Immigrant-focused Medical Legal Partnerships: A Practical Innovation to Improve Immigrant Health and Social Well-being

Abstract

The Problem: Immigration status is an important social determinant of health that can limit access to health care and related services. Few medical legal partnerships (MLPs) address immigration-related legal needs of patients.

Purpose of Article: An immigrant-focused MLP (IMLP) addresses immigration legal needs and provides advice to vulnerable patient-clients and their families regarding potential legal consequences of accessing health care and other public benefits. In this article, we outline the core elements of an IMLP and provide case examples from our ongoing IMLPs.

Key Points: Although many of the core elements of an IMLP are similar to those of an MLP, an IMLP focuses specifically on immigration-related legal needs of patient-clients. IMLPs can complement and extend MLP services by providing legal assistance to non-citizen immigrant individuals and mixed status families.

Conclusions: IMLPs may improve immigrant patient-clients' health and social well-being and create eligibility for public benefits. An IMLP can be a scalable innovation to improve access to health and legal services. Challenges to institutionalizing an IMLP may include limited sustainable funding, few legal service providers with immigration expertise and capacity, patient-client identification, and the politicized nature of immigration.

Medical legal partnerships (MLPs) are collaborative interventions that embed legal service professionals in health care settings to address complex social and legal conditions that contribute to poor population health outcomes and health disparities.^1,2 Medical and legal professionals serve complementary and reinforcing roles in addressing patient well-being.³ In 2007, the American Bar Association formally endorsed the concept of medical-legal partnerships.⁴ Since then, the American Academy of Pediatrics, the American Medical Association, the Association of American Medical Colleges, and the Agency for Healthcare Research and Quality have promoted the MLP model.^5,6 As of April 2021, there were 450 medical-legal partnerships operating across 49 states in the United States,⁶ but the majority of MLPs in the United States serve only citizens and legal immigrants.

Few MLPs address immigration-related legal needs of patients (E. Lawton, January 21, 2020). Often this is due to regulatory constraints associated with funding received through the Legal Services Corporation, which was established by the U.S. Congress to fund civil legal aid for low-income individuals. This funding excludes most immigrant categories (e.g., undocumented, asylum seekers, Deferred Action for Childhood Arrivals, Temporary Protected Status, and most other temporary statuses). The only noncitizen categories such agencies can serve are lawful permanent residents, some temporary workers, and survivors of domestic violence, sexual assault, or human trafficking. However, addressing immigration-related legal needs is vital to improving immigrants' access to health care. In the United States, undocumented immigrants and many authorized immigrants are excluded from federally funded health benefits programs under the 1996 Personal Responsibility and Work Opportunity Reconciliation Act. There is also substantial variation in immigrants' eligibility for state-funded health benefits programs.⁷ Immigrants' poor access to care such as lack of health insurance has been associated with lower likelihood of health care utilization including preventive care, leading to increased risk for undiagnosed diabetes and other diseases.^8–10 In light of the socio-political situation in the United States during the coronavirus disease 2019 pandemic, there is a heightened sense of urgency around increasing access to care by vulnerable populations such as immigrants, and, thus, increased demand for immigration-related legal services.¹¹

An immigrant-focused MLP (IMLP) addresses legal needs that may prevent immigrants from obtaining health care for themselves and their families, such as the legal need of acquiring a form of immigration status that provides access to affordable health care coverage as well as the need for personalized advice on potential immigration consequences, if any, of accepting public benefits for oneself or a family member.

An IMLP can assist eligible immigrant patient-clients in obtaining legal status, which may result in public benefit eligibility (i.e., eligibility for full-scope Medicaid, ability to purchase insurance under the health care exchanges, or access to employer-sponsored insurance). Such eligibility can help ensure financial compensation to health care providers for delivering medical services to immigrant communities that experience high rates of poverty and uninsurance.¹² Moreover, immigrants who qualify for benefits programs after an IMLP intervention may have additional resources to receive preventive health care, thus potentially improving long-term health outcomes.

