Symposium – 2023 – Access to Justice

Medical-Legal Partnership as a Model for Access to Justice

Ms. Donaldson, a mother of three, receives an eviction notice. She shows up in court, like so many other tenants, without a lawyer, facing an experienced landlord’s attorney who has been before the same judge dozens of times. She is evicted in a matter of minutes and finds her family unhoused, with grave impacts on their health and well-being.

The United States is plagued with a “justice gap” that leaves many Americans with unmet civil legal needs. Americans with low income do not receive the legal help they require for as many as 92% of their substantive civil legal problems. 1 Legal Servs. Corp., The Justice Gap: Measuring the Unmet Civil Legal Needs of Low-Income Americans 7-8 (2022), https://perma.cc/5CUP-L5VJ. The justice gap requires many legal aid agencies to triage, becoming “emergency rooms” for clients with unmet legal needs. This national crisis calls for new innovations so that access to justice (A2J) can function more like primary care, promoting better use of resources and preventing legal crises that can cause long-lasting harm. 2 See Bharath Krishnamurthy, Sharena Hagins, Ellen Lawton & Megan Sandel, What We Know and Need to Know About Medical-Legal Partnership, 67 S.C. L. Rev. 377, 385-86 (2016) (describing how advocates are “devising upstream strategies to prevent, rather than react to, urgent issues” among those who are living in poverty and under-resourced).

Imagine a different world, one in which Ms. Donaldson’s experience of the legal system facilitated justice and empowered her to solve her problems and achieve better well-being for her family. 3 This story is based on the de-identified experiences of clients of the Georgetown University Health Justice Alliance Law Clinic, a medical-legal partnership with the Georgetown University Law Center and Georgetown University Medical Center. Imagine that months earlier, Ms. Donaldson took one of her children to the doctor. While at the health clinic, Ms. Donaldson received a “legal check-up”: a screening for unmet civil legal needs. She shared that she was trying to rid her apartment of mold, roaches, and mice that her landlord refused to address and that her food stamps had been terminated, making it difficult to pay rent.

Recognizing that Ms. Donaldson could benefit from legal help, the doctor referred her to a partner organization providing free legal services. The legal team successfully advocated for the landlord to remediate the hazardous housing conditions, in partnership with the pediatrician who shared a letter about why those conditions were especially harmful to Ms. Donaldson’s asthmatic child and required urgent attention. In addition, the legal team reinstated her food stamps and secured rental assistance and additional benefits, improving her financial situation and ultimately preventing her eviction. Her child’s asthma attacks ceased, and the family avoided significant trauma and health harms by remaining housed.

The legal team also helped Ms. Donaldson understand her rights and how to effectively assert them, elevating her future power to self-advocate. And recognizing that many low-income clients face similar substandard housing conditions, the legal and pediatric teams, in collaboration with Ms. Donaldson and grassroots organizations, advocated for changes to the city’s housing inspection processes to ensure more timely and robust housing code enforcement.

Ms. Donaldson experienced justice as a result of interventions by a medical-legal partnership (MLP). MLPs embed lawyers in healthcare teams to address health-harming civil legal needs facing low-income patients. MLPs are community-based, integrating low-barrier legal services into healthcare settings and bringing free and accessible legal services right to the people who need them in familiar places. MLPs work interdisciplinarily, training non-lawyer partners to understand and screen for legal issues; provide legal information, resources, and referrals; and advocate around problems that are often intertwined with health and well-being. Moreover, MLPs operate preventively, providing A2J in advance of a legal crisis, and facilitate structural change through a “patients-to-policy” approach.

