Guest Blog: Out of the Hospital and Into Reality

Kenneth DavisBeth Breslin

As administrators of two of the largest health systems in the nation, we have long known that the best patient care cannot be delivered exclusively inside the walls of our facilities. No matter how high the standards of care, how cutting edge the technology, how sophisticated the systems – not even how talented and dedicated the staff – we cannot do our jobs unless we look outside the hospital and into the reality of our patients’ lives. And for the poor and low-income New Yorkers we serve, that reality can be bleak. Many are homeless or precariously housed, unemployed or underemployed, struggling to pay for nutritious food, and have limited education.

If you are poor, you face substantial barriers to good health. An estimated 40 percent of health outcomes are shaped not by genetics or bad habits, but by powerful social and economic factors – most notably income, education, and employment. If you are poor you are more likely to develop cancer or cardiovascular disease, or to become disabled. You are less able to access or afford healthy food, which often leads to obesity, hypertension and diabetes. You often do not have private insurance, may not know about the healthcare benefits you are entitled to, or have the resources to navigate a complicated insurance system.

Both of our hospital systems – one public and one private – recognize the importance of understanding the circumstances in which our most vulnerable patients live. Out of that understanding have come a number of initiatives designed to address the social determinants that lead to and exacerbate poor health – particularly for Medicaid and Medicare beneficiaries, who are among the highest users of the healthcare system, and most likely to face societal and economic barriers to effective care.

Addressing the multiple factors that determine health requires changing the way we think about it. Health is not the sole domain of medical practitioners, but a responsibility we share with myriad community partners, advocates, and social service organizations. Coordinating with these partners, we work to break down impediments to improved health, helping patients understand their health conditions, adhere to their care protocol, and access nonmedical services, such as financial and housing assistance, transportation, food and nutrition support, and employment services.

Among the social services initiatives that have been most successful in removing nonmedical barriers to better health outcomes are the partnerships we and other hospitals have forged with legal service providers, known as medical-legal partnerships. Across the country, attorneys are training healthcare professionals to understand the legal issues their patients face, and being integrated into low-income patients’ health care teams to address legal problems that impede treatment or recovery.

In New York, we are fortunate to have been working for many years with a division of the New York Legal Assistance Group (NYLAG), LegalHealth, which is the country’s largest medical-legal partnership. Their attorneys assist patients at locations within the hospital on a range of issues, including identifying healthcare coverage options, securing coverage, and helping patients negotiate with insurance providers when disputes arise. They also help patients deal with the threat of eviction, other landlord tenant issues, foreclosure or unemployment, and secure Social Security Disability and other benefits, among other matters.

Here is an example of how the partnership works: a woman suffering from Stage 3 breast cancer began missing chemotherapy appointments at the hospital. Because her healthcare team was trained to identify the health-harming legal needs of patients, when she next came in, they probed and discovered that due to her illness she had lost her job, fallen behind in rent, and was facing eviction. The stress of her legal problems was causing her to forego her treatment. The hospital staff referred the patient to an onsite LegalHealth attorney who represented her in housing court and successfully prevented the eviction, enabling the patient to focus once more on her health.

Patients are not the only ones these attorneys help – healthcare systems benefit as well. When a lawyer acts as a part of the healthcare team, doctors are not burdened with issues outside of their expertise, and can focus on their patients’ health. Healthcare institutions and practices benefit financially when their patients are not struggling with complicated legal issues that cause them to miss medical appointments and treatment, decreasing efficiency and productivity, and compromising care. And by assisting clients in obtaining health coverage, legal services help to move uncompensated care paid for by the hospital to compensated care paid for by third-party payors. From the hospital perspective, the return on investment can be substantial. According to a recent study commissioned by NYLAG, for every one dollar spent on their services, LegalHealth generates about two dollars in direct financial benefit for hospitals, and even more in indirect financial benefits.

Medical-legal partnerships and other social services are receiving increasing attention since the implementation of the Affordable Care Act (ACA) in 2013, which expanded federal Medicaid coverage to approximately 32 million more lower-income individuals with a host of unmet social needs that affect their health. In addition, various Medicaid reform programs underway across the country, such as New York State’s delivery system reform incentive payment (DSRIP) program, have the primary goal of reducing avoidable hospital use by 25% over five years. DSRIP puts particular emphasis on initiatives that bring together medical and social service organizations to move care out of hospitals and into the community.

The primary goal of every health care institution is to improve the health of the patients who walk through its doors. Doing so in today’s dramatically changing healthcare landscape demands that we leverage every opportunity to innovate and collaborate. By addressing the link between poverty and health, medical-legal partnerships have improved lives and lowered costs. There are now 273 hospitals and health centers in 36 states working in similar partnerships. Based on our own success, we urge every hospital executive to consider joining us.

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Helping Veterans Face a Web of Legal Crises

Keith Hoffman A version of this blog post was published by Huffington Post.

