.

By January 2017, the partnership engaged LAWM lawyer Scott Stuart to offer legal counsel eight hours a week on-site at Cherry Health's downtown Grand Rapids location. Additional grant funding from the Department of Health and Human Services Administration for Community Living enabled the partners to hire full-time lawyer Dave Ballard.

"It's been going really well," Tschosik says. "We have continued to meet every other week just to keep the partnership going, address issues, and think more broadly about how to reach, who to reach, and service delivery."

Cheryl Tschosik.

Having legal counsel to address social determinants like housing, food, income, and domestic violence has a direct positive impact on patients' physical and mental health. All legal issues can cause stress, anxiety, and depression, which also takes a toll. That's why Hoekwater and Tschosik assert that including legal assistance as part of an integrated health model makes perfect sense.

"What we love about this medical-legal partnership is that individuals don't always know that they have a legal issue," Hoekwater says. "Also, instead of someone having to go to our office and make an appointment, they are coming to Cherry Health (and) getting screened by a health provider that we've trained who might realize a lawyer could help."

Any of Cherry Health's community health workers, physicians, or nurses can refer patients for legal assistance. And, according to Hoekwater and Tschosik, that assistance is improving patients' health outcomes. Hoekwater notes that 60% of people with chronic health have legal issues.

Cherry Health patients who've received legal assistance include a man whose health problems were being exacerbated by letters from the IRS. Stuart was able to get help from LAWM's tax lawyer and greatly reduce the amount the patient owed. A terminally ill, widowed father of four was able to legally appoint caregivers for his children. Victims of domestic violence have found it easier to access legal help when it was provided during a visit to the doctor without their partner's knowledge.

"About one-third of the cases are housing cases. Normally people wouldn't seek help until eviction. Here they get some advice and prevent evictions," Tschosik says.

"If you have the resources, you can seek out help from a lawyer sooner," Hoekwater says. "If you don't have those resources, you wait until it's an emergency."

Navigating legal complexities in indigenous communities

MLPs are also making inroads in Michigan's Native American communities, where dealing with state, federal, and tribal jurisdictions make any legal matter much more complicated. Serving 12 tribes in Michigan, Michigan Indians Legal Services (MILS) has been providing legal services since 1975. The organization began pursuing MLPs with the Little River Band of Ottawa Indians and the Little Traverse Bay Bands of Odawa Indians last year.

Cameron Fraser.

"We are really excited to work in partnership with medical professionals and with both tribes that we are partnering with. We are hoping to improve people's health by having more legal interventions," says Cameron Fraser, MILS executive director. "Definitely within the community where there's poverty, there's also going to be more medical issues and mental health issues. There's also going to be a higher need for intervention on the legal side relative to those issues that put people into poverty."

When the MLP launches, Fraser hopes it will address social determinants of health so clients are free to focus on their medical issues.

"Studies show that alleviating legal problems relating to medical issues — relieving the stress — can help health," she says. "People become healthier if they don't have those legal problems going on."

A freelance writer and editor, Estelle Slootmaker is happiest writing about social justice, wellness, and the arts. She is the development news editor for Rapid Growth Media, communications manager for Our Kitchen Table, and chairs The Tree Amigos, City of Wyoming Tree Commission. Her finest accomplishment is her five amazing adult children. You can contact Estelle at [email protected] or www.constellations.biz.

Cheryl Tschosik and Pamela Hoekwater photos by Adam Bird. Debra Chopp photo by Doug Coombe. Cameron Fraser photo courtesy of Cameron Fraser.