MLP scholarship has uncovered the power of lawyers to address health-harming legal needs and identified A2J as a social determinant of health. 4 See, e.g., Danya E. Keene, Sascha Murillo, Emily A. Benfer, Alice Rosenthal & Ada M. Fenick, Reducing the Justice Gap and Improving Health through Medical-Legal Partnerships, 40 J. Legal Med. 229, 242-43, 245 (2020). Research shows the benefits of MLPs, including patient stress reduction, health improvements, and return on investment for hospitals and healthcare systems. 5 See, e.g., Elizabeth Tobin Tyler, Medical-Legal Partnership in Primary Care: Moving Upstream in the Clinic, 13 Am. J. Lifestyle Med. 282, 286 (2019); Krishnamurthy et al., supra note 2, at 382-83. The MLP literature argues for expansion of the MLP model as a healthcare innovation. Some scholars have focused on the lessons from the MLP movement for legal and medical education. 6 See, e.g. Jennifer Rosen Valverde, Preparing Tomorrow’s Lawyers to Tackle Twenty-First Century Health and Social Justice Issues, 95 Denv. L. Rev. 539, 579-82 (2018); Edward B. Healton, William M. Treanor, John J. DeGioia & Vicki W. Girard, Training Future Health Justice Leaders-A Role for Medical-Legal Partnerships, 384 New Eng. J. Med. 1879, 1881 (2021); Emily A. Benfer, Educating the Next Generation of Health Leaders: Medical-Legal Partnership and Interprofessional Graduate Education, 35 J. Legal Med. 113, 138-47 (2014). For example, I have argued alongside co-authors that MLPs provide maxims for law school clinics to pursue health justice. 7 See Emily A. Benfer, James Bhandary-Alexander, Yael Cannon, Medha D. Makhlouf & Tomar Pierson-Brown, Setting the Health Justice Agenda: Addressing Health Inequity & Injustice in the Post-Pandemic Clinic, 28 Clinical L. Rev. 45, 45 (2021) [hereinafter Health Justice Agenda] (identifying maxims for law school clinics to pursue health justice, including transdisciplinary collaboration, upstream interventions, adaptability, racial justice, systemic advocacy, and community-based strategies). As both a framework for health law scholarship and a movement, health justice focuses on the potential for law to dismantle subordination as a root cause of health inequities. 8 See Lindsay F. Wiley, Ruqaiijah Yearby, Brietta R. Clark & Seema Mohapatra, Introduction: What is Health Justice?, 50 J.L. Med. & Ethics 636, 636 (2022). Health justice builds the power of individuals and communities affected by health disparities “to create and sustain conditions that support health and justice.” 9 Id. Therefore, health justice is not just healthcare justice; it is also economic justice, racial justice, housing justice, and other forms of justice that necessitate access to legal resources to address unmet legal needs that drive health inequity. 10 See Sheila Foster, Yael Cannon & Gregg Bloche, Health Justice Is Racial Justice: A Legal Action Agenda for Health Disparities, Health Affs. Forefront (July 2, 2020), https://perma.cc/6YAS-SENV.

MLPs have been promoted as a unique and promising innovation in healthcare and health justice. This essay argues that they also represent an important innovation in A2J because they offer a model that is community-integrated, preventive, interdisciplinary, and transformative. MLPs embody principles that should drive broader A2J innovation to address our country’s justice gap.

I. Medical-Legal Partnerships’ Guiding Principles for Access to Justice

People with financial resources can seek out lawyers and legal information for marital, financial, and end-of-life planning to prevent legal crises. Conversely, indigent Americans often lose their homes, jobs, financial security, and even their children without access to legal information or assistance. 11 See Samantha Morton, Legal Information and Rights Education as an Element of Care: A Promising Health Justice Strategy, Health Affs. Forefront (June 7, 2021), https://perma.cc/M5CG-DC2N.

In fact, nationally, people with low income seek legal assistance for only one out of every four civil legal problems that impact them substantially. 12 Legal Servs. Corp., supra note 1, at 8. Many individuals do not identify their problems as legal in nature or lack understanding of their legal rights. 13 See id. at 45; Keene et al., supra note 4, at 235-36. In addition, people fail to obtain legal assistance because they face difficulty locating and accessing legal services; perceive the process as overwhelming and requiring too much time and emotional resources; think lawyers would be cost-prohibitive; lack comfort, familiarity, and trust in legal services; feel shame, embarrassment, resignation, or frustration; and/or hold negative views of the legal system more generally—meaning that many of those with the greatest need go without help. 14 See, e.g., Diana Hernández, “Extra Oomph”: Addressing Housing Disparities through Medical Legal Partnership Interventions, 31 Hous. Stud. 871, 878-79 (2016); Rebecca L. Sandefur, The Importance of Doing Nothing: Everyday Problems and Responses of Inaction, in Transforming Lives: Law and Social Process 112, 123-27 (Pascoe Pleasence, Alexy Buck & Nigel J. Balmer eds., 2007). Moreover, many eligible people delay contacting a lawyer, which can have long-term consequences such as missed deadlines, unfavorable settlements, and loss of legal claims. 15 See Marni von Wilpert, Medical-Legal Partnerships in Mississippi: A Model to Improve Access to Justice, 82 Supra 199, 206, 213 (2013).

These barriers also mean that many people with low income often fail to pursue legal assistance before their issues have become more complex and high-stakes, making those cases even more challenging for under-resourced legal services organizations. 16 Id. at 205-06. While this crisis-oriented work is critical, it is costly, inefficient, and limited in its ability to address the needs of many low-income Americans.

MLPs’ guiding principles can help to close the justice gap, both through the expansion of MLPs and through the creation of other partnerships that use the same principles to foster A2J innovation.

A. Community Integration

By placing legal resources in healthcare settings, MLPs lower obstacles to access and capitalize on a convenient, familiar, and regular point of service. Families routinely attend doctors’ appointments, and their established relationships with medical providers can help potential clients feel more comfortable engaging with lawyers. 17 Hernández, supra note 14, at 872; von Wilpert, supra note 15, at 212. A 2020 study found that MLPs reduced barriers to legal information, advice, and assistance by creating an access point for legal resources that was straightforward, affordable, and trustworthy. 18 Keene et al., supra note 4, at 235.