VA medical centers are places where many veterans receive health care, socialize, and engage with other veterans in support groups and therapy sessions. The VAs are also epicenters of veterans in crisis. As an attorney working in a medical-legal partnership at VA hospitals in New York City, I have seen firsthand how veterans, in particular those who are chronically ill, can be overwhelmed by multiple, interconnected crises.

One of my clients, an Iraq War veteran who has severe post-traumatic stress and a brain injury from a roadside bomb, has been unable to work since he left the military a year ago. The veteran’s wife is now his full-time caretaker, but his VA compensation claim took nearly a year to process, so the couple cannot afford an apartment of their own. They joke that they are on the “couch tour,” bouncing between family and friends’ houses, but the veteran’s memory problems, panic attacks, and homelessness strain their marriage. Another client sought legal advice after meeting with her support group for survivors of military sexual trauma.  She is fighting to keep her children in her life even as she struggles to maintain stable housing, secure VA benefits for a disability caused by her service, and battle an alcohol addiction that has led to a criminal conviction.  She considers violating parole to visit her children.

I wish these stories were unique, but they are not. Many veterans that I represent are living on the street, victims of domestic violence, overwhelmed with debt that accumulates while they wait for benefits to be processed, and involved in the criminal justice system. In order to attack layers of problems like these, advocates must address many civil legal needs, including housing, employment and family matters, and representation in VA benefits cases. This requires more than just the commitment and passion of dedicated civil legal services attorneys. We need to recognize the limitations of our economic and human resources, and find creative ways to empower veterans facing social challenges and in the process multiply the impact we can have. In the last several months, I have had the good fortune to be involved in developing initiatives that are doing just that.

Leveraging Resources to Untangle the Web

veterans legal stand down

69 veterans attended NYLAG’s July 27 legal stand down at the Manhattan VA Hospital.

Working with the New York Legal Assistance Group’s LegalHealth division, which partners with medical professionals to address the legal needs of low-income individuals with serious health problems, and Latham & Watkins LLP, my Equal Justice Works fellowship sponsor, I have created two new educational and outreach initiatives targeting veterans. The first is a series of “Legal Stand Downs,” events where veterans can learn about their legal rights and have the opportunity to ask legal experts questions about their individual situations. The series, which is modeled after the stand down concept used during the Vietnam War to provide a safe retreat for units returning from combat, has thus far provided information to over 200 veterans in the areas of family and housing law. In the months ahead we will conduct additional Legal Stand Downs covering VA benefits, consumer debt and bankruptcy.

The second effort is The New York City Veteran’s Legal Guide, published with generous support from Latham & Watkins and input from more than 20 NYLAG and Latham attorneys and paralegals. The guide contains information on 50 of the most common legal issues facing veterans, including: how to deal with housing problems like evictions and requesting repairs; information about various VA benefits; the basics of the Family and Medical Leave Act; and how to get an order of protection – always with clear direction on when to consult an attorney. More than 300 guides have been distributed to veterans, VA hospital staff, social workers, and veterans’ organizations across New York City.  A second edition of the guide will be printed in 2016.

These new programs empower veterans by demystifying complex government and social programs, and helping them know their rights. They also provide a basic understanding of the law that can help people to catch legal problems before they reach crisis-level, or prevent legal problems from arising in the first place.  They teach veterans about when to seek legal counsel, so that when they face enormous legal challenges, they do not have to fight alone.

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Gender-Based Violence and Male Privilege

Kim Susser A version of this blog post was published by Huffington Post.

Anyone can be the victim of violence. Women are sometimes violent towards their male intimate partners. Same sex couples can be violent toward one another. But the majority of domestic violence crimes and sexual assaults involve men abusing women. According to the National Intimate Partner and Sexual Violence Survey, while one in four women has experienced severe physical violence by an intimate partner, only one in seven men has experienced it. Similarly, while one in five women has experienced sexual violence in her lifetime, only one in 59 men has experienced it.

DVAM NYLAGOur society gives men more power than people of other genders. On average, men make more money than women and transgender or gender non-conforming people; there are more men than women in elected office; and gender-based violence is overwhelmingly perpetrated by men against women. We live in a world where men learn that they are entitled to power, which is why domestic violence, sex trafficking and sexual assault share the dynamic of power and control.

Many recent examples covered by the media demonstrate how social norms, sometimes referred to as “male privilege,” underlie gender-based violent crimes.

Male privilege pervades college and professional athletics. Athletes at all levels are provided unparalleled entitlements and taught that they will be shielded from repercussions for wrong-doing. As a result, studies on college campuses show that athletes disproportionately perpetrate sexual assaults and are frequently not brought to justice. Over 100 colleges and universities have been investigated for their response to reports of sexual violence. Professional athletes are also consistently in the news for violence perpetrated against intimate partners, while the profit-driven athletic programs that value their athletic skills above the safety of women turn a blind eye.

Violence is a learned behavior. Just as children who are raised in violent homes learn violence as a means of resolving conflict, student athletes learn early on that they can get away with violent behavior from the preferential treatment they are given, and from observing their role models in professional sports. In 2009, University of Michigan football freshman kicker Brendan Gibbons allegedly raped a female student at a fraternity party. That same night, a police report was made. But not until 2014, just after his final season as a starter on the nationally ranked football team, was Gibbons “permanently separated” from the school for violating the university’s Student Sexual Misconduct Policy.

