Episode 5: How Law Can Make a Difference in Health Outcomes

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RISA GOLUBOFF: Hello, and welcome to Common Law, a podcast from the University of Virginia School of Law. I'm Risa Goluboff, dean of the law school.

LESLIE KENDRICK: And I'm Leslie Kendrick, the vice dean.

RISA GOLUBOFF: So one of our themes for this podcast is that law is everywhere, and part of that is that law ends up in somewhat surprising places sometimes. So we're going to talk, today, about how law is actually in the doctor's office with us. We often think about our own health as something we control to a large extent. We control what we eat, and how we exercise, and we think about our health and our wellness as things that are internal to us.

But in fact, as you walk into the doctor's office, you bring with you where you live, what kind of food you have access to, the kind of pollutants you find in your neighborhood. And people walk into the doctor's office very differently situated with regard to those things, and often very differently situated across race, and across class, socioeconomic status, educational status.

And that means we can't all be fixed in the doctor's office, because medical problems are, in part, social problems. Social problems that can, and should, be addressed by law. So we're going to zoom out from the doctor's office today and think about the structural inequalities and the structural determinants of health and health care that are with us all in the doctor's office, whether we're aware of it or not.

LESLIE KENDRICK: That's right. And that means that doctors and lawyers who-- I think there's kind of an old saw that they have a kind of oppositional relationship and they don't like each other and they don't get along. But the fact of the matter is that doctors and lawyers can work together to address some of the underlying causes of health care issues in our society. And that's something that you can call a medical-legal partnership.

RISA GOLUBOFF: Medical-legal partnership. Yeah, we have one right here at the University of Virginia and there are several hundred all around the country. And they are really trying to tackle public health problems, as well as individual health problems, by going back to the source and not looking at individual medical issues on an individual basis, but asking where do they come from, how do they get produced, and importantly for us, how does law help structure how people live and what their health care looks like.

LESLIE KENDRICK: That's right. So medical care isn't just a matter of the prescription pad, it's also about addressing the underlying causes of illness. And here to talk to us about that today is our friend and colleague Dayna Bowen Matthew. She's a graduate of the University of Virginia School of Law, and now, I'm delighted to say, a member of our faculty.

She's the author of Just Medicine, A Cure for Racial Inequality in American Health Care, and she's an expert in issues in health care delivery, health care disparities, and, in particular, medical-legal partnerships. Dayna, it's a pleasure to have you on the show with us. Thank you for being here.

DAYNA BOWEN MATTHEW: Really glad to be here.

RISA GOLUBOFF: So your expertise comes from so many different directions. You've had substantial experience in policy work in both Congress and at the federal agency level, you studied economics at Harvard as an undergraduate before receiving your JD here at the University of Virginia Law School.

DAYNA BOWEN MATTHEW: Hoowah, hoowah.

RISA GOLUBOFF: Hoowah, hoowah. After law school, you practiced as a lawyer here in Charlottesville, and then you went to the University of Colorado where you were a professor and where you also got a PhD in health and behavioral sciences.

DAYNA BOWEN MATTHEW: That's right. That's right.

RISA GOLUBOFF: OK. So you know this from the law side, the litigation side, the economic side, the policy side, at every level, and then also as a health and behavioral scientist.

DAYNA BOWEN MATTHEW: Well, that's the future of law.

RISA GOLUBOFF: I think-- That is the future of law. So let's talk about that.

LESLIE KENDRICK: Fortunately, that is the topic of our show for this season. This season's about the future of law. So Dayna, you, as we just heard, you're at the cutting edge of two very important areas, both legal services and health care. And I've heard you say that in the future, we could see more medical-legal partnerships that could revolutionize the way that we deliver both medical and legal services. So I'd love to talk about this. So first of all, can you just start us off-- tell us what are medical-legal partnerships.

DAYNA BOWEN MATTHEW: Sure. They are exactly like they sound. It is when law and medicine get together to deliver health care. So it's a different way to deliver health care. Not just a referral model where you say, oh, patient, you need help from a lawyer, I'll refer you, but a model where the lawyer's actually in the clinic and part of the delivery team. Why? Well, because so many medical problems have a legal component to them. So we think of health-harming problems that are harming people and can only be solved by law.

