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2 Meet the Authors Joel Teitelbaum, JD, LLM Sara Wilensky, PhD, JDAssociate Professor and Director of the Hirsh Health Law and Policy Program, Department of Health Policy & Management, Milken Institute School of Public Health, The George Washington University Sara Wilensky, PhD, JD Special Services Faculty for Undergraduate Education, Department of Health Policy & Management, Milken Institute School of Public Health, The George Washington University

3 Good Health Requires More Than Good Medical Care

4 Spending In the U.S. States with higher ratios of social and public health spending to Medicaid and Medicare spending have better health outcomes.

5 Non-clinical Resources and Services That Affect HealthAccording to the U.S. Health Resources and Services Administration (HRSA), enabling services are defined as “non- clinical services that aim to increase access to healthcare and improve health outcomes” and include services such as case management, referrals, translation/interpretation, transportation, eligibility assistance, health education, environmental health risk reduction, health literacy, and outreach.

6 Law is a Social Determinant of HealthLaw can be used to design/perpetuate social conditions that can have terrible physical, mental, and emotional effects on individuals and populations Law can be a mechanism through which behaviors and prejudices are transformed into distributions of relative well- being among populations (cont.)

7 Law is a Social Determinant of Health (cont.)Law can be determinative of health through their under- enforcement Law can be used to structure direct responses to health- harming social needs that result from things like impoverishment, illness, market failure, and individual behavior that harms others Laws can be interpreted in ways that can help or hinder health.

8 Making the Connection: A Matter of SemanticsCommon Civil Legal Problem Social Determinant of Health Families wrongfully denied food supports or housing subsidies Lack of basic resources Children living in housing with mold or rodents, in violation of housing laws Physical environment Seniors wrongfully denied long-term care coverage Lack of access to insurance

9 Making the Connection: A Matter of Civil Legal Aid PracticeTop 3 service areas of Legal Services Corporation (LSC)-funded legal practice: Family law: 33% Housing: 27% Income maintenance: 12% Total: 72%

10 Why Do People Need Civil Legal Aid?Civil Legal Aid Helps People Solve Legal Problems of Everyday Life Legal Needs That Impact Health (I-HELP Model) Income & Insurance Housing & Energy Education & Employment Legal Status Personal & Family Stability Insurance access & benefits Food stamps Disability benefits Social Security benefits Debt relief Shelter access Access to housing Sanitary housing conditions Utilities access Americans with Disabilities Act compliance Discrimination Individuals with Disabilities in Education Act compliance Unlawful termination Immigration asylum, Violence Against Women Act Criminal record issues Guardianship, custody, divorce Domestic violence Child abuse & neglect Advance directives, estate planning

11 Under the Law, Legal Assistance Now IS Viewed as an “Enabling Service”In 2014, the Health Resources and Services Administration (HRSA) — part of the U.S. Department of Health and Human Services — modified its funding eligibility rules to allow health centers to use federal “enabling services” funds to pay for on-site civil legal aid to help meet the primary care needs of the population and communities they serve.

12 Who Needs Civil Legal Aid?Huge Population of Low-income People With Unmet Civil Legal Needs Legal aid provides otherwise unaffordable legal services The Need The Services 1 in 6 live people live in poverty Every low income person has 2-3 unmet civil legal needs that negatively affect their health There is no guarantee to legal services in civil matters Legal aid primarily serves people who live in households with annual incomes at or below 125% of the federal poverty guidelines 65M qualified for legal aid in 2014 Legal Aid Legal Need

13 There Isn’t Enough in the Legal Aid Pharmacy Without Changing How Legal Care is Provided.8,000 civil legal aid attorneys in U.S. with a $600 million budget & help from law schools & pro bono partners try to serve 65 million low-income people with 2-3 needs. They are able to meet less than 20% of the need each year, and unfair, unhealthy systems go unchanged.

14 Integrating Civil Legal Aid as Part of Quality Health CareMedical-legal partnership embeds lawyers alongside health care teams to improve both individual and population health.

15 The Medical-Legal Partnership ApproachTRAIN & IDENTIFY NEED TREAT PATIENTS TRANSFORM CLINIC PRACTICE IMPROVE POPULATION HEALTH Individual patient interventions are pathways to finding policy interventions for improving population health.

16 Impact of Treating Legal Problems With MLPPeople with chronic illnesses are admitted to the hospital less frequently. People more commonly take their medications as prescribed. People report less stress. Less money is spent on health care services for the people who would otherwise frequently go to the hospital. Clinical services are more frequently reimbursed by public and private payers.

17 Class Exercises – Choose a PurposeSet the mood/attention grabbers Explain content Critical analysis Writing skills

18 Set the Mood/Attention GrabbersGoal: Get your students present and focused for class Examples Quick oral or written discussion question Start class with overall themes/question, 5 min to respond in writing Quick small group discussion Ungraded quiz – with or without answers Sample quick questions Have them read an article for home (50 state survey of voters) and start with one interesting fact from article Insurance – have them relay one experience they have had dealing with health insurance Econ – why are we studying econ in a health policy class Uninsured – Kasier quiz – do on-line or on paper and discuss answers as they come up in class lecture/discussion

19 Explain Content Goal: Ways to convey or reinforce information beyond lecturing and class discussion Examples Budget exercise Large group discussion of federal gov’t spending areas Small group research/discussion of current spending breakdown interactive/2010/11/13/ weekinreview/deficits-graphic. html?_r=0 Student group lectures with professor input Oral or written questions to explain connections across several classes Example for #2 – health reform, split students into individual mandate, employer mandate, state exchanges, EHB, public health provisions, student provide several key points, professor amplifies/corrects as needed Example for #3 – first three classes on Finance, Access, Quality. At end of quality class use providing care to vulnerable populations as an example of how all three areas intersect.

20 Critical Analysis Goal: Practice/improve critical analysis skillsExamples All in-class stakeholder exercise Provide fact pattern Provide stakeholders Give time to research in class What tools are available to your stakeholder? What is the key message your stakeholder wants to convey? What has your stakeholder done regarding this issue? Students present findings from research Class discussion

21 Critical Analysis: All In-class Stakeholder Exercise - MylanMylan, a pharmaceutical company based in Pennsylvania, has been rushing to counter a firestorm of criticism over its pricing of lifesaving EpiPens. EpiPen, whose list price has climbed nearly 550% over eight years, dominates the more than $1 billion market to treat serious allergic reactions. A backlash over Mylan’s pricing tactics is growing. Politicians, physicians and lawmakers have criticized the price of EpiPen. Since acquiring the rights to sell EpiPen in late 2007, Mylan has increased the list price of a pack of two to $

22 Critical Analysis: All In-class Stakeholder Exercise - MylanMylan, the pharmaceutical company Jason Chaffetz (R-Utah) and Rep. Elijah Cummings (D-Md.), Chair and Ranking member of the House Oversight and Government Reform Committee Allergykids Foundation, an organization that has been increasing awareness about the skyrocketing costs of epipens Allergy & Asthma Foundation of America, a patient advocacy group that has taken funding from Mylan in the past and is listed as an “ally” by Mylan Pharma, the trade association representing Pharma companies Senator Chuck Grassley (R-Iowa), who chairs the Senate Judiciary Committee Hillary Clinton, Presidential candidate

23 Critical Analysis ExamplesHomework/in-class combined stakeholder exercise In class: provide background information/lecture, split into stakeholder groups Homework: individuals research stakeholder position In class: small group discussion to come up with a stakeholder position, small group develop 2 min “elevator speech” that includes clear policy position/proposal and key points/evidence, one member of group gives speech Class discussion on clarity and persuasion of speech

24 Critical Analysis: Homework/In-class Combined Stakeholder Analysis – State ExchangePolicy issue: how to improve state exchanges in ACA Stakeholders Insurance companies States Exchange users Providers American public/taxpayer Hillary Clinton, presidential candidate Donald Trump, presidential candidate

25 Writing Skills Goal: Practice/improve writing skills with a focus on precision and clarity (often also involves critical analysis skills) Examples Descriptive Table Discuss purpose/how to create a descriptive table Provide three pieces of legislation to compare Homework: individuals create descriptive table In class: view various descriptive tables, identify similarities and differences, discuss which tables are most effective and why Descriptive Table example: Right to Try Act – ID HB 481 (passed), HI HB 1013 (failed), DE S 38 (pending)

26 Writing Skills Examples Leave Behind DocumentsDiscuss purpose of “leave behind” documents Information provided to policymakers to support advocate’s position Features of good leave behind documents Identify the advocate Identify the issue Provide key information to understand the proposed policy/bill Provide key policy points, especially why that policymaker should care Include a specific ask, what do you want the policymaker to do? Should be easy to follow and visually pleasing

27 Writing Skills – Leave Behind DocumentsHomework: individuals create a leave behind document for bill included in or similar to the ones used for descriptive table In class: split into small groups, join efforts to create one group leave behind documents by taking best from each individual effort In class: review group leave behind document, discuss which ones are more effective and persuasive Right to Try example, students create a leave behind document for a fictional state considering Right to Try legislation, could make it more targeted to real state, real stakeholders

28 Writing Skills Examples EditorialsIn class: lecture on editorial topic and purpose/how to write an editorial editorial.html Topic example: Should states expand Medicaid under ACA? In class: split class so half the class writes in support of one view and half writes in support of the opposite view Homework: individuals write editorials

29 Writing Skills – EditorialsIn class: small group peer review Read each other’s editorials and provide feedback based on peer review questions Does the editorial have a catchy title? Is point of view in editorial clearly explained at the beginning? Does the editorial provide convincing evidence to support its point of view ?(I ask students to provide cites even though editorials usually do not have citations) Does the editorial counter expected arguments from opposing side? Is the writing clear, concise, and interesting?

30 Writing Skills – EditorialsIn class: After peer-review, group discussion on both substance of the issue and what they learned in the peer review process about writing persuasive editorials Homework: revise editorial and include commentary about what/why made specific revisions

31 Live Q&A Session Voice Your Question: Type Your Question: Press *1Follow the prompt to record your name The operator will open your line, in turn Type Your Question: Use the chat or Q&A box feature in the lower right-hand side of your screen

32 Essentials of Health Policy and Law, Third EditionVisit go.jblearning.com/Teitelbaum3 to: Request a complimentary instructor’s copy Download sample chapters Request access to instructor materials Includes a comprehensive eBook, chapter quizzes, and pre-loaded assessments.

33 Thank you for participating!Sophie Teague Recorded webinar will be posted on the LinkedIn Public Health Faculty Lounge