An IMLP can also advise noncitizen patient-clients on the legal consequences, or lack thereof, of accepting public benefits or social welfare assistance for which they qualify. For example, in 2019, the prior administration enacted changes to the "public charge" rule, a provision of the Immigration and Nationality Act that barred immigrants who were "likely to become primarily dependent on the government for subsistence." The rule change broadened the public charge analysis to consider a wide range of factors, including age, health, education, household income, and having applied for or received a broader group of means-tested public benefits. Because the public charge rule only applied to certain categories of intending immigrants, the actual impact was limited in scope; however, the rule change spawned fear within immigrant communities that resulted in nearly one-third of immigrant families with children avoiding use of public benefits due to concerns about adverse immigration consequences in 2019.¹³ An IMLP can respond to policy changes that adversely affect access to critical public benefits by educating health care professionals about such changes and advising noncitizen patient-clients about any potential risks associated with applying for or receiving benefits based on their particular circumstances.

It is important to note that an IMLP is not in competition with a traditional MLP that may already be established within a health care facility. Instead, an IMLP can complement and extend MLP services by providing legal assistance to non-citizen immigrant individuals and mixed status families—a population and set of services that most traditional MLP programs do not engage with due to funding restrictions. While traditional MLPs are able to serve a narrow group of noncitizen clients, including lawful permanent residents and victims of certain crimes, they typically offer only specialized immigration legal services tailored to these narrow categories such as naturalization or representation in victim-based application types. They generally do not have broad expertise in immigration law or public benefits eligibility for different immigrant classes, as they cannot serve most immigrant categories. Furthermore, if a patient's immigration status cannot be immediately determined (as is frequently the case with indigent or incapacitated patients), general MLPs may be precluded from serving them.

The purpose of this paper is to describe the development of an IMLP, outline the core elements of an IMLP, and provide structure and case examples from our ongoing IMLPs.

DEVELOPMENT OF THE IMLP

In 2015, the University of Nebraska Medical Center (UNMC) College of Public Health hosted a series of dialogues with leaders of community organizations in South Omaha (zip code 68107), a community with a high percentage of foreign-born individuals (32.3%).¹⁴ Leaders noted how the university holds a unique and powerful position to address structural barriers to health and made it clear that more needed to be done to address the needs of undocumented and legally vulnerable individuals. Leaders agreed that the university should be a "leader and a catalyst" to push issues forward. One of the ideas that surfaced was an extension of the MLP to address immigration-related needs.

The faculty member who led these dialogues (A.K.R.) began to discuss the possibility of an IMLP internally with various university committees and initiatives. She hosted a grand rounds presentation on January 20, 2016, about the intersection of immigration law and health care, and Charles "Shane" Ellison, Legal Director/Deputy Executive Director for Justice for Our Neighbors, was the speaker. Since then, the Immigrant Legal Center (ILC), formerly known as Justice for Our Neighbors, a Nebraska-based nonprofit immigration legal service provider, has been able to test the feasibility of the IMLP model with various health care facilities. This paper is the result of a collaboration between UNMC College of Public Health faculty and staff (A.K.R., F.W., and S.A.Q.) and ILC's Legal Director (A.D.). All partners contributed to writing. The UNMC team developed the concept and structure of the manuscript, and ILC's Legal Director drafted sections that required expertise as the partnering immigration legal service provider.

Beginning in 2017, ILC entered into a series of IMLPs to provide legal screening and representation to patients and their family members at three Omaha-area health care facilities: UNMC, an academic medical center with community-based primary care clinics (IMLP established 2019), a federally qualified health center (IMLP established 2017), and a pediatric-focused hospital (IMLP established 2017). Each facility supports the equivalent of one ILC attorney or Department of Justice-accredited legal representative and attendant paralegal and administrative support.

