Civil Legal Aid’s Strong Return on Investment

Episode Notes

Transcript

Karen Dale:

It is not a healthcare discussion. It’s a human being discussion, and us humans need as much support as necessary. That’s what makes the difference between people thriving and surviving.

Announcer:

Equal access to justice is a core American value. In each episode of Talk Justice an An LSC Podcast, we’ll explore ways to expand access to justice and illustrate why it is important to the legal community, business government, and the General Public Talk. Justice is sponsored by the Leaders Council of the Legal Services Corporation.

Ron Flagg:

Hello and welcome to Talk Justice. I’m Ron Flagg, president of the Legal Services Corporation and your host for this episode. Today we’ll be talking about the economic impact of legal aid. You’ll hear about a recent analysis of return on investment studies published by LSC. It found that nationally civil legal aid returns an average of $7 for every dollar invested. We’ll also hear about how a legal aid partnership with a Medicaid managed care organization not only supports patient health outcomes, but also improves healthcare system savings. Joining us today are two guests, Karen Dale is market President for AmeriHealth Caritas Medicaid managed care organization in Washington dc. Holly Stevens is Chief Data Officer at LSC. Holly, why don’t we start off with you? Can you tell us about LSC’s recent return on investment brief and the studies that you analyzed?

Holly Stevens :

Absolutely, and thanks for having me on. Ron, the ODGA team recently reviewed 56 statewide return on investment studies of legal aid conducted between 2003 and 2023 covering 39 states. The studies concluded all case types from housing and domestic violence to public benefits and healthcare, and what we found was compelling. As you noted, Ron. On average, every dollar invested in civil legal aid returns about $7 in economic benefits, and that benefit includes direct cost savings, financial recoveries for clients, and broader indirect benefits. But what really stood out to our team was how consistent the findings were. Despite various methodologies, geographies, the case type compositions of the specific states legal aid organizations, the consistency in the findings was a strong signal that legal aid is a smart financial investment.

Ron Flagg:

Holly, you referenced direct and indirect economic benefits that are captured in the studies. Can you elaborate on what those direct and indirect benefits are?

Holly Stevens :

That’s a great question. We don’t want to get too wonky here, right? The direct benefits are probably what people would expect. Things like recovered wages, child support payments, or immediate savings from preventing an eviction or securing additional healthcare coverage. And then there are indirect benefits which are just as powerful. Legal aid can prevent deeper crises that would otherwise strain public systems. So these kinds of indirect benefits are emergency shelter, housing, emergency hospital care, or even foster care. And then we also have ripple effects. When someone keeps their job or stays in their home, they’re better able to contribute to their local economies. They maintain their family stability, they might even reduce their child’s school disruptions or increase attendance. And I think that’s where Karen’s work comes in, right? Looking at these broader health and social outcomes. There’s a real synergy between legal aid and health sectors and other sectors around healthcare to improve patient outcomes.

Ron Flagg:

I’m going to get to Karen in a moment. Holly, I want to ask you one more question. Of course. At LSC, we see legal aid first and foremost as a force for justice, and our mission is to create paths to equal justice for those who cannot afford an attorney. So how is it that you and the data team decided that it was important to do a return on investment analysis and to look at that nationally and think about the economic impact?

Holly Stevens :

Sure. As you said, Ron, LSC, we we’re always focused on the core mission of increasing access to justice and improving legal aid delivery systems. But we’ve also seen these studies come around one by one over the years, and we know that policymakers and funders and even community partners are becoming more savvy and they want to know what’s the impact? What’s the return on investment? Why are my dollars worth it in this area? Why am I spending and donating or investing in legal aid? And so while there’s a number of ways to answer that question, this systematic review was one way to determine that answer. And so it brought together these studies that are often difficult to find or published in various places. And so it gives legal aid organizations a powerful tool to leverage these studies and to leverage the collective understanding across all studies to tell their story to local funders, state legislators, or even potential partners. And healthcare and housing. These studies kind of give them the tools to tell a different story or add to the story that they’re already telling with their work and their client stories.

Ron Flagg:

Well, that’s great, and I think your study is terrific, and I hope our listeners will take a [email protected]. Karen, let’s jump to you. Why don’t you start out by telling our listeners about AmeriHealth Caritas?

Karen Dale:

I’m really pleased to share that AmeriHealth Caritas District of Columbia just celebrated this month, 12 years of serving district residents. Notably, what makes us stand out is that yes, we’re an insurer, but even more than that, we see ourselves as thought leaders, as people who care deeply about our community in a way that ensures their dignity and that they have an equal chance to achieve good health and wellbeing. And we know for that to happen. It’s not just about the healthcare delivery system. It is about all those social factors and circumstances that sometimes affect people differently, right? We talk about healthcare inequities and disparities, and we know that there are parts of our city and people who we serve who due to their economic circumstances, where they live their zip code, they don’t have that equal chance. Our work is deeply embedded in equity by saying that we must work hard and tirelessly with the community we serve to understand what those circumstances are and address them. And so that I think makes us stand out. It gives us our compass, our direction in terms of what we do. And we are privileged at this point to serve 120,000 district residents, and we do mean serve. We see ourselves not as knowing what is better for people than they do, but rather as that partner along their journey to health and wellbeing.

Ron Flagg:

Karen, that’s terrific. I’m gratified to be living in the district and to be in a community that’s so well served. How did AmeriHealth Caritas DC begin its legal aid partnership with Children’s Law Center? How did that arise and what role, if any, did return on investment play with your decision to engage with legal aid

Karen Dale:

In pursuit of that direction that I talked about? We focus on data. We want to understand what is occurring in the health ecosystem, what is occurring. When we look at costs, we say what is occurring that could be causing that? Not in a way to blame the person who might be incurring more costs, but to more deeply understand. And that involves two things. The first is the data, which is what it kind of tells you where to look and what hypotheses you might develop. And then the most important part is understanding the why, and that’s where deep listening comes into play. So we have lots of conversations. We have conversations with the people we serve. We have conversations with stakeholders such as providers and community-based organizations, and they give us this rich input that then gets us to a point of understanding. And we don’t stop at understanding, but we want to keep going.

So as we learn more, we seek to understand more. And so that’s a repeatable approach we utilize. And it was no different in this. So here’s what the data told us. It told us that we had a number of children who we’re going to the emergency room and they were diagnosed with asthma. Many of these children lived in the poorest parts of our city where we know families are living below the poverty line. And so we started kind of making some hypotheses saying, well, if they’re living in poorer places, it is likely that the housing that they’re living in is not conducive, and it may be health harming to their asthma diagnosis. It’s more likely that in some of that older, not maybe as well maintained housing that things like mold mice, roach infestations, et cetera, oftentimes carpeting that is not being cleaned frequently might be exacerbating their asthma.

A curious thing we found was that these children had asthma action plans, and they were following the asthma action plan. These children had all their preventive care or most of their preventive care being addressed. That means they were going to get an annual physical. They were going to the dentist twice a year. So that was puzzling, right? Things are going well with the exception for these frequent visits to the er. And so in talking with stakeholders, we learned about Children’s Law Center and learned more about medical-legal partnerships. And we thought, oh my goodness, having a lawyer as part of the healthcare team makes a difference. There was already at that point, evidence to that. And so what we wanted to do was figure out how best to partner. It was a journey of gathering data, looking at numbers and incidents of ER visits that were not necessary, doing more talking with stakeholders.

But eventually where we landed was that if these families had the legal support to intervene with their landlords so that the health harming housing conditions were addressed, it was highly likely that there would be savings. And to your question about the return on investment, I’ve been in healthcare a really long time, and what I’ve learned is if you start with just a focus on money, you’re missing the opportunity to have a much larger scale impact. And so the most compelling reason for me was to support these families that I wanted them to have an advocate for what their child needed. I wanted to reduce the incidents of things like the child with asthma is going to the ER often, and then if there are any other children in the house, they’re oftentimes going with them so that you’ve got a whole family in the er, which causes a number of things that are not good for children. So probably not everybody got sleep that night that they went to the er. There might be impacts to school attendance, being late to school, missing school altogether, the impact on the caregiver losing time from work, the stress that brings to a parent or caregiver. And so we really wanted to address both the social return on investment and the healthcare financial return on investment. And what we have found through this partnership is that both can be addressed. And Children’s Law Center in our partnership has done an amazing job doing that.

Ron Flagg:

How does the partnership work on the ground?

Karen Dale:

Well, first, I’ll say very well. So any of my members who has a child diagnosed with asthma can be referred to Children’s Law Center. The referral can come from their pediatrician or any other person engaged with them from a care team perspective, which includes my team such as my care managers who might be supporting the family with this child with asthma. So they make the referral to Children’s Law Center. They are functioning as a representative, a legal representative. So the family caregiver must provide consent for them to intervene and represent them. And then Children’s Law Center gets to gathering information to understand what is occurring. Very often. It’s something that the landlord can address, and then the outcome and the payment to them is based on a positive intervention. So whatever the things were that were identified, when they have successfully addressed that, they notify us. And then that’s where we are. We say based on not spending the money unnecessarily for the person to be in the er, the child to be in the er, the whole family, sometimes we share that. So it’s like a shared savings program. We’re sharing with them the savings that we achieve over baseline based on them positively creating a positive outcome from the intervention.

Ron Flagg:

So could you give us examples of how legal AID’S involvement has improved outcomes for patients and led to positive economic impacts for the health system?

Karen Dale:

It’s best? Yes, I can. And it’s best done by sharing a story. So we referred a child to Children’s Law Center, and they provided advocacy. They submitted a demand letter to the landlord because there was wet and moist ceilings. There were doors that failed to close. The exterior front door didn’t lock. So there were some safety concerns as well as the concerns around asthma. One of the things that we’ve learned is that if the air conditioning system or whatever those systems are, whether it’s air conditioning in the summer or heat aren’t working or haven’t been cleaned properly, that can become a problem if the heat isn’t working properly, so the air is too dry, that can be a trigger. And any place outside the domicile that’s also infested with roaches, mice, whatever, things like the laundry room. Parents don’t often leave their children in the apartment depending on their age by themselves.

So if you’re taking your child down to a laundry room, that’s also infested. That can be a trigger. And so after four months of advocacy, the other thing we’ve learned is landlords don’t necessarily, some of them don’t rush to addressing the things unless they are absolutely pushed and forced. The case was successfully resolved and all the things that were on the demand letter that the lawyer representing them were addressed. And so what was wonderful too, that the work being done was lifting a burden from the family to have to go through that because some landlords will threaten families with eviction when they push too hard to get what they rightfully should have as a healthy environment. So the part around the cost avoidance, let’s say this child was going to the ER visits like three times and had also been hospitalized and had several outpatient visits needed more rescue inhalers, more medication, the cost for that could run somewhere around $20,000.

And then after this intervention, when all things were buttoned up and addressed, what we find are things like the number of emergency room visits decrease. So it may go from three to one. Usually there are no hospitalizations that are happening because the medication and all the other things are managing effectively the child’s asthma. And even though we sometimes see more office visits, that’s not a bad thing. That’s better than a hospitalization. And so that net savings is what occurs repeatedly. And we’ve been in this contract since 2019 and we’ve not failed at any point to demonstrate a return on investment, both from the standpoint of finances. And that return has been, on average about $10,000 per positive intervention and outcome. And we’ve seen the social benefit in terms of what the families report, the burden being lifted, the upheaval that occurs in the household no longer happening.

Ron Flagg:

Karen, that’s such a compelling story. And the work you do is tremendously compelling. Holly, Karen has just provided really quite concrete examples of the kinds of return data that go into these studies and that you use. But what sort of limitations are there when it comes to analyzing return on investment that we should keep in mind as we go forward?