DVAM stat2The perpetuation of male privilege in athletics only worsens when young athletes become professionals in a billion-dollar industry that will do anything to protect its stars. Greg Hardy returned from a four-game suspension from the NFL (reduced from ten) after allegedly throwing his girlfriend, Nicole Holder, on a futon full of firearms and strangling her, with “guns blazing.” Milton Bradley, a baseball player in the MLB, was allegedly emotionally and physically abusive to his wife, Monique Bradley, for ten years. The MLB continued to support Bradley until this past April when he was sentenced to 32 months in jail — a sentence that may now be reduced by 27 months. Likewise, Floyd Mayweather, widely agreed to be the best boxer alive, has seven assaults against five women that have resulted in citations and arrests. And last year, NFL player Ray Rice was caught on video knocking his partner, Janay Palmer, unconscious. One month later, Rice and Palmer were married. People wondered why she stayed, but many women knew the answer — they recognized the power and control dynamic at work. The hashtags #WhyIStayed and #WhyILeft quickly went viral, with domestic violence survivors sharing their stories of the shame, guilt, and fear that come with being abused by someone they love and knowing things may only get worse if they report it or try to leave.

According to the Everytown for Gun Safety 2015 Report, there is a noteworthy connection between mass shooting incidents and domestic or family violence. In at least 76 of the cases (57%), the shooter killed a current or former spouse or intimate partner or other family member, and in at least 21 incidents the shooter had a prior domestic violence charge.

DVAM stat3Typically, when a woman is abused, her abuser tells her it’s her fault that this is happening to her. He might tell her that she has been disrespectful, or that the abuse is deserved. Male privilege gives him permission to shift responsibility to his female victim for the acts he has committed. The shooters in Oregon, and last year at UC Santa Barbara, each cited the belief that because they did not have girlfriends they were being denied something they were entitled to. The latter used this to justify mass murder.

NYLAG offers free legal services to survivors to help them shift the power dynamic. By obtaining tangible relief including orders of protection, child support, divorce, immigration status and safe custody and visitation arrangements, we help our clients to break the cycle of violence that allows their abusers to maintain control. During October, Domestic Violence Awareness Month — and the rest of the year — it is important that we recognize why violence against women happens in the first place and work together at all levels to confront it.

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On the Road to Healthcare Justice

Ashe Blog Card

A version of this blog post was published by Huffington Post.

Over the past two years, activists, advocacy groups and community members have secured significant gains in the fight for increased access to healthcare for transgender and gender non-conforming (TGNC) communities in New York and nationally.

The New York Legal Assistance Group’s LGBTQ Law Project works daily —both through direct client representation and broader public policy advocacy–to ensure that low-income LGBTQ New Yorkers are able to access health insurance and a range of medical services at hospitals and in doctor’s offices free of discrimination.  Unfortunately, our transgender and gender non-conforming TGNC clients in particular experience significant barriers to accessing those services during some of their most vulnerable moments. They are turned away from emergency rooms, experience harassment by medical providers, are denied access to health insurance because of mismatched identity documents, or go without basic medical care altogether because of an inability to pay.

TGNC communities across the country are subjected to similarly degrading treatment, and at staggering rates.  According to the largest national survey of TGNC communities in the United States, TGNC people experience devastating levels of discrimination, harassment, and mistreatment in nearly every aspect of their lives, resulting in disproportionately high levels of poverty, housing insecurity, and unemployment.  This is particularly true for communities of color, who are four times more likely to live in extreme poverty and earn less than $10,000 annually.  Over half of those surveyed reported being harassed in places of public accommodation, including at hospitals and health centers.  Nearly one-fifth report being refused medical care due to their transgender or gender nonconforming identity and almost one-third postponed medical care all together out of fear of discrimination or mistreatment.  These social and legal stressors contribute to a documented trend of TGNC communities suffering worse health outcomes overall.

Growing Momentum Towards Change

Legislatures and agencies in New York and across the country have begun to address these disparities by enacting policies that increase TGNC access to healthcare and remove discriminatory barriers to care that have existed for many years. For example, in May 2014, Medicare officially lifted a decades-old ban on transition-related surgery.  In December 2014, Governor Cuomo issued guidance clarifying that private insurance companies in New York can no longer deny medically necessary treatment on the basis of a recipient’s gender identity or expression.  And even the federal government recently issued historic guidance that prohibits healthcare and insurance discrimination on the basis of gender identity and expression under the Affordable Care Act.

One of the most recent of these groundbreaking victories occurred in March 2015, when the New York State Department of Health removed its decades-old categorical exclusion on transition-related care. NYLAG advocated strongly for the removal of Medicaid’s ban and submitted official comments to the Department of Health, urging a broad and inclusive rule.  Because our clients are low-income, and most use Medicaid as their primary insