New York is the first state to endorse the importance of offering free legal services onsite at health care facilities. Gov. Andrew Cuomo signed into law the Health-Related Legal Services Program in 2011. This law amended the New York Public Health Law to authorize the New York Department of Health to designate certified “health-related legal service programs” and directs the Department to establish standards and guidelines under which a program may qualify for designation.
The law defines a “health-related legal service program” as “a collaboration between health care service providers and legal services programs to provide on-site legal services without charge to assist, on a voluntary basis, income eligible patients and their families to resolve legal matters or needs that have an impact on patient health or are created or aggravated by a patient’s health.” The law endorses the medical-legal partnership model of providing direct legal services, but for reasons we describe below, it refers to the programs as “collaborations” instead.
The first medical-legal partnership started in Boston in 1993, and since that time the model has spread rapidly. Now medical-legal partnerships offer free legal services at 231 (and counting) medical sites across the United States to the most vulnerable members of society: children, seniors, veterans, and the chronically ill. The New York law is a significant step toward realizing a more integrated approach to public health that recognizes the effect social determinants of health have on a patient’s well-being. The social determinants of health are the circumstances under which people are born, grow up, live, work, and age and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics. Medical-legal partnerships help low-income individuals with chronic and serious illness resolve the myriad legal problems—such as issues with housing, insurance, income supports, immigration, and consumer debt—that can dramatically affect their health outcomes. Medical-legal partnerships further benefit their clients by training health care professionals to recognize legal issues that may negatively affect medical outcomes.
The New York Legal Assistance Group’s LegalHealth division is now the country’s largest medical-legal partnership. It was founded in 2001 with two lawyers and one on-site medical clinic at Mount Sinai Hospital. By 2007, as the efficacy of the model spread in New York, LegalHealth lawyers were staffing weekly intake clinics at 14 hospitals and community health clinics in all five boroughs of New York City. We began contemplating how we could institutionalize this model and were joined by several other New York State medical-legal partnerships in believing that the model demonstrated success and warranted financial support from the State. What initially started as a funding initiative ultimately became an unfunded law that recognizes medical-legal partnerships as a new public health tool and benefits the medical-legal partnership movement.
We overcame numerous obstacles and learned several valuable lessons from the time the idea for the bill was conceived in 2007 until the law finally passed in 2011. We hope that our accomplishment will inspire other medical-legal partnerships to advance the cause in their states, and by sharing our experiences here, we seek to aid them in their progress. We acknowledge that our approach would not be possible for organizations receiving funding from the Legal Services Corporation (LSC) due to the restrictions on lobbying and prohibition on any attempt to influence legislative activities imposed on LSC organizations by the Legal Services Corporation Act. However, we hope that LSC organizations may still participate in the promulgation of the medical-legal partnership model by supplying data and reporting factually on the efficacy of the model and the benefits to clients.
Story of a Bill
In New York, legislation is made by committee. After a bill is introduced, it is assigned to the appropriate committee in each house for analysis, discussion, possible public hearings, and, if necessary, revision. If a majority of members of the committee support the bill, it is reported to the next appropriate committee or to the floor for a full vote. If not, it is said to “die in committee.” In practice, the leaders of the Assembly and Senate often negotiate agreements in private while a bill is still in committee. Full roll-call votes on the floor are often a mere formality.
We knew a bill would not be passed without the support of leaders in both the Senate and Assembly Committees on Health. We approached Sen. Kemp Hannon and Assemb. Dick Gottfried, the chairs of their respective health committees. Both expressed interest in expanding medical-legal partnerships in New York State through a legislative initiative.
With the support of Senator Hannon, a $2 million budget proposal was made to Gov. Eliot Spitzer’s office in the fall of 2007. The proposal was to fund 15 medical-legal partnerships around the State and included additional funding for one oversight entity that would supply technical assistance. The goal was to include it as a line item in the Governor’s budget. Although the Governor’s office was initially enthusiastic, this first legislative attempt ultimately became a casualty of the 2008 economic crisis.
Lesson 1: If at First You Don’t Succeed, Form a Coalition.
Interest in medical-legal partnerships was blossoming in 2008, and LegalHealth had just been awarded a grant from the Charles Evans Hughes Foundation to provide technical assistance and support to organizations interested in starting medical-legal partnerships throughout the country. We recognized that established and fledgling medical-legal partnerships across New York would benefit by sharing resources and information. In May 2008, 13 New York State legal services organizations attended the inaugural meeting of the New York Coalition of Medical-Legal Partnerships. The primary focus of the meeting was to share resources and collaborate on a strategy to get the legislation passed.
The coalition was essential to the success of the legislation. The coalition gathered from existing medical-legal partnerships in New York information such as funding sources, annual costs, types of services offered, legal matters handled, and the number of people served. This information demonstrated the impact that medical-legal partnerships have on the population and justified the legislation. The Coalition served as a staging ground for the development of the grassroots effort needed to pass the bill. The Coalition drafted a statement in support of the bill and successfully solicited the support of many organizations such as UJA-Federation of New York, the New York State Bar Association, Upstate University Hospital, Syracuse University, MFY Legal Services, The Family Center, Legal Services of Central New York, New York City Health and Hospitals Corporation, and the American Medical Association. The Coalition reached out to attorneys, medical professionals, and patients to secure letters of support from a broad constituency of interested parties.
Lesson 2: After You Form a Coalition, Get a Lobbyist.