Settings that provide low-barrier and meaningful access to justice are those that are not just community-based but community-integrated in order to facilitate direct engagement with the community and with multiple sectors outside of law. Such settings are not only directly located in under-resourced neighborhoods, but also involve partners who are themselves members of the community or who at a minimum are already providing core community services and have an established track record of building the power of community members. For example, the Georgetown University Health Justice Alliance Law Clinic collaborates with school-based health centers where teens and parents have long sought healthcare, including behavioral health services and educational supports, and where providers have elevated the voices and priorities of youth in the community. 19 See Lisa Kessler, Yael Cannon, Nicole Tuchinda, Ana Caskin, Christina Balz Ndjatou, Vicki W. Girard & Deborah F. Perry, Co-Creating a Legal Check-up in a School-Based Health Center Serving Low-Income Adolescents, 15 Progress Cmty. Health P’ships 203, 204 (2021).

B. Preventive Approaches

Just as primary care doctors practice preventive medicine, MLPs facilitate a preventive version of A2J by training doctors to proactively screen for and identify legal issues among their patients through a “legal check-up” model and then connect their patients to legal assistance. 20 See, e.g., id. at 203. This upstream approach averts entry into harmful situations and systems, including those that perpetuate racial inequities. For example, by addressing legal needs preventively in ways that promote financial stability and connect people to a range of resources, MLPs can keep families out of the family regulation system, students out of the school-to-prison pipeline, and people with low income out of largely lawyerless state courts unsuited to addressing broader social needs. 21 Kara R. Finck, Medical Legal Partnerships and Child Welfare: An Opportunity for Intervention and Reform, 28 Widener Commonwealth L. Rev. 23, 44 (2019); Yael Cannon & Andrew Hsi, Disrupting the Path from Childhood Trauma to Juvenile Justice: An Upstream Health and Justice Approach, 43 Fordham Urb. L.J. 425, 488, 490 (2016); see Colleen F. Shanahan, Jessica K. Steinberg, Alyx Mark & Anna E. Carpenter, The Institutional Mismatch of State Civil Courts, 122 Colum. L. Rev. 1471, 1476-77, 1501-1507 (2022); Anna E. Carpenter, Colleen F. Shanahan, Jessica K. Steinberg & Alyx Mark, Judges in Lawyerless Courts, 110 Geo. L.J. 509, 511-12 (2022).

Moreover, by proactively helping clients understand their problems as legal in nature, the MLP model promotes greater “legal consciousness.” 22 The term “legal consciousness” encapsulates “a person’s attitudes toward, willingness to mobilize, suppositions about, and experiences of the law” and “‘commonsense understanding’ of how the law works.” Kathryne M. Young & Katie R. Billings, Legal Consciousness and Cultural Capital, 54 L. & Soc’y Rev. 33, 34 (2020) (first quoting Kathryne M. Young, Everyone Knows the Game: Legal Consciousness in the Hawaiian Cockfight, 48 L. & Soc’y Rev. 499, 501 (2014); and then quoting Laura Beth Nielsen, License to Harass: Law, Hierarchy, and Offensive Public Speech 7 (2004)). Clients experience increased legal consciousness when MLPs help them understand their legal options, gain the knowledge and tools to support self-advocacy to enforce their own rights, and plan for potential changes over time, rather than waiting for a legal crisis to occur. 23 See, e.g., Diana Hernández, “I’m Gonna Call My Lawyer:” Shifting Legal Consciousness at the Intersection of Inequality, 51 Stud. L., Pol. & Soc’y 95, 109-11 (2010); Morton, supra note 11. These approaches can prevent subsequent legal issues over the long-term, well after the immediate legal assistance has concluded.

C. Interdisciplinary Collaboration

MLPs work interdisciplinarily by bringing together professionals across industries to serve patients. Interdisciplinary collaboration allows for more holistic and effective diagnosis and client-centered problem-solving. Legal issues rarely exist in a vacuum. Often, they are connected to social, health, family support, educational, and other challenges. Addressing those issues concurrently is critical to meeting clients’ needs.

Through MLP collaboration, both lawyers and non-lawyers improve their advocacy for and support of the people they serve. For example, doctors can help attorneys give meaning to the rights of patients and standards in Medicaid law, while attorneys can help doctors appropriately document test results to meet eligibility or treatment standards. 24 MaryBeth Musumeci, Augmenting Advocacy: Giving Voice to the Medical-Legal Partnership Model in Medicaid Proceedings and Beyond, 44 U. Mich. J.L. Reform 857, 897-98 (2011).

Collaborating across disciplines, lawyers and their partners can work with clients to identify and attack the roots of their problems and link clients to an array of legal and non-legal services. 25 See, e.g., Health Justice Agenda, supra note 7, at 58. The MLP approach allows for streamlining and efficient role divisions that are made clear to the client. 26 See Keene et al., supra note 4, at 237.

