Author: Sophia Rappazzo

The ‘Elder’ Medical-Legal Partnership and Caregiving from an Interdisciplinary Lens

New frameworks, interdisciplinary collaborations, and models of health care may need to emerge to address the impending “caregiving crisis,” or growing strain on the elder caregiving workforce with our aging population. The medical-legal partnership (MLP) model is one potential approach in addressing elder well-being, health, and the caregiving crisis. Medical legal partnerships are an established interdisciplinary framework, combining the legal and medical worlds to holistically serve a population’s needs. Within MLP clinical sites, attorneys are placed directly onsite to work with healthcare providers in identifying and remedying health-harming legal needs.

The model is based on the understanding that health issues are seldom solvable by addressing medical needs. For instance, an elder patient and their caregiver may need assistance in accessing incapacity plans or safe housing for an elder at risk for falls at home. By utilizing the MLP model, clinics can assist older adults and caregivers in navigating the multidimensional, overlapping legal and health issues that elders face, potentially reducing some of the burden on the caregiving population. Addressing common elder issues in one clinic with the expertise of two professions can help streamline access to other resources like public benefits, support the dignity and autonomy of elders, and address a variety of unmet financial, housing and legal needs. The MLP can also assist with the fact that elders have specific barriers to legal and healthcare related to mobility, transportation, and isolation by acting as a “one stop shop” for holistic support. Contributors to elder law also point out that medical providers and attorneys are well-positioned to collaborate so that providers can identify elder abuse.

While MLPs have become increasingly popular, they have scarcely been tailored to elder populations. The Medical-Legal Partnership for Seniors (MLPS) in San-Francisco, a law school clinic that trains medical providers on the legal needs of elders, is one example of an MLP tailored to the elder populations. But for the most part, MLPs have been utilized at the pediatric level where pediatricians are trained to identify the causes of their patient’s health conditions, which often stem from social determinants of health (SDOH) like poor housing conditions. Research has suggested that SDOHs are more important to individual health than genetic predisposition, where SDOHs such as socioeconomic resources, working conditions, housing, environment, race, and gender may be “fundamental causes” of health outcomes. These same SDOHs shape elder health, independence, and overall wellbeing, where intersecting factors and elder social identities may compound poor legal and health outcomes for elders. For example, a low income, older woman of color experiencing housing instability may face intersecting barriers that healthcare nor legal interventions alone can adequately address. Recognizing this, MLP interventions should be multi-pronged to address underlying social factors like structural racism and critically assess their own role in reinforcing systemic inequities. Elders are not a monolithic group, and ‘non-essentializing’ this population is critical in delivering equitable care.

Overall, the MLP framework could be more widely utilized to benefit the elder population and promote their health and justice. Having stronger societal supports like numerous MLPs tailored to elder needs may furthermore assist incrementally in the caregiving crisis, given that elder issues are only becoming increasingly relevant as our population continues to age. The MLP model thus may be a promising method to expand on caregiver and elder supports in the United States.

The Need to Improve and Enforce Digital Accessibility for Telehealth Patients

Telehealth, health care through technological services, has been an increasingly used form of care since the COVID-19 pandemic when digital health care became increasingly necessary to limit in-person interactions. Telehealth is conducted completely online and, therefore, has the potential to be revolutionary for disabled folks who would benefit from the convenience of a digital platform. The digital aspect of telehealth would allow patients to avoid barriers to accessibility that come with in-person appointments, such as issues like transportation and mobility or the need to avoid potential exposure to communicable diseases.

While patients could avoid the barriers to in-person care through telehealth, telehealth has proven to come with digital barriers of its own, largely stemming from a lack of digital accessibility. Telehealth, in theory, would expand access to health care for disabled individuals. In practice, telehealth has not realized its potential because of the inequities associated with online access, such as website inaccessibility. This has resulted in an increasingly inequitable healthcare landscape, where disabled people continue to bear the brunt of systemic inaccessibility. The health care costs are higher for disabled folks with intersecting identities, whereas disabled Black and Latino folks are more likely to suffer from poor health outcomes.

Telehealth is usually inaccessible for several reasons that the Department of Justice (DOJ) has outlined, including poor color contrast, use of color alone to give information, lack of text alternatives on images, no video captions, inaccessible online forms, and mouse-only navigation. In an age where access to information and health services is a health determinant, inaccessible internet access is unacceptable. Digital accessibility is a civil rights issue.

While the Americans with Disabilities Act (ADA) does not explicitly discuss digital accessibility, courts have interpreted Title II of the ADA, a section on discrimination based on disability by state and local governments, to include protecting digital accessibility. This precedent supports protecting digital accessibility for government healthcare agencies. Despite this precedent, legislative action should establish enforceable website accessibility requirements under Title II.

Title III of the ADA, which discusses private businesses and public accommodations, is less resolved when it comes to its protections on website accessibility, creating a lack of uniform protections. Some courts have held that telehealth platforms are places of accommodation, meaning that they fall under ADA requirements of protection, but others have found that they do not qualify. Protections for disabled folks are therefore different by location and private telehealth services can have digital accessibility barriers without consequence. Because Title III lacks enforceable digital accessibility standards, these barriers remain unaddressed.

Given that telehealth is an increasingly relevant mode of healthcare, we should advocate for improved access to its services for everyone by enshrining digital accessibility into the ADA. The exclusion of disabled folks through digital barriers is unacceptable when they are a group that could benefit the most from its benefits. Disabled folks already disproportionately receive less health care because many are disproportionately below the poverty line, making payment impossible, and face issues with accessible in-person services, transportation, and communication. Making healthcare access more difficult by not improving accessibility in all spaces, including digital spaces, leads to more negative outcomes for disabled people, especially for disabled people with intersecting identities. Without stronger enforcement of compliance with digital accessibility guidelines, disabled patients will continue to face digital barriers to healthcare.