LESLIE KENDRICK: So can you walk us through a little bit? What is it that happens under the traditional model? Say a patient comes in. What happens under the traditional model that's less than optimal that could be changed by a medical-legal partnership?

DAYNA BOWEN MATTHEW: Right. So I used two paradigms. The easiest one is asthma. So you have a kid with asthma. They walk into the clinic and they get fabulous primary care. They walk out with an inhaler, an albuterol inhaler, let's say.

But if nobody in the clinic has bothered to ask whether they live in an apartment that is moldy, pest infested, that has lead paint, or in other ways doesn't meet the building code, which is a legal requirement, that kid's albuterol is powerless in the face of the law that has been violated in their lives. So the medical-legal partnership fixes that by saying, we can't get a kid better physically and medically unless we also address the social circumstances in which they live.

And a lot of those have legal components to them. So we ask both questions in the clinic at the same time, and we try to ask it preventively. That is, before the crisis ensues. And as a result, you get better outcomes. The albuterol is going to work better if you also get rid of the mold in the kid's apartment.

LESLIE KENDRICK: Wow. So you would have a lawyer working down the hall from the doctor, who will talk to the patient and their family, and then might do what? Might--

DAYNA BOWEN MATTHEW: Well, the point that I want to make is that that's the easy case. So the lawyer is going to do that on an individual level by making sure that that kid's apartment comes up to code. But really on a structural level, it's likely that that kid lives in a public housing development where every apartment is in violation, and the incidence of asthma is disproportionately affecting the population in that area.

And no amount of access to medical care is going to solve that until lawyers are involved in what we call structure or cause lawyering on behalf of the health issues that those patient populations are facing in housing developments. And that's just one area. We worry about it with respect to all kinds of legal problems that organize what we call the social determinants of health.

RISA GOLUBOFF: So give us the other example that you were saying would be a more complex example.

DAYNA BOWEN MATTHEW: So I like the structural examples because one is actually occurring right now under our auspices at the University of Virginia. So we think about environmental justice problems as ones that have very important health impacts. When I worked at the EPA-- The EPAs objective, of course, is to protect the public health by making sure that pollution is minimized and distributed evenly. It's not, right?

We can do a map and look at disadvantaged populations, whether the or low income populations, elderly populations, populations with extremely high child or youth components, and minority populations. When you map those onto stressors and sources of pollution, Robert Bullard told us, in 1986, that those map almost perfectly, those pollution sources on poor neighborhoods.

So where will you find landfills? In poor and minority neighborhoods. Where will you find Superfund sites? Brownfields? In poor and minority neighborhoods. Where will you find interstate highways? In poor and minority neighborhoods.

So in Buckingham County, the Atlantic Coast Pipeline is going to have one of three compressor stations in the state where? In a poor and minority neighborhood, right?

LESLIE KENDRICK: This is Buckingham County, Virginia, where the Atlantic Coast Pipeline is going to come through. And--

DAYNA BOWEN MATTHEW: Union Hill.

LESLIE KENDRICK: OK. Say a little bit more about what this unit is that will be there.

DAYNA BOWEN MATTHEW: So it's going to be a natural gas-fired compressor station. And the concern, of course, is that the population that will be exposed to any of the pollution incidents or stressors that come from that compressor station is predominantly black, is predominantly poor, and already is disproportionately suffering the kind of health disparities that are making people of color, people who are poor, die quicker and live sicker.

So what does a lawyer have to do with that? Well, one of the things we know is that the organization of where pollution gets to live, where it gets located, can be contested, as well as reorganized, by law. So again, the structural kind of involvement of lawyers in health-related issues is what a medical-legal partnership is best at.

RISA GOLUBOFF: So this seems like a real upending of the way we usually think about the relation future of doctors and lawyers, right? That traditionally [INAUDIBLE]

DAYNA BOWEN MATTHEW: Yes.

RISA GOLUBOFF: --they don't like each other, they don't work together. If they're interacting at all, it's because lawyers are suing doctors, right?

DAYNA BOWEN MATTHEW: Exactly.

RISA GOLUBOFF: That's not this at all.

DAYNA BOWEN MATTHEW: So I live in a medical-legal partnership, my husband is a doctor,

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RISA GOLUBOFF: The personal is professional.