D. Transformative Reform

MLPs utilize a “patients-to-policy” approach to pursue law and policy change. 27 See, e.g., Megan Sandel, Mark Hansen, Robert Kahn, Ellen Lawton, Edward Paul, Victoria Parker, Samantha Morton & Barry Zuckerman., Medical-Legal Partnerships: Transforming Primary Care by Addressing the Legal Needs of Vulnerable Populations, 29 Health Affs. 1697, 1700 (2010). Through their individual advocacy, MLP lawyers and their healthcare partners listen to the concerns of clients and identify policies and practices that have harmful impacts—and then advocate for long-term systemic solutions, promoting population wellness and structural justice. 28 See, e.g., Story Series Features Teams that Took SDOH Problem-Solving from Patients-to-Policy, Nat’l Ctr. for Med.-Legal P’ship (May 2, 2018), https://perma.cc/VE4F-RXHF.

For example, in advocating for parents whose children experienced lead poisoning as a result of substandard housing conditions, the legal and medical team at the Georgetown University Health Justice Alliance Law Clinic listened to the concerns and outrage of clients around these issues. 29 E.g. Yael Cannon, Equipping the Next Generation of Health Justice Leaders, Bill of Health (Sept. 20, 2021), https://perma.cc/WC44-9VMT (describing how the Clinic listened to the concerns of one client). The team identified a variety of problems with the relevant laws in the District of Columbia, such as the reactive nature of laws that only prompt intervention after a finding of elevated lead levels in a child and a lack of accountability for landlords. 30 Id.; Terrence McCoy, D.C. Council Will Consider Law to Strengthen Prevention of Lead Poisoning in Homes, Wash. Post (Sept. 27, 2018, 5:42 PM EDT), https://perma.cc/4Y5F-HSK6 (“Right now, so many of D.C.’s laws and practices surrounding lead are reactive-the response starts after we’ve found a child who has lead poisoning . . . .” (quoting Anne Cunningham of Children’s Law Center)). In response, the team’s law and medical students advocated at the D.C. Council for legislation to address structural problems and institute prevention and accountability mechanisms lacking in current law. 31 Cannon, supra note 29. Moreover, the team centered the experiences of their clients, not only by telling their stories but by supporting a client in preparing her own testimony before the Council, an approach prioritized by the Health Justice Alliance Law Clinic to elevate clients’ power in pursuit of transformative change. 32 E.g. id.

MLPs increasingly collaborate with clients and grassroots organizations to serve as resource allies and ensure that affected individuals drive health justice agendas. 33 See Elizabeth Tobin Tyler, Aligning Public Health, Health Care, Law and Policy: Medical-Legal Partnership as a Multilevel Response to the Social Determinants of Health, 8 J. Health & Biomedical L. 211, 244 (2012); Valverde, supra note 6, at 579. MLP scholars have also called for an intersectional approach centering structural racism, rather than limiting the scope to poverty, to ensure that A2J interventions are not merely creating repeat clients but rather increasing the collective power of marginalized communities and dismantling racial injustice that legal (and medical) systems have perpetuated. 34 See Medha D. Makhlouf, Towards Racial Justice: The Role of Medical-Legal Partnerships, 50 J.L. Med. & Ethics 117, 120 (2022); Health Justice Agenda, supra note 7, at 73, 80-82.

II. MLP Expansion to Advance Access to Justice

Federal and state governments are increasingly promoting and supporting MLP expansion. As President Biden noted recently, MLPs are “innovative and evidence-based solutions to access to justice.” 35 Memorandum on Restoring the Department of Justice’s Access-to-Justice Function and Reinvigorating the White House Legal Aid Interagency Roundtable, 2021 Daily Comp. Pres. Doc. 420 (May 18, 2021), https://perma.cc/44KA-7TU4. The U.S. Health Resources and Services Administration allows health centers to use federal funds to support patient access to civil legal aid, 36 U.S. Health Res. & Servs. Admin., Service Descriptors for Form 5A: Services Provided 27 (2014), https://perma.cc/DVQ5-ES6D (“Additional enabling/supportive services are beyond any required case management services and support a health center patient’s access to non-medical, social, educational or other related services (e.g., child care, food banks/meals, employment and education counseling, legal services/legal aid).”). and some states have codified processes to certify and fund MLPs. 37 N.Y. Pub. Health Law § 22 (Consol. 2019); Ga. Code Ann. § 31-2-4 (2022). Moreover, recent federal legislation allocated $2 million in funding for MLPs to address health-harming legal needs. 38 Staff of H.R. Comm. on Appropriations, 117th Cong., Consol. Appropriations Act, 2023 Comm. Print of the Comm. on Appropriations U.S. H.R. on H.R. 2617/P.L. 117-328 1954 (Comm. Print 2023); H.R. Rep. No. 117-403, at 208-09 (2023) (recognizing the importance of MLPs and recommending $2,000,000 for MLP grants); Solomon Center, Rep. DeLauro Help Secure Funding for Medical-Legal Partnerships, Yale L. Sch. (Feb. 10, 2023), https:// perma.cc/B3P8-C3LM.