The New York Legal Assistance Group, LegalHealth’s parent organization, is closely affiliated with the UJA-Federation of New York. LegalHealth was able to engage the assistance of Edie Mesick, a UJA-Federation lobbyist, to guide and assist the Coalition in our efforts to gain support for the bill. As the State Government Relations Executive for UJA, Mesick was familiar with the formal and informal procedures used to garner support in Albany. She helped us make critical connections with the members of both houses and offered valuable insight regarding the political climate in the state. Most importantly, she was a consistent contact between the Coalition and the legislators, promoting the value of the bill in dozens of meetings over several years. LegalHealth and other Coalition members joined in these lobbying efforts, but we would have been far less effective without the expertise of a dedicated lobbyist.
Lesson 3: Communication Failures Are Opportunities for Education.
Shortly after joining the Coalition, Mesick, through her meetings with legislators, discovered a profound lack of understanding in Albany over what a medical-legal partnership entails. We were surprised to learn that legislators believed the purpose was to put lawyers in hospitals so they would be in a better position to bring medical malpractice claims against hospitals and physicians. Initial opposition to the bill was largely due to this misunderstanding and the legislators’ reluctance to provide a mechanism for litigation against medical providers.
Becoming aware of this communication failure and misunderstanding was the first step to moving forward with the bill. We were relieved to learn that legislators did not object to the actual mission of medical-legal partnerships and were pleased to have the opportunity to educate them about how medical-legal partnerships can improve the health and well-being of their constituents. We accomplished this change of heart with many educational meetings in Albany over several years.
Lesson 4: Be Flexible.
While it initially struck us as trivial, another challenge to passing the legislation was settling on appropriate nomenclature. Legislators objected to the term “medical-legal partnership” because of New York’s strong corporate practice laws and the prohibition on “partnerships” between doctors and lawyers. Laws prohibiting the “corporate practice of medicine” are a mix of common law and statutory law. By prohibiting employment or control of physicians by corporations or other non-physicians, the laws seek to prevent physicians from encountering conflicts of interest between their patients and for-profit corporations. Both the legal and medical professions have strong traditions of the expectation of independent judgment and undivided loyalty toward their clients or patients. These laws protect the public from the unlicensed practice of law or medicine by requiring that all partners in a professional corporation or partnership be licensed to practice the same profession. Thus, both lawyers and physicians are prohibited from forming business corporations or partnerships with non-lawyers and non-physicians respectively.
After learning about the objection to the word “partnership” from Assemblyman Gottfried’s office, we were initially unwilling to change the title. A “medical-legal partnership” is a term of art that is used nationally to describe a particular model of delivering legal services to low-income clients with health conditions. It is not the type of business entity contemplated by the corporate practice laws, does not intrude upon the sanctity of the lawyer-client nor physician-patient relationship, and does not put the public at risk of the unlicensed practice of law or medicine. We first sought to persuade the legislators with more education and communication about the subject. However, we soon decided that the limited time we were able to get with the legislators was best used discussing the merits of the bill rather than arguing over the name. At a suggestion from Assemblyman Gottfried’s staff, the solution was to use the word “programs” instead. Thus, for the purpose of state designation, medical-legal partnerships are referred to as “health-related legal services programs.”
Lesson 5: Take the Long View.
After the first bill failed as a line item in the Governor’s budget in 2008, Senator Hannon introduced legislation for a funded statewide program to be housed within the New York State Department of Health, this time being intentionally vague regarding a dollar amount. However, as the extent of the economic crisis deepened and Albany became preoccupied with budget issues in 2008 and 2009, we realized that there would be limited resources even for existing health and human services across the state. We recognized that the economic and political climate would not likely support any new spending. Rather than continue to push for a funded version of the bill, which likely would have been futile, or jettison the legislation altogether, we made a strategic decision to proceed without any provision for funding.
After much discussion with both Senator Hannon and Assemblyman Gottfried, LegalHealth and the Coalition drafted a new version of the bill with input from the sponsoring legislators. At first, some legislators had difficulty grasping the value of the legislation without funding. The Department of Health was also initially reluctant to support an unfunded version of the bill because of the additional administrative costs imposed on the Department. Ultimately, the Department was persuaded by the potential of medical-legal partnerships to improve the health of New York residents, thus reducing the cumulative cost of health care for the state. After two more years of a consistent and targeted lobbying effort, the bill finally passed both houses and was signed into law in September 2011.
Although it is disappointing that the Health-Related Legal Services Programs Law as passed does not include provisions for funding, its value to medical-legal partnerships, New York State, and the public should not be underestimated. By passing the law, the New York State legislature has explicitly recognized the important work of medical-legal partnerships and demonstrated its understanding and agreement that legal advocacy for New Yorkers with health concerns is most effective when doctors, social workers, and lawyers collaborate. Now that a mechanism for designation by the Department of Health exists, New York medical-legal partnerships are in a better position to ask for State funding in the future as the economy improves. In the meantime, medical-legal partnerships are now poised to attract funding from other sources as a result of the legislative stamp of approval.
While medical-legal partnerships are better positioned to ask for funding and expand their work as a result of legislative support, the ultimate beneficiaries of the development and growth of medical-legal partnerships are the patients and their families. In 2013, LegalHealth alone trained over 700 medical professionals and handled over 5,400 new matters for patients referred by their medical providers in New York.
After soliciting the coalition for help with drafting requirements for state designation, the Department of Health designated the state’s first “Health-Related Legal Services Programs” in April 2013. LegalHealth is proud that our partnership with Beth Israel Medical Center was one of the first to receive designation from the Department of Health. The Legal Aid Society’s partnership with St. Luke’s-Roosevelt Hospital also received designation. Since the initial designations, more New York partnerships have been recognized, and others are pending.
Since it passed, the bill has been featured at several national conferences with the goal of educating practitioners and advancing the success of the medical-legal partnership model. LegalHealth has provided technical assistance to multiple medical-legal partnerships throughout the United States interested in passing their own state legislation. Perhaps the Affordable Care Act, with its emphasis on care coordination, will spur even greater adoption of this highly effective model.