DAYNA BOWEN MATTHEW: --and I had to find a way to recast this relationship because, in fact, what I did at McGuireWoods for three years was, largely, insurance defense-related work. And we represented doctors. Whenever I walk in the room, I say I'm a lawyer and then there's this hissing sound, and I say, oh, but I defend doctors, I'm on the right side of that equation.

And the softening, it's almost as if you see light bulbs go on. People don't realize that lawyers help organize resources for good. And this is, again-- I'm hooked on this phrase "the future of law"-- the future of law is not just to be used as a shield against bad, but an affirmative thing to be used for the good. So that's a medical-legal partnership.

LESLIE KENDRICK: So how did you get involved with medical-legal partnerships?

DAYNA BOWEN MATTHEW: So I started an organization called the Colorado Health Equity Project back in Boulder. And I did that because it was a weird confluence of events. Over time, I realized that my law students were hungry for real life applications of the law that we were learning in class. So I teach public health law, which is population-based health law. I teach constitutional law and I write a lot about civil rights.

Well, you're constantly talking about social justice issues and things that need fixing with law students. And law students want to get to work on those. They want to see something of what they're doing actually play out in real time. And so we ended up with the Legal Services Corporation in Boulder asking the question, what clinics would be willing to host a lawyer and a law student, because it was an educational tool, to be honest.

I never dreamed that what we would see was lawyers who wanted to do good inspired by the zeal, the energy, the innovative inspiration of law students. Law students are the magic sauce, to be honest with you. They are the ones that will-- I'm thinking of one landlord--tenant case. They will go out in the middle of January in subzero weather and help move a family out of a condemned trailer park into a lovely two-bedroom apartment.

Because they did that. They did the legal part, and then they saw that family not only move from one really bad social situation to a much better social situation, but turn their health care around. This was a family that was missing appointments, that was depressed, that had no social security income. They had been cut off from Medicaid, lots of things had gone wrong in their lives legally, and it was adversely affecting their health.

Law students got in there with the guidance of lawyers and turned that family's life around. So that's how I got started, but it felt like retail. It felt like one family at a time. For them, it changed their lives, but it was one family at a time. So then it's grown into more policy-oriented stuff lately.

LESLIE KENDRICK: And it's grown and you've imported it. When you moved back from Colorado to Virginia you brought this model with you, and what have you been doing here in Virginia?

DAYNA BOWEN MATTHEW: Well, I'm very lucky it was here when I got here in the form of-- and this is unusual. Common Cause is the name of the medical-legal partnership that's just started here recently. But already at the law school, the model of having law students work with Kimberly Emery and people over at the medical school had already been in the works. What was unusual here was that a new physician, Drew Harris, came along. And he works on asthma, and he's very interested in creating a medical-legal partnership in the asthma pulmonology clinics.

To have them be driven by a physician, that was new and exciting. So they are doing what I would call the retail patient-by-patient medica-legal partnership, and I'm trying to structure something more institutional, something that would look at large, what I call cause lawyering, about housing developments, or about pollution, for example, the Atlantic Coast Pipeline. Larger issues of discrimination, for example, that are hitting at the population level because, again, I do public health as opposed to health care law, and they are doing the health care law medical-legal partnership here.

RISA GOLUBOFF: So it strikes me that to do public health law the way you are doing it means you're doing housing law, and environmental law, and all other kinds, right?

DAYNA BOWEN MATTHEW: That's exactly right. Yeah.

RISA GOLUBOFF: Public health actually encompasses a huge swath of the law.

DAYNA BOWEN MATTHEW: Well, that's my view and understanding. And that's another future-looking view of what health and health law is-- the direction it's going into. Its interdisciplinary and it's broad, because if you think about the social setting in which people are either healthy or not healthy, it's far more impactful than their health care, right? Our research tells us, right now, that about 10% of health outcomes are determined by access to health care.

Another 10% based on genetic or biological disposition, a whopping 30% to 40% has to do with where you live, you work, you play. That's your social and environmental circumstances. So to the extent that law organizes any of those social factors and variables, that's where the health-- population health outcome needle is going to be moved. That's where the action is.

