From San Francisco to Miami to Baltimore, this fall’s mayoral elections will shape the future of American cities for decades to come. While many of these elections focus on housing, homelessness, and public health, access to legal representation is an overlooked approach that sits at the intersection of all three. Many have argued that legal representation is a civil right; it can also be a fundamental public health necessity.
Legal representation can keep people in stable housing, prevent evictions, and address unsafe living … [+]
Consider Michelle’s story. Michelle is a 52-year-old grandmother who lives in social housing with her two young granddaughters. Their unit was riddled with black mold and the sewerage was so bad that they had to use buckets of water to bathe. Despite repeated pleas to her landlord, no repairs were made. As their living conditions deteriorated, so did their health. Michelle made several trips to the emergency room – first for respiratory problems due to mold exposure and later for gastrointestinal problems exacerbated by the unsanitary conditions. Michelle’s health, along with that of her granddaughters, continued to deteriorate as the underlying problem was not addressed. Worse still, due to a rent miscalculation, her landlord threatened to evict her and her family. However, when she received legal help, the problems were resolved within weeks and the threat of deportation disappeared.
Michelle’s story is not an isolated one. Legal issues often lead to health crises, especially in the area of housing. As an ER physician in San Francisco, I have treated patients who have lost their homes because they cannot afford legal advice to challenge unsafe living conditions, address domestic violence, or prevent wage theft. In California, for example, it is estimated that 92% of low-income families with legal problems do not have access to legal help. And once someone becomes homeless, their health deteriorates rapidly.
Legal barriers often accelerate or even initiate the journey from housing instability to homelessness. Without access to legal representation, people are evicted from their homes, lose access to critical services, or face unsafe conditions without recourse. For two decades, I have witnessed the devastating toll of untreated mental health issues, substance use, and chronic diseases among the homeless, as well as the impact it has on our emergency departments and health care system. Research shows that homelessness worsens both mental and physical health problems. A study from San Francisco-based Open Door Legal found that legal representation prevented 46% of clients at risk of homelessness from losing their homes. The costs? About $3,100 per person. Compare that with the $83,000 Santa Clara County spends annually on each homeless person, with 61% of those costs going to health care.
It’s no secret that healthcare and housing are inextricably linked. And while there is increasing recognition of this reality, for example through new Medicaid programs that provide housing assistance and non-medical services such as air purifiers or financial coaching, a key component is missing. People living in insecure housing need legal advocates to protect their rights.
We could prevent countless public health emergencies by providing legal assistance before people reach the point of crisis. Legal representation can keep people in stable housing, prevent evictions, and address unsafe living conditions before they lead to emergency care. The downstream effects of legal intervention are profound: fewer health crises, fewer emergency room visits, and fewer people forced onto the streets.
Universal legal representation can be both a moral imperative and a pragmatic imperative. It is a key part of the strategy for rising health care costs associated with homelessness. If we can reduce homelessness in a cost-effective way, our healthcare system will be much less burdened.
As we enter an election cycle focused on public health and housing, policymakers can benefit from understanding that legal representation can be a health intervention. We need a system in which access to justice is given equal priority to access to healthcare, because in many cases they are one and the same. It’s time we consider access to legal representation as an essential part of our public health infrastructure.