There’s a little bit of regional variation to certain legal needs. So for instance getting shut off for electricity doesn’t seem to be as big a deal in California because it’s more temperate … it’s some- thing that regularly happens that people have no lights on but the general feeling when I talk to medical-legal partnerships in the Bay Area for instance is that that is not a legal issue that they want to take on. They’d rather take on mold in housing. Mold in housing to them is the biggest deal. And so I do think that some of it is, it could be the temperature variations or the cost of hous- ing is much more significant in the North East and therefore you may have more people making those tough trade-offs between rent and eating, things like that.
… the bigger deal for me is not the geographic variations but the population variations. So for instance elders have a much different legal profile than kids do. Or teenagers have a much different
legal need profile than the average little kid does. And someone who’s getting out of prison has a huge one or someone who is an IV drug user, and so to me some of it is about identifying those high-risk populations within your country and designing an MLP that will have the maximal impact.
… for me as a pediatrician I would say that most MLPs should be in geriatrics, like that’s where the biggest cost is. Those are the people that use the most healthcare dollars that I think could be avoidable if we just got the right kind of legal profile that allows them to stay in their homes versus having to move into a nursing home; that allows them to make a decision or design their proxy so that they weren’t in the ICU for two weeks before they died because that’s not what they actually wanted. And just those smaller tweaks is where you make the huge potential benefits.
Randye Retkin, Attorney and Director of LegalHealth – New York Legal Assistance Group:
[T]here are definitely communities throughout the city that have problems with asthma more so than other communities … this is New York so to say ‘Is sickle cell an issue?’ – I mean we could find sickle cell if we looked for it, we could find more asthma cases. For example, we focus a lot on cancer cases. About one fourth of our cases are people with cancer. Is there more cancer in New York? No, it’s just a bigger city and I’m sure diagnoses are fairly similar to most big cities. It’s really what you choose to target … we could focus on diabetes, that’s a huge problem in New York … I wouldn’t say that there’s more of anything, it’s all here.
Liz Tobin Tyler, Attorney and Legal Academic, Roger Williams University School of Law:
I think poverty is relatively similar across the States … That being said there are different state laws and there are different enforcement mechanisms in different communities, so the extent to which those things impact health can be different based on the community you’re in. … I’ll just give you a comparison between Massachusetts and Rhode Island on housing. So in Rhode Island we are still fighting the battle of getting our housing code enforcement office agencies to cite lead hazards as a violation of the housing code. For years they said there’s a separate organization, that’s the Rhode Island Department of Health, that inspects for lead and the Rhode Island Department of Health only inspects for lead after a child is poisoned, because they focus on health, not on hous- ing. This is the way we structure our system so the housing code office would say ‘If there’s a lead problem, it’s their problem,’ right, but we only do it after a child is poisoned … We kept saying to the housing code office ‘Well, chipping and peeling paint is a housing code violation, why can’t you cite that?’ ‘Well we can cite that but we can’t say it’s lead paint because we are not lead inspectors.’ With [the MLP’s] help and with the local organization called the Childhood Lead Action Project and the fact that I told them that we could sue them for not doing what they’re supposed to do under the law because in fact there is a piece of the housing code that says that … they are sup- posed to find an inspector to go and investigate if they suspect lead … of course they weren’t doing that so I finally said to them okay you have violated the law, we can sue you. Then they started to pay a little more attention so we finally have gotten to a place where they were now, because we do have a relatively strong law that says that landlords must maintain their property so it’s lead safe and they have to have a certificate to prove that, they now cite those properties if they don’t have a certificate, which is something … So that’s in Rhode Island … In Massachusetts for years they’ve been citing landlords for lead and they have a comprehensive integrated housing court that deals with both eviction issues and housing conditions in the same place, so they have a much better response and the judges are much more willing to respond to housing conditions problems in Massachusetts than they are in Rhode Island … [M]y point is the problems are the same but the responses can be quite different. … [N]obody’s done a study of this but I suspect you could poten- tially see different health outcomes based on the different enforcement mechanisms and responses based on where you are.
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