The purpose and motivation for forming and funding an IMLP differed among sites. For example, UNMC and associated clinics were home to two longstanding MLPs with an established institutional champion. There are consistent monthly meetings of all MLP partners, the institutional champion, and associated health care facility staff (i.e., social work leads, institutional legal counsel, and financial office staff) to share information and resources, answer questions, and build institutional support for the program. There are shared goals, measurable outcomes, and processes in place to address issues as they arise. This facility's IMLP was the result of a partnership between the hospital and associated clinics, ILC, and UNMC faculty, which was initially funded by a private foundation as a three-year pilot program that aimed to produce reimbursement to the facility that exceeded the foundation's investment. As part of the pilot, the hospital and clinic staff would identify potential patient-clients and submit a referral to ILC. ILC would review the referral and set up a legal consultation with the patient-client. UNMC faculty were engaged to evaluate both the economic and social return on investment. The IMLP has been integrated into the monthly MLP meetings and has the full support of the institutional champion.

A total of 687 patient-clients have been served through the three IMLPs, thus highlighting a clear need for immigration legal services in these settings. Table 1 highlights the funding source for each partnership and its purpose, number of referrals, resulting legal consultations completed with patient-clients, and cases that have been represented resulting from these IMLPs.

CORE COMPONENTS OF AN IMLP

While the format of each partnership varies, there are several common elements in addition to a formal agreement between a health care institution and legal service providers, which include 1) outreach to facility staff to make them aware of the IMLP services and encourage patient/family referrals, 2) continuing education for facility staff regarding developments in immigration law and policy that may affect their patients, 3) referral of patients/families who disclose a need for immigration legal services, 4) legal consultation with patient/family to screen for immigration options and other legal service needs as well as provide Know Your Rights and safety planning information, 5) extended legal representation of patient-clients, 6) case management to ensure eligible patient-clients access Medicaid and other appropriate benefits, and 7) evaluation and reporting. Below we expand on the core components of each element.

Table 1.

Funding Sources and Purpose, Total Referrals and Consultations, and Previous 2-year Caseloads from IMLP Partnerships

Outreach to Facility Staff and Partners to Stimulate Referrals

Staff in various roles may learn of a patient's need for immigration legal services; therefore, it is critical that they are aware of the IMLP and how to make a referral for services. IMLPs should conduct outreach not only to health care providers, but also to other health care facility staff such as social workers and financial counselors as well as community-based organizations such as churches or immigrant-serving institutions. Within the health care setting, outreach efforts may include identification of departments with a high percentage of presumably undocumented patients; dissemination of printed program materials; and scheduling standard office hours or a "legal service provider in residence" during which a legal service provider (i.e., attorney or accredited legal representative) works out of the health care facility to answer questions staff may have and receive patient referrals in real time.¹⁵

Education and Training for Facility Staff on Immigration-related Issues

IMLPs should provide general education on the U.S. immigration system and issues impacting immigrant communities to health care facility staff. For instance, from 2018 to 2020, ILC's IMLPs addressed concerns related to changes to the "public charge" rule, which barred certain low- and middle-income individuals from qualifying for permanent residency. Rhetoric, misinformation, and uncertainty about the scope of the rule produced fear wherein even immigrant families to whom the rule change did not apply were afraid to accept any form of public assistance, and many families disenrolled their U.S. citizen children from crucial benefits programs for which they qualified such as the Supplemental Nutrition Assistance Program and full-scope Medicaid.^16–18 Although the current administration has withdrawn from the new rule and is not applying it, the response to the 2019 public charge changes exemplifies how IMLPs can help preserve health care and benefit access in the face of specific policy developments. Through educational efforts, the IMLP can help facility staff reduce the anxiety of immigrant patients by providing accurate information on the impact of current and anticipated federal and state policies on their immigration status and eligibility for public assistance programs.

