Lack of rural lawyers harms people’s health

MIDDLETON, WI - NOVEMBER 19: Wind turbines rise up above farmland on the outskirts of the state capital on November 19, 2013 near Middleton, Wisconsin. A bill that would make it easier for residents living near power generating wind turbines to sue for any perceived negative impacts to their health and property values goes before the Wisconsin legislature on Wednesday. Critics believe the bill (SB167) could kill the wind energy business in Wisconsin. (Photo by Scott Olson/Getty Images)

In Polk County, patients without insurance often come into the care of the county’s public health or social services departments. When that’s the case, the county is able to connect those people with ABC for Health, a nonprofit law firm that helps people gain healthcare access. 

The organization, based in Madison, has a branch in Polk County. That branch, and its partnership with the public health department, allow people in the area to get healthcare they otherwise wouldn’t have access to, according to Mike Rust, the chief operating officer for ABC for Rural Health. 

Just this year, Rust was called to help the family of an immigrant who was having a medical crisis. The woman’s medical bills were stacking up after a number of emergency visits, Rust says. The family had even borrowed money to pay its bills. 

With the help of ABC, the woman was able to retroactively get Medicaid coverage dating to March 1, which covered an emergency that required an $8,000 loan. The woman was also able to keep her coverage which helps with her ongoing medical needs. 

Another uninsured client this year had a visit with the public health department on a Thursday. The client, a diabetic, was running out of insulin, Rust says. 

The health department called ABC. The man was able to get presumptively approved for Medicaid by the local hospital, schedule a doctor’s appointment and get his insulin by Friday afternoon. 

If ABC had gone through the normal routes for  gaining Medicaid coverage, the man would have run out of insulin over the weekend. 

“While the doctor would see him, the pharmacy wasn’t going to give him the insulin without him paying for it, but by utilizing our experience, we knew there’s a back door to this,” Rust says. “We can use presumptive eligibility through the hospital and get him insulin before he gets out of the clinic.” 

ABC only covers Polk County and parts of the surrounding area. Without the organization’s advocacy, the immigrant family would still be in debt and the diabetic man could have had a serious medical crisis. 

The effects on healthcare access when legal services aren‘t available is the topic of an article published this month by Michele Statz and Paula Termuhlen, professors at the University of Minnesota, Duluth Medical School. The research in the article is largely based on rural areas in Northern Minnesota and Northern Wisconsin. 

The article, “Rural Legal Deserts Are a Critical Health Determinant” states that the most common type of legal problem for poor rural residents is healthcare access. What is not as obvious is that not having access to lawyers and legal services ultimately harms the health of people in these communities.

“It doesn’t take much to think about how if you don’t have housing security or you’re experiencing intimate partner violence and you don’t have access to legal representation, those physical and mental health needs are exacerbated,” Statz tells the Wisconsin Examiner. 

But increasingly, there are fewer lawyers practicing in rural areas and even fewer that have the expertise and partnerships to navigate the health needs of the community. Often civil lawyers in these places focus on family or housing law, and ABC for Rural Health is in just one of the state’s 72 counties. 

“Despite meaningful attention to social and structural determinants of health — many of which are intrinsically legal — and to physician–attorney collaboration, there has so far been little, if any, formal recognition of this unique rural disparity among public health researchers,” the article states. “This is surprising, given that the same U.S. regions experiencing hospital closures and physician shortages, often characterized as rural health care deserts, are largely also classified as rural legal deserts.”

There’s a strong body of research on medical-legal partnerships, and a body of research on the justice gap in rural areas, Statz says. The problem, she says, is that the research too often focuses on just urban areas or just the criminal-legal system — when civil law needs in rural areas are desperately lacking. 

Three quarters of low-income rural residents experience at least one civil legal problem in a year, according to the Legal Services Corporation. Only 14% of rural individuals receive assistance for their civil legal problems. Most of those problems involve healthcare access. 

“There’s a pretty strong literature on medical-legal partnerships; the problem is they focus almost exclusively on urban contexts,” Statz, a Wisconsin native, says. “One thing that has been phenomenally frustrating to me is that overwhelmingly … access to healthcare or issues involving health insurance or medical benefits, [are] identified as the top legal needs among rural community members.”

Like most other disparities, this one has only been deepened by the COVID-19 pandemic. Rural areas have older populations that are more susceptible to the virus and less reliable internet service prevents telehealth access while also making it more difficult to see a lawyer remotely. 

Statz’s article finds that rural legal deserts ultimately have a cost to the community. Rust says that Polk County’s behavioral health clinic was able to increase revenue by $100,000 just by helping patients get healthcare coverage. 

ABC, Rust says, was able to reduce the number of uncovered patients at the clinic from 400 to 26. 

The solutions to the wider problem are hard to find. Statz says that there isn’t a silver bullet when it comes to reducing the attorney shortage. 

Community education systems need to be improved so lawyers are more likely to stay in a community and build a family.Statz drew a line from the current rural attorney shortage to the passage of Act 10 in 2011, which she says hurt rural schools, increasing brain drain from rural areas. 

Young lawyers also need affordable housing and a strong community that can hopefully draw them to the area after graduating from law school in metropolitan areas. 

In Wisconsin, most law students get their degrees in Milwaukee, Madison or Minneapolis, how, Statz asks, do small communities convince young lawyers to move there to practice? 

For one rural lawyer in Minnesota, Statz says, the obstacles were more basic than education, housing or even broadband internet access — there was a lack of available office space in the area he practiced in. 

Rust, who isn’t a lawyer, believes some of the services can be provided without putting lawyers in every small town. He’s been trained by lawyers in Madison to provide legal services and help people navigate a complicated system. That, he says, is perhaps a more replicable option. 

“We put people up here who were trained by lawyers to do health benefits counseling,” Rust says. “We have daily case meetings with the team of lawyers. You could expand legal services without expanding the number of lawyers. There are ways to get the impact filled just by making sure an expansion or programming like ours is tied in with legal support that can bring to bear all the things they do.”