We're really going to change health disparities if we can change people's access to food security, people's access to safe, sanitary, decent housing. Even educational attainment, we see a really close correlation between lack of educational attainment and poor health outcomes. So if we really want to improve population health outcomes-- I think it's great that everybody has health insurance that's great, but that'll hit 10% of the equation.

LESLIE KENDRICK: So this just touched on your own work. Deals-- in part, you do so many different things, but-- part of it's about looking empirically at what we can learn about the impact that medical-legal partnerships have, and that other types of interventions have, and I just wondered what you could tell us about what your research has uncovered about how impactful these can be.

DAYNA BOWEN MATTHEW: Well, right now, I may have the largest database of retrospective data, with respect to patients who have been treated or had exposure to medical-legal partnerships, and inquiring empirically about what the difference in their outcomes looks like. It's not a huge database. It's 31,000 patients.

RISA GOLUBOFF: That sounds like a lot to me.

DAYNA BOWEN MATTHEW: Well, you know, as far as big data is concerned, what we'd really like to see is millions of patients that had exposure to or the opportunity to, and then prospectively to do a random clinical trial. Well, even though medical-legal partnerships, in my view, are the future of law-- they're interdisciplinary, they're preventive, their population-based, all of those things will make a difference-- the evidentiary base is nascent. And so what we've got is the history of this 31,855 patients who had the opportunity to get medical-legal partnership intervention in the past.

Some of them got it, some of them didn't. And then we have about 202 variables to look at from the electronic health records to see what their outcomes might be. That is, how they differ before and after, and how they differ as compared to a structured control population. So it's retrospective. It's not the gold standard, but it's about the best, probably, that exists in the academe in the policy world right now. And that's what we're trying to refine.

RISA GOLUBOFF: And do you have any preliminary conclusions that you can draw yet that you can tell us about?

DAYNA BOWEN MATTHEW: Well, research is wonderful in some ways. We had these great hypotheses, some that appear to be confirmed, and some of which were not confirmed, right? So the good news first, we think that lots of the process variables are going to show us that we're likely to reduce costs of delivering health care to people when we give them lawyers, as well as physicians or clinicians, because we'll keep them out of the emergency room.

So we see a marked reduction in emergency room use. We see a reduction in the number of inpatient hospital days, we see a reduction in the missed or canceled appointments, so people access preventive care more regularly. And all of these, again, are upstream results of what we believe, ultimately, will result in decreased health disparities and better health outcomes. Where we were really trying to nail health outcomes, we weren't able, with this size population, to confirm it.

So one of the things we wanted to look at is whether or not we had better immunization compliance, because we know from the literature that if a patient from zero to age eight has a really good immunization record, the likelihood that they will be healthy for the rest of their lives is markedly increased. So if we could show that, we would have happily said medical-legal partnerships make that big a difference. It turns out that there are too many, what we call, confounding variables.

There are too many other things that could explain why a kid gets or doesn't get their immunizations regularly, and what we needed to do was isolate the medical-legal partnership and we haven't gotten to do that yet. So there are some things in the work. I really am very hopeful about Drew Harris's work. He's looking at asthma outcomes. It's one of the best areas to look at pre and post, and maybe he'll be able to show some real clear health impacts. But ours have been process and they're pretty encouraging.

RISA GOLUBOFF: What do you mean when you say process?

DAYNA BOWEN MATTHEW: So we are not looking at the health outcome themselves, right? We're not looking at whether a kid gets more sick or less sick, complies more or less with their actual medical regimen, is taking more serious or less serious drugs. Those are the medical outcomes, directly. Process is, we think that if these things happen, the process of improving their access to health care, their utilization and uptake of health care, or the process of staying out of the hospital, will ultimately either cost us less money or get better health care outcomes. Not directly, but indirectly.

RISA GOLUBOFF: And, ideally, both. Cost less money and get better health outcomes.

DAYNA BOWEN MATTHEW: Ideally, both. Exactly. Exactly And we think there's a lot of room to do that. One of the things that we found out-- and this wasn't my research. It was research of others have collected in the book Just Medicine. One of the things we found out was that about 84,000 people die needlessly from health disparities. That's a lot of room for improvement. So medical-legal partnerships aren't the only answer, but it is our hypothesis, and my belief, that it is one of the big answers because it aims at social determinants of health.

RISA GOLUBOFF: Can you say more about disparities in health care? What do you mean by that? What is that phrase about?

DAYNA BOWEN MATTHEW: Sure. Disparities are inequities that are not fair, not justifiable from a clinical perspective, but that are causing people to be less healthy in ways that are avoidable. So we can avoid that asthma kid being sicker if we can get that asthma kid's housing to be as healthy as the rest of the population. So what we're looking at when we aim at health equity is an equal opportunity to be healthy.

So the poor kid with asthma doesn't have an equal opportunity to be healthy because their housing puts them behind, and they're going to do less well in school. If they do less well in school, they're going to get a less successful job. If they get a less successful job, their housing is, again, likely to be inferior, and all that goes with that. We look at housing, in particular, because at the neighborhood level, we can see that correcting housing-- This is a Move To Opportunity experiment that was done over several years, longitudinally.

When we move people to better neighborhoods, we improve all kinds of things that have health impacts. We improve their educational opportunity, their food access, we reduce the likelihood that-- this is in Colorado-- that they have to pass four marijuana dispensaries in order to get to third and fourth grade.

We reduce the likelihood that they live near two interstate highways and, therefore, are sucking down the kinds of exhaust fumes that go with that. We improve so many things that are directly related not only to health, but their life chances over time. And when we do that, we have an opportunity to, frankly, address one of the grand challenges of our time, which is inequality.

RISA GOLUBOFF: Where would you say, in terms of the future of law and looking at the future, where in the arc of the history and future of medical-legal partnerships and the social determinants of health, where are we? Are we right at the beginning? Are we at an inflection point? Are we at a level of maturity? What's going to come next? Where have we been and where are we going?

DAYNA BOWEN MATTHEW: I think we're at a turning point. So medical-legal partnerships, in particular-- The first one was founded somewhere around 1995. There's some dispute as to whether that was the actual first one in the Boston Medical Center, but the history goes back to about 1995, which is relatively recent. And they've proliferated more and more, so that they're about 300 around the nation today. That's a great pilot, to be honest with you, because most of those are founded by and run by enthusiastic, zealous people who are doing this work not because it has been structurally accepted, meaning we have a payment system that reimburses for this.

In many instances, it's like our law school medical-legal partnership where we did one, two, three, four, eight maximum cases a year. But the real structural issues still remain to be-- I think we're at the beginning-- remain to be tackled by medical-legal partnerships that are part of an alternative-based payment system, that are reimbursed, and that are deeply embedded in all of the primary care systems. Now right now, they mostly are directed towards low income and vulnerable populations. That's a great place for them to be.

But the truth is that access to justice is an issue for modest and middle income families as well. So to the extent that we have to pivot so that these are paid for, so that they scale up, and so that they address not only low, but also modest income families, we're at a turning point. We really do have to think about how to sustain the model.

RISA GOLUBOFF: Do you mean access to justice? Or do you mean access to health care?

DAYNA BOWEN MATTHEW: I mean both because, right now, I think of access to justice as a social determinant of health. If the kid with the albuterol doesn't have access to a landlord-tenant lawyer, their access or inaccess to justice is affecting their ability to access health or healthy living. So right now in the United States, 90% of landlords who go to landlord-tenant court have an attorney. 90% of tenants don't. So that's why I say access to justice will also-- it will have an impact on the likelihood of success for-- I'm going to keep with my kid with albuterol. Getting that mold abated or the lead abated, it will be impacted by their access to justice because a lawyer will help.

LESLIE KENDRICK: So what needs to happen for this to scale up

DAYNA BOWEN MATTHEW: A couple of things are important. The model itself has to have a sustainable way of being financed. So how does that happen? Well, that was one of the really important things I learned in my time on Capitol Hill, a place-- That's not the sandbox I want to play in, but I really did learn a lot about what it means to find a "pay-for." That's a term-- I have air quotes going on right now-- a pay-for. How are we going to pay for that great idea that you have?

And a lot of what's happening right now in the policy world, with respect to paying for any of the social determinants of health interventions, my opinion-- Now this is my opinion-- is talking about taking money from already scarce pots and trying to make them do more. I think that's an ill-advised solution. So a lot of the talk is about taking Medicaid funds, looking at our waiver system-- 1115 waivers, DSRIPs, and other types of waivers-- and finding ways to have those pay for, well, civil-legal representation for medical-legal partnerships, or supportive housing, or other types of interventions that are social.

That is taking an already scarce pie and trying to slice it even more thinly. Medicaid is barely paying for health care services itself. I think a better solution is looking at ways in which we break down the silos for how we pay for things that do have a direct impact for health. So that has to happen before we can really scale up an intervention, that takes housing as health care, and treats it as health care. And we need lawmakers to figure out how to do that change in financing structures before we're going to scale up that model. That's one example. It's probably the most important one right now.

LESLIE KENDRICK: Dayna, you mentioned the time you spent on Capitol Hill and you've just done so many different things that I don't think we've even begun to scratch the surface, but I wanted to mention a couple of them. You were a health policy Fellow for senator Debbie Stabenow of Michigan at the height of the Flint water crisis. And you also served as a senior advisor to the director of the Office of Civil Rights for the EPA under the Obama administration. And you are currently helping senator Cory Booker draft an environmental justice bill.

So you say it's not your sandbox, but it sounds like you've spent a lot of time in it. And I would love to hear your thoughts about these experiences, but I'm also interested in what advice you have to law students and to lawyers who might think, I want to get involved with access to health care as an access to justice issue. And it seems like your career itself encapsulates so many different ways of doing that. But is there a playbook here, or how should someone think about getting involved if this is something they want to get involved with?

DAYNA BOWEN MATTHEW: I'm going to go backwards a little bit and I promise I'm going to answer that question, but it--

LESLIE KENDRICK: No, you don't have to answer

DAYNA BOWEN MATTHEW: --really does-- it requires me to think that my best piece of advice is to work out of your life experience and let your passions drive you. I don't think I've been more fulfilled in my career and happier with what I'm doing than I am at this very moment, and that is because I'm doing the things that I feel like I was built to do all along in my career. So I grew up in the South Bronx and I had two parents who were really just dedicated to my education.

And so by fourth grade, I was really literally straddling worlds. I would leave the South Bronx and I'd travel an hour and a half to a totally different world. Riverdale, New York, median income somewhere around $91,000, $92,000 per household, median family income. South Bronx where I left, somewhere around $8,000. I mean, we were talking two different worlds.

And over time, I came here to law school, and I had a clerkship, and I got the opportunity to teach starting here and then, over the course of many more decades than I care to admit, I began to see that my scholarship and my interests were being informed by the problems I saw traveling between two worlds in fourth, fifth, and sixth grade. So if you want to get involved, find where your passion is, find what you were built to care about, and that's what has happened for me.

It turns out that as the academy health behavioral scientists, sociologists, legal scholars have begun to understand inequality as one of the major issues of our time, so then we are beginning to see that we're not going to solve it, but for inter- and trans-disciplinary solutions. So how lucky can I be sitting in a university with world class economists, sociologists, urban planners, medical providers, lawyers, even religious scholars, who all care about inequality. Why is that important?

You have to-- this is my second piece of advice after your passions. You have to find ways now to solve big problems across disciplines. So we have to collaborate with people who deliver health care and medical-legal partnerships, for example. We have to collaborate with people who deliver social science data for evidence-based lawmaking. All of us have to get together to solve the problems. I feel like the low hanging fruit, it's been solved. The problems are much more complex now. So besides your passions and your ability to cross disciplines, I think you should just have fun.

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LESLIE KENDRICK: Very good advice.

RISA GOLUBOFF: Great.

[LAUGHTER]

Excellent advice. I love the whole thing. Well, thank you so much. It's been a pleasure to have you.

DAYNA BOWEN MATTHEW: It's been my pleasure to be here. Thanks for having me.

RISA GOLUBOFF: So Leslie, I'm thinking about where Dayna ended and the trans-disciplinary and cross-disciplinary approach. And thinking about, in a large sweep, the history of the 20th century is a history of increasing specialization, right? And in our professions and in our disciplines, we get more and more specialized.

And that makes it harder and harder for people to talk to each other across the disciplines, and we get more and more siloed. And that we're now in this new moment where we've got to get out of those silos, and, as Dana says, the low hanging fruit is gone. In order to continue to make progress and improve the human condition, we have to cross those boundaries and get out of those silos.

LESLIE KENDRICK: That seems right. And that's not to take anything away from developing deep expertise. I think the level of specialization throughout the 20th century has brought enormous benefits to society in a lot of different ways. But it's about not having blinders on so that you only see the particular issue that's in front of you. I think the medical example is a great one, where you can write a prescription for a particular illness, but the causes of the illness go much deeper and much broader than that.

And all of us need to take off our blinders and be able to see, more broadly, how the piece of the puzzle that we're working on interrelated with others. And I think if we're talking about the future of law, that's not just about how law relates to technological change, but it's also about how law can be a tool to help understand societal problems more deeply, more broadly, and address them in ways that are more interdisciplinary and more creative.

RISA GOLUBOFF: I think that's totally right and I think that's the direction we've been going with legal education, too. So we train our students to do law. They've got to know that deep expertise, they've got to understand how legal analysis works and what the law is, and then they have to learn practical skills and get out there in the world and start solving problems the way Dayna was talking about her students did and do.

And then finally, they've got to have a sense of what exists outside the boundaries of the law, they have to learn extra disciplinary and cross-disciplinary fields so that when they approach the law, they do it with a sense of what's outside it and understanding who they have to collaborate with for a particular problem in order to solve it. And I think the medical-legal partnerships are such a great example of bringing all three of those types of learning together.

LESLIE KENDRICK: That's right. They have all of those. You have to know the law, you're getting practical experience and utilizing it in a practical environment, and you're also doing it within a cross-disciplinary environment. So it's got all of that together. You often talk about that as the three-legged stool of legal education.

RISA GOLUBOFF: I do. I do. I think all of our students should be doing all three of those things in order for them to be successful lawyers in the world. And I think that is the future of legal education and the future of law.

LESLIE KENDRICK: So it strikes me, though, that one reason that the future of law looks this way and why legal education has to have this three-legged stool component, has to have a kind of tripartite component, is that that reflects a development in how we understand different social problems and how we understand health care. That if health care is an issue that's not often seen in its own silo, but is something that's embedded in the world, it has a social component to it, it's related to inequality, it becomes something that law is a tool that's relevant to. So law expands its boundaries because we understand problems in different ways than we used to.

RISA GOLUBOFF: I think that's exactly right. And especially from my vantage point as a civil rights historian, health care hasn't always been thought of as a civil right or as intimately related with equality and inequality. And you can go all the way back to Franklin Delano Roosevelt, President Roosevelt. He had a second Bill of Rights that he articulated that had social and economic rights in it, and health care was in there. And yet, we don't start thinking about health care as some kind of civil right until very, very recently.

It takes a really long time before health care-- We have universal coverage from the Affordable Care Act, but as Dana said, it's not really until the 1990's that you start seeing medical-legal partnerships in that people understand the relationship, the deep relationship, between inequality and other spheres of life. And inequality in health care and in health outcomes, and in basic wellness. And I think we don't even really know, right at this minute, what future inequalities will identify or how we'll think about them, but I think we can be sure that law will be a part of them.

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LESLIE KENDRICK: That seems right.

RISA GOLUBOFF: So that's going to do it for this episode of Common Law. If you enjoyed it, you might also enjoy some of our past episodes. They're all available on our website commonlawpodcast.com. You can also subscribe to our podcast there. Again, that's commonlawpodcast.com.

LESLIE KENDRICK: If you haven't already, please consider leaving us a review, or maybe a bunch of stars on Apple podcasts or wherever you get your podcasts. It's a really helpful way for us to get our podcast noticed by other people who may not yet know about the show.

RISA GOLUBOFF: Common Law is produced by the crack team of Mary Wood, Tyler Ambrose, and Tony Field. We record our show at the studio Virginia Humanities. We'll be back with you in a couple of weeks with a brand new episode in our Future of Law series that you won't want to miss. It's all about how the law is going to have to adapt to the brave new world of autonomous vehicles. I'm Risa Goluboff.

LESLIE KENDRICK: And I'm Leslie Kendrick. Thanks so much for listening.