Referral of Patients and Families

A successful IMLP requires patient-client referrals. Referrals may come through different mechanisms depending on the structure of the IMLP within the health care facility. In some cases, a health care staff member such as a social worker or financial counselor may make a referral directly to the IMLP. In other cases, patients or family members may need to contact the IMLP themselves through a hotline or other referral channel. One screening challenge unique to IMLPs is that health care staff generally, and appropriately, do not question patients or their family members as to their immigration status. Therefore, unless patients self-disclose, it may be difficult for health care providers or social workers to identify patients in need of immigration legal assistance. Financial counselors can be an important referral source, as they often become aware of a patient's noncitizen or undocumented status based on the absence of a social security number or a denial of a Medicaid application. The IMLP can educate health care facility staff on ways to sensitively and discretely offer access to immigration legal services without directly questioning the patient or family member's immigration status. Additionally, health care facility staff often underestimate the complexity and specificity of immigration and public benefits law and may ask the IMLP to provide an immediate answer as to a particular patient's status and options; however, without a complete legal consultation and perhaps a Freedom of Information Act request to produce the client's complete records, the IMLP representatives are frequently unable to determine status or eligibility. Therefore, the IMLP must set health care facility staff expectations appropriately with respect to the time and labor required to assess a patient-client's potential legal options.

Legal Consultations

An IMLP attorney or accredited legal representative screens, identifies, and advises the patient and/or their family members on any immigration legal options that exist such as asylum; Special Immigrant Juvenile status, U- or T-Visas for victims of certain crimes or trafficking; statuses that confer temporary protection from deportation such as Temporary Protected Status or Deferred Action for Childhood Arrivals; family-based options; naturalization; or simply a Freedom of Information Act request to determine an individual's immigration history or current status. Where no immediate options exist, or whenever appropriate, IMLPs may provide Know Your Rights information to empower undocumented individuals to protect their rights in interactions with law enforcement and immigration authorities. They may assist in safety planning to help individuals make plans for the care of their property and their loved ones in the event of their detention or deportation. IMLPs can also reassure anxious patient-clients that they can safely receive public benefits for qualifying family members and explain any potential risks involved based on the family's particular circumstances. Where patient-clients are facing labor or employment issues, housing or food insecurity, behavioral health concerns, or other issues beyond immigration legal service needs, the IMLP can make appropriate referrals to services.

Extended Legal Representation

If the IMLP identifies an immigration legal option and determines that the legal service provider has the capacity and necessary expertise to take on the case, the IMLP can enter into a representation agreement with the patient-client and file for the relief identified. Depending on the immigration benefit sought, the extended representation assistance may require anywhere from a few weeks to a few decades. If a patient-client merely needs help obtaining proof of their immigration status from the local immigration office, the IMLP may be able to acquire such documents in a matter of days or weeks. By contrast, a patient-client who is seeking a U-Visa based on their victimization with a qualifying crime may wait approximately 15 years for their visa to be approved and another 4 years to access permanent resident status.

Case Management to Assist in Accessing Benefits

Unfortunately, there are many barriers to accessing lawful immigration status that provides access to benefits, including an immense backlog of cases throughout the immigration system, the inability to obtain employment authorization or a social security number while certain applications are pending, and few immigration options that provide timely access to Medicaid eligibility. Thus, it may take many years for a patient-client to acquire an immigration status that provides access to health care coverage or that realizes reimbursement for the health care provider. Case management services can support patient-clients through the process, helping them to understand the status of their case, expected timeline for processing, and next steps. Moreover, when a patient-client obtains an immigration status that qualifies them for Medicaid, insurance coverage through the exchanges, or employer-sponsored coverage, IMLP staff work with medical social workers to assist the patient-client in accessing coverage. In some states where full-scope Medicaid is obtained, health care providers may be eligible for reimbursement for the 90-day period before eligibility as well as future expenses. Thus, assistance which results in access to full-scope Medicaid is most likely to result in financial compensation for health care providers. Because Medicaid reimbursement rules vary by state, the IMLP should understand the retroactive eligibility waiver rules for the state where reimbursement would be requested.