While further study of MLPs is needed to understand and maximize their impact, MLP expansion could signify “a significant shift in vision, resource allocation, and prevention opportunities for the civil legal aid community.” 39 Krishnamurthy et al., supra note 2, at 378-79. For discussion of the need for further study of MLPs, see Keene et al., supra note 4, at 245; Emily A. Benfer, Abbe R. Gluck & Katherine L. Kraschel, Medical-Legal Partnership: Lessons from Five Diverse MLPs in New Haven, Connecticut, 46 J.L. Med. & Ethics 602, 607 (2018); Hazel Genn, When Law is Good for Your Health: Mitigating the Social Determinants of Health through Access to Justice, 72 Current Legal Probs. 159, 192 (2019).

III. Applying MLP Principles to Guide and Strengthen Broader Access to Justice Innovation

Rachel Rossi, Director of the U.S. Department of Justice’s Office for Access to Justice, argues that A2J means much more than access to the courthouse and requires community-based solutions, preventive efforts, work outside of legal systems, and transformational advocacy to reform the laws and legal systems themselves. 40 Rachel Rossi, Director, Off. for Access to Just., Keynote Remarks at the Stanford Law Review Symposium: Access to Justice (Feb. 10, 2023), https://perma.cc/7NE8-XWLV. MLPs provide a mechanism for the realization of these ideals. But, in addition to MLP expansion, MLP principles can also be used to guide A2J innovation more broadly outside of healthcare settings and partnerships. Community integration, preventive approaches, interdisciplinary partnerships, and transformative reform principles should be used as central principles to strengthen future A2J innovation.

A. Community Integration to Strengthen Access to Justice Innovation

Beyond MLP expansion, legal resources should be brought to the people who need them most in settings that they already frequent and trust.

Interdisciplinary partnerships can integrate legal resources into schools, libraries, nursing homes, shelters, food banks, faith centers, veterans service organizations, community centers, barber shops, low-income tax assistance centers, and other settings. 41 See, e.g., The Role of Medical-Legal Partnerships for Socially Vulnerable Older Adults, Nat’l Ctr. for Medical-Legal P’ship & Nat’l Ctr. for Equitable Care for Elders 4-5 (2020), https://perma.cc/F65J-HTWP; Tiffany Penner, Comment, Lawyers in Schools: Navigating the Risks and Rewards of School-Based Medical-Legal Partnerships, 59 Hous. L. Rev. 479, 492-93 (2021); Christine Timko, Emmeline Taylor, Amia Nash, Daniel Blonigan, David Smelson, Jack Tsai & Andrea K. Finlay, National Survey of Legal Clinics Housed by the Department of Veterans Affairs to Inform Partnerships with Health and Community Services, 31 J. Health Care for Poor & Underserved 1440, 1450 (2020). By creating “smart” locations for legal information, advice, and representation, 42 Genn, supra note 39, at 173. people can access legal information and services and other supports in places where trusted relationships already exist. 43 See, e.g., von Wilpert, supra note 15, at 214-215 (describing the “one-stop-shop legal services delivery model”); Health Justice Agenda, supra note 7, at 68 (describing upstream prevention when lawyers engage with community-based partners who already have trusted relationships with members of at-risk populations).

This approach decreases transportation barriers, which is especially important in rural areas, and reduces the need to arrange childcare or take leave from work because people can save time through more streamlined “one-stop shopping.” 44 See, e.g., von Wilpert, supra note 15, at 214-215. The co-location of services also increases access for those facing the greatest barriers to A2J, such as older people and people with disabilities, and can reduce the stigma associated with legal aid 45 Genn, supra note 39, at 185-86. by embedding it with other supports with which people more naturally and regularly interact.

A2J research should determine where prospective clients go for healthcare, school, worship, and other services as a starting point for identifying potential settings and collaborations. 46 See Krishnamurthy et al., supra note 2, at 387 (“[C]ivil legal aid agencies should uniformly and consistently collect the single data point that depicts where clients who seek their services get their health care.”). Legal assistance and resource providers should assess the dimensions of those institutional contexts and look for partners who have trust and established relationships with people who are likely to need legal resources. 47 Tanina Rostain, Techno-Optimism & Access to the Legal System, Daedalus, Winter 2019, at 93, 95 (2019) (describing the success of medical screenings and health information dissemination at barber shops as a result of long-term relationships of trust and the need for legal A2J technologies to have similarly trusted intermediaries.).

B. Preventive Approaches to Strengthen Access to Justice Innovation

In addition to MLP expansion, other A2J innovations should similarly work upstream to prevent legal crises like eviction before they occur.