Holly Stevens :

Yeah, all studies have limitations. All of the research as you read, there’ll be a limitation section, right? And ROI studies are no different. And the study that we did is no different. One of the things to consider here, as Karen was saying, this study kind of leveraged cost avoidance, what was kind of a trend happening before compared to a trend happening after an intervention, right? And looking at that prevention, the studies in the systematic review leverage a whole bunch of methodologies, cost avoidance, return on investment, economic impact, social return on investments. These all are specific types of studies that also leverage different kinds of methodologies. And those each have their own set of limitations in addition to the period of time of the studies that we looked at in this period of time that a study takes into consideration in terms of the before an intervention and after an intervention, and where it measures that economic impact or the benefits to a child or to their families is important to consider.

And there’s also the rigor of the studies, right? The studies that we looked at and the studies that are being done in other specific areas of law like the one Karen’s speaking about, or the ones that we see in right to counsel and landlord tenant work, the level of rigor and who’s doing the study matters. Also, when the study was done, impacts that level of rigor, the technology that’s available to capture data, to capture the outcomes in a sophisticated way, that what the ability to capture the what that Karen mentioned has changed over time. And so now we could expect that to be easier and to be more sophisticated. And legal aid organizations themselves are sitting on a ton of data that is actually very useful in this way to look at, and that has improved dramatically over time outside of the kind of specific research methodologies, there’s also the ability to just capture these financial returns.

Most studies are focusing on direct and let’s just say more easily measured outcomes, recovered wages or child support, the avoided costs and eviction or reduced emergency room visits. Those are fairly easy to kind of attribute a financial dollar to. But legal aid does so much more than that. And Karen was mentioning this, right? It stabilizes families, not just the child, but the rest of the family. It helps people avoid or prevent long-term crises. And those benefits are harder to quantify, but no less real and no less important. And there’s a concept I think that’s important to think about here that is actually more common in healthcare and social investment work. That’s called a blended value. And that encourages us to look beyond just that financial return and consider the total value created. And it takes into consideration those economic benefits, some of the social benefits we’ve talked about, and even more emotional benefits.

And so when a legal aid attorney helps someone stay housed, it’s not just about the cost avoidance, it’s also that improved health, the improved health of their family, better educational outcomes for kids, and the long-term community stability. Those are blended returns, and they’re the part of the full impact that Legal Aid delivers, even if they don’t show up in a spreadsheet, which much to my dismay. So while the ROI helps us start the conversation, it’s certainly not the only measure of impact. And it’s why combining these studies with on the ground client stories and other pieces of data is so valuable to help stakeholders understand that true value of legal aid.

Ron Flagg:

Karen and Holly, it’s been great hearing from you today. I had like to give each of you a chance to share a final thought about this research or the impact of legal aid. Karen,

Karen Dale:

I wish that everyone understood the value that it’s not a healthcare discussion. It’s a human being discussion and US human need as much support as necessary. That’s what makes the difference between people thriving and surviving surviv. I loved how Holly talked about blended value. That’s how we should always think about creating better outcomes. It’s not so that one entity derives all the value. We want to look around the table and everyone is satisfied that they have contributed in a way that was good for the people being served. And so I’m really happy to have had this opportunity to share with your audience. Don’t let the sharing stop here. We should continue to have these conversations so that more people understand the blended value, why it matters, and how communities can be more uplifted.

Ron Flagg:

Holly, final thoughts?

Holly Stevens :

We often think of legal aid as a standalone service, but as Karen just mentioned, it really compliments other efforts that other sectors are doing to improve efficiency, reduce public costs, and strengthen communities. And so I think I would just emphasize that the strong return on investment supports better outcomes across all systems, healthcare, housing, education, family stability. And I hope this research in our conversation helps policymakers and funders and partners see that legal aid as a partner and as a practical kind of high value investment, and one that contributes to a more effective and coordinator service delivery in a whole bunch of other areas outside of the law.

Ron Flagg:

Thank you, Karen and Holly for joining me to discuss the social and economic return on investment from Legal Aid. Your remarks could not be timelier and more important. And thank you to our listeners for tuning into this episode of Talk Justice. Be sure to subscribe so you don’t miss an episode. Stay well.

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