Evaluation and Reporting

IMLPs should use a combination of qualitative and quantitative methodologies to determine progress toward achieving their organizational goals. Qualitative methodologies may include, for example, follow-up interviews with patient-clients and key health care staff members. Quantitative methodologies may include systematic tracking of client referrals and their eligibility and enrollment in federal and state public benefits programs, tracking of patient-clients' health care utilization and associated reimbursements from payers, follow-up surveys of patient-clients to identify outstanding issues and gauge satisfaction and quality of life, and surveys of health care facility staff to identify education gaps pertaining to immigration issues and opportunities for further engagement and collaboration. If applicable, determining return on investment for funders of IMLP services may also be undertaken. IMLPs should provide periodic reports to health care facilities about the successes, challenges, and outcomes of their work.

Based on our experience, IMLPs may improve immigrant patient-clients' health and social well-being and create eligibility for public benefits. Table 2 highlights some case examples from patient-clients that have been served through our IMLP projects. In one case, IMLP staff were able to obtain an emergency custody order and file an application for Special Immigrant Juvenile status for an acutely ill child, which allowed them to qualify for non-emergency Medicaid. Now, the child can obtain routine dialysis and is eligible for a kidney transplant should it be needed. Both the child and her mother were able to return to live with family, and the mother was able to return to work. In another case, the IMLP filed a Freedom of Information Act request that was used to request a copy of their refugee documentation from the local immigration office, enabling the patient-client to be approved for Medicaid and resulted in $78,000 in reimbursements to the hospital thus far.

Based on the results of traditional MLPs^19,20 and our preliminary data, we anticipate that our IMLP projects will produce improvements in health and social well-being among patient-clients, and they have already demonstrated return on investment (i.e., reimbursement; decrease in uncompensated care) for health care facilities. However, as these projects are relatively new, they are currently being evaluated to assess outputs (e.g., number of referrals, consultations, and extended representation cases) as well as both the short-term (e.g., legal literacy, patient-clients' stress and anxiety) and long-term outcomes (e.g., health status, quality of life, adherence to treatment, satisfaction with care, and financial return on investment).

We believe that an IMLP is an innovation that can be scaled across health care organizations, particularly those that serve a high or increasing percentage of immigrant patients. IMLPs can offer relative advantages to patients and health care facilities such as addressing immigration legal needs of vulnerable patients, reducing the emotional and financial burden of seeking health care while uninsured, recovering reimbursement for provided services, and promoting caring and social equity within the health care system. However, there are several considerations to note. First, scaling this innovation requires that there is a structure and dedicated funding mechanism in place to sustain the IMLP for the long-term. Next, those promoting an IMLP may need to find institutional champions in health care facilities to advocate on their behalf as well as legal service providers with capacity to engage in this work. The IMLP must also be able to identify potential patient-clients and generate sufficient referrals. Finally, partners may need to develop a shared strategic vision for how to discuss an IMLP, in light of the complex and oftentimes highly politicized nature of immigration.

Table 2.

Example Patient-clients, Legal Remedies, and Outcomes from IMLP Services

In conclusion, because immigration legal status is a social determinant of health,²¹ structural approaches for redress are necessary. An IMLP can complement and extend a traditional MLP program and provide critical access to immigration-related legal services, which may be a tipping point for overcoming many structural barriers, various social determinants of health, and changing the trajectory of a patient-client and their family's life. This is especially important and timely given the near and long-term impacts of the coronavirus pandemic on immigrant communities in the United States. Further, an IMLP may assist both health care providers and legal service providers to better understand the issues that immigrant patient-clients face, foster interprofessional collaboration, and reduce barriers and delays to needed services. By institutionalizing an IMLP, we can holistically serve and prioritize the health and social well-being of immigrant patient-clients, an underserved and vulnerable population.