Proactive screening facilitates identification of legal issues that might not otherwise be detected. Lawyers and non-lawyer partners can then provide assistance prior to any formal legal proceedings. 48 See, e.g., Musumeci, supra note 24, at 893; Health Justice Agenda, supra note 7, at 65. For example, lawyers can engage in advocacy that can address legal needs around public benefits, special education, health insurance, family, immigration, housing, employment, consumer protection, and other issues prior to any formal legal proceeding. For example, by proactively identifying legal issues such as substandard housing conditions, housing discrimination, rental assistance needs, wage and hour claims, and benefits denials, attorneys, legal navigators, and non-legal partners can help stabilize housing and financial security and prevent evictions before they occur. 49 See Kathryn A. Sabbeth, (Under)Enforcement of Poor Tenants’ Rights, 27 Geo. J. on Poverty L. & Pol’y 97, 107-11 (2019). Such early intervention can keep legal problems from becoming more time-consuming and complex for the client and conserve scarce legal resources. 50 Jeffrey Selbin & Mark Del Monte, A Waiting Room of Their Own: The Family Care Network as a Model for Providing Gender-Specific Legal Services to Women with HIV, 5 Duke J. Gender L. & Pol’y 103, 125-26 (1998).

Preventive legal screening can also address multiple unmet legal needs at a given time, which is important because individuals living in poverty often experience two or three legal problems at once. 51 Andrew F. Beck, Melissa D. Klein, Joshua K. Schaffzin, Virginia Tallent, Marcheta Gillam & Robert Kahn, Identifying and Treating a Substandard Housing Cluster Using a Medical-Legal Partnership, 130 Pediatrics 831, 832 (2012). Clients can receive assistance for multiple issues simultaneously or sequentially as they arise, in a departure from traditional “models of legal aid that are focused on the resolution of a single issue and require clients to self-identify legal need.” 52 See, e.g., Keene et al., supra note 4, at 238-39, 243; Beck et al., supra note 51, at 832 (“Given that families living in poverty often experience 2 to 3 unmet legal needs, when patients and families are referred for a single issue ([e.g.], poor quality housing), legal advocates can assist with other issues simultaneously.”).

The MLP model can prevent harmful and costly outcomes like a summons to landlord-tenant court for an eviction or entanglement in the family regulation or juvenile justice systems. A2J models should similarly work to prevent entry into courts and systems that can cause harm and racialized violence to marginalized and minoritized individuals, like the loss of their home, children, financial security, or liberty. 53 See Shanahan et al., supra note 21, at 1475-76 (arguing that state civil courts cause violence due to the mismatch between their institutional design and the social needs of litigants, which can lead to harmful results including government control and violence when these needs go unmet, such as in child welfare matters). Because preventive models thwart costly outcomes in the short- and long-term, including expensive health harms, policymakers may become more motivated to invest in A2J initiatives. 54 See Robin L. Nobleman, Addressing Access to Justice as a Social Determinant of Health, 21 Health L. J. 49, 74 (2014).

C. Interdisciplinary Collaboration to Strengthen Access to Justice Innovation

Beyond MLP expansion, partnerships with other disciplines should broaden the reach of A2J efforts, engaging with non-lawyers and “silo-busting” in the pursuit of justice and well-being for clients.

Through ongoing education, collaboration, and consultations, non-lawyers can be trained to advocate and disseminate legal information to expand A2J. 55 Keene et al., supra note 4, at 244; Krishnamurthy et al., supra note 2, at 381. With a growing focus on the role of non-attorneys like legal navigators, the A2J community can benefit from looking to other sectors, like healthcare, for A2J “extenders.” 56 Ellen M. Lawton & Megan Sandel, Investing in Legal Prevention: Connecting Access to Civil Justice and Healthcare through Medical-Legal Partnership, 35 J. Legal Med. 29, 36 (2014). Beyond MLPs, partnerships like the South Carolina Justice Navigators Network are training social service providers to identify clients’ problems at an early stage, make targeted referrals, and help people access legal information and resources with the support of technological tools. 57 About Us, South Carolina Justice Navigators Network, Geo. L., https://perma.cc/G9SV-QRAZ (archived May 18, 2023). As these models proliferate, lawyers become less siloed and grow their collaborations with non-attorney advocates, resulting in the strengthened collective impact of interdisciplinary teams. Such partnerships across disciplines have the added benefit of reducing reliance on attorneys. 58 See, e.g., Keene et al., supra note 4, at 237, 244.

In addition to co-location, true interdisciplinary collaboration links clients to resources extending beyond the immediate legal issue, such as social services, rental assistance, housing navigation, school supports, financial counseling and other stabilizing services, which can also prevent future legal needs. When practiced by a team that recognizes that meeting legal needs is not just about mere “access” or conflict resolution, interdisciplinary collaboration can promote holistic substantive justice. 59 A common tendency in bar discussions of access to justice is to conflate procedural and substantive justice, and to treat the provision of services as an end in itself . . . . Lawyers also should expand and strengthen relationships with other service providers. Many clients have problems that would benefit from holistic, multidisciplinary approaches . . . . One-stop shopping is particularly beneficial for elderly, rural, and disabled clients who cannot readily shuttle between multiple agencies. Deborah L. Rhode, Whatever Happened to Access to Justice?, 42 Loy. L.A. L. Rev. 869, 872, 899 (2009); Yael Cannon, Closing the Health Justice Gap: Access to Justice in Furtherance of Health Equity, 53 Columbia Hum. Rts. L. Rev. 517, 535-36 (2022) (arguing that access to justice should encompass not just procedural justice but also substantive justice, which cannot be achieved if people are experiencing unmet legal needs that harm their health); see, e.g., Hernández, supra note 14, at 873; Keene et al., supra note 4, at 244.”

D. Transformative Reform Approaches to Strengthen Access to Justice Innovation

In addition to MLP expansion, A2J approaches should facilitate transformative change through advocacy for structural reforms to address the root causes of unmet civil legal needs. 60 See Sandel et al., supra note 27 at 1699 (describing how MLPs promote change outside of healthcare systems by encouraging “the enactment or amendment of laws and regulations to benefit vulnerable populations”). A2J innovations can draw on the MLP patients-to-policy strategy to take a similar “clients-to-policy” approach, 61 Yael Cannon, Unmet Legal Needs as Health Injustice, 56 U. Rich. L. Rev. 801, 807 (2022). building on their individual casework and engaging non-lawyer partners to advocate for policy solutions and obviate the need for future legal representation.

To achieve transformative reform, A2J advocacy cannot singularly focus on getting lawyers to people, but instead must promote the power and agency of the people whom lawyers aim to help. Dina Shek has argued that MLPs should shift away from traditional top-down approaches and toward community-led justice efforts like “community lawyering” and “rebellious lawyering” to challenge institutional racism and shift the balance of knowledge and decision-making toward those most affected by injustice. 62 Dina Shek, Centering Race at the Medical-Legal Partnership in Hawai’I, 10 U. Mia. Race & Soc. Just. L. Rev. 109, 131-133 (2019). Similarly, to achieve transformative reform, community engagement and advocacy to advance racial justice should be central to A2J pursuits and clients—and community members themselves should drive the A2J agenda.

IV. Overcoming Challenges Moving Forward

A2J innovations that embrace these principles are not without challenges. For example, MLPs have had to develop strategies to address ethical considerations related to client privacy and information-sharing that other non-MLP partnerships might similarly encounter. 63 Jessica Mantel & Leah Fowler, The Promises and Perils of Medical Legal Partnerships, Ne. U. L. Rev. Forum (Oct. 15, 2019), https://perma.cc/SL6X-3MFM.

And other community partnerships may experience additional challenges without the advantages of MLPs. Healthcare is a more highly resourced sector than others, 64 See Lawton & Sandel, supra note 56, at 34. and physicians are already trained and skilled at interviewing and screening. 65 See von Wilpert, supra note 15, at 212. In addition, healthcare teams may already have the trust of their patients, 66 See id. and may already be discussing related issues such as nutrition and housing. Moreover, the MLP movement and the growing scholarly framework of health justice have already demonstrated the connections between health and legal needs. 67 See, e.g., Lawton & Sandel, supra note 56, at 34; von Wilpert, supra note 15, at 212; Cannon, supra note 61, at 807. Despite these unique MLP attributes, A2J advocates should explore how other partnerships can use MLP principles to similarly grow into movements drawing on their own strengths. School-based legal services and public library initiatives, for example, provide powerful opportunities for collaboration. 68 See generally Marco A. Murillo, Christine Abagat Liboon & Karen Hunter Quartz, Immigrant Family Legal Clinic: A Case of Integrated Student Supports in a Community School Context, 24 J. Educ. Change 365 (2023) (describing a school-based immigration legal clinic in a high poverty neighborhood connecting families to resources to which they normally would not have access); Public Library Initiative, Legal Servs. Corp., https://perma.cc/M65F-9YEH (archived May 18, 2023) (describing a program that trains public library staff on civil legal information to help connect patrons to services). Although outside of healthcare, such partnerships can serve to advance health justice by addressing legal needs and reforming systems that harm health and drive health inequity.

Even if such partnerships are successfully launched, direct-service A2J efforts alone will never meet the daunting level of need and do not address the underlying structural injustices that lead to civil legal issues in the first place. As Juliet Brodie and Larisa Bowman argue, “lawyers aren’t rent,” 69 See generally Juliet M. Brodie & Larisa G. Bowman, Lawyers Aren’t Rent, 75 Stan. L. Rev. Online (forthcoming 2023) (on file with author). nor are they pathways to homeownership or jobs with a living wage. Doctors, community health workers, and other potential collaborators in the fight for A2J are similarly limited in their individual power and cannot replace comprehensive and radical transformation of unjust systems. To that end, Bowman and Brodie argue that A2J efforts, such as right-to-counsel initiatives in eviction cases, should be paired with efforts towards emergency and long-term rental assistance, as well as more radical reform of a housing market that promotes profit-generating rents. 70 See id. (manuscript at 7-8).

This is where the transformative reform principle of MLPs is critical. Meaningful change must go beyond the singular A2J focus of getting lawyers (or non-lawyers with legal information and resources) to people who need them. The MLP model of a patients-to-policy approach demands a broader A2J “yes and” clients-to-policy approach; legal advocacy to effectuate individual rights should be a springboard for pursuit of systemic reform. 71 See Cannon, supra note 61, at 807. And engaging with grassroots and community organizations, such as tenant-led movements like Cancel the Rent, can effect substantive justice. As A2J efforts pursue a right to counsel, they can also pursue a right to housing and other similar power-shifting reforms. 72 See Brodie & Bowman, supra note 69 (manuscript at 7-8). For attorneys funded by the Legal Services Corporation, such systemic advocacy may necessitate lifting current restrictions on lobbying and law reform efforts and pursuing creative advocacy efforts in the meantime. 73 See Statutory Restrictions on LSC-Funded Programs, Legal Servs. Corp., https://perma.cc/4VNS-ZHVY (archived May 18, 2023); Cannon, supra note 61, at 869-71 (discussing how these restrictions limit the advocacy of legal aid organizations to pursue law reform, but noting that LSC grantees are permitted to provide information about proposed government actions that can promote systemic change, such as Iowa Legal Aid’s surfacing of data and client stories to support eviction prevention policies).

Another current limitation on achieving such ideals is the fact that the civil A2J movement remains largely a conversation among the legal community. Mobilizing lawyers and other interdisciplinary partners in support of community members can bring the fight for A2J outside of the legal field and into the national consciousness. Advocates for criminal justice reform, such as Black Lives Matter, have made great strides in creating a national movement calling for structural change. Civil justice also necessitates building a movement that engages non-lawyers and facilitates a societal shift in legal consciousness. 74 The idea that the civil justice movement needs to look to the criminal justice reform movement’s success in mobilizing, articulating a vision, and creating a movement outside of the legal community came from a discussion among participants at the Stanford Law Review Access to Justice Symposium (Feb. 2023). See also Kathryn A. Sabbeth, Simplicity as Justice, 2018 Wis. L. Rev. 287, 292 (2018) (discussing how attention to the costs of the criminal legal system has led to decriminalization and arguing that “the pressures imposed by systemic costs could inspire consideration of policies that would otherwise never be attempted” and the development of a perception of the high costs of eviction litigation could similarly “put pressure on governments to improve substantive housing laws to promote affordable housing”). Civil A2J advocates must tell the justice gap story to raise awareness of how easy it is for people to lose their homes, jobs, or even children without access to a lawyer or the information and tools needed to exercise their rights. 75 See Morton, supra note 11. That story must make clear that these injustices disproportionately and gravely harm people of color, people living in poverty, and other marginalized and minoritized people. A shared vision of A2J, with support from counternarratives that center the stories of people traditionally relegated to the margins, is necessary to build momentum towards meaningful reform. 76 See Richard Delgado, Storytelling for Oppositionists and Others: A Plea for Narrative, 87 Mich. L. Rev. 2411, 2412-15 (1989); Yael Cannon & Nicole Tuchinda, Critical Perspectives to Advance Educational Equity and Health Justice, 50 J.L. Med. & Ethics 776, 778 (2022); Health Justice Agenda, supra note 7, at 77.

With so much work to be done, how can the A2J movement drive innovations that are more community-integrated, preventive, interdisciplinary, and transformative? Creating a pipeline of lawyers and other professionals poised for such collaboration is critical. Academic MLPs, which are situated in universities, engage in research to explore these questions and train aspiring lawyers, doctors, social workers, and other professionals to partner across disciplines to address injustice. 77 See Vicki W. Girard, Deborah F. Perry, Lisa P. Kessler, Yael Cannon, Prashasti Bhatnagar & Jessica Roth, The Academic Medical-Legal Partnership: Training the Next Generation of Health and Legal Professionals to Work Together to Advance Health Justice, Nat’l Ctr. for Med.-Legal P’ship, 15-21 (2022). When law, medical, nursing, social work, and other students learn to integrate their services into the community; to problem-solve interprofessionally, preventively, and collaboratively; and to engage in advocacy for structural reform that promotes the power of the people they serve, those students will effect transformative change and advance justice. 78 See, e.g., Healton et al., supra note 6, at 1880; Elizabeth Tobin Tyler, Allies Not Adversaries: Teaching Collaboration to the Next Generation of Doctors and Lawyers to Address Social Inequality, 11 J. Health Care L. & Pol’y 249, 266-67 (2008).

Training the next generation of A2J leaders to implement the guiding principles of MLPs—both through MLP development and the creation of other A2J partnerships—can create leaders poised to close the justice gap.

*Yael Zakai Cannon, JD, Associate Professor and Director, Health Justice Alliance Law Clinic, Georgetown University Law Center. The author thanks Bethany Hamilton, James Teufel, Erin Daksha-Talati Paquette, David Studdert, Tanina Rostain, Neel Sukhatme, Rebecca Johnson, Llezlie Green Coleman, Vicki Girard, and Marta Beresin for their valuable feedback, as well as the staff of the Stanford Law Review for their excellent editorial skills. The author also thanks Sierra Campbell and Samantha Rudelich for their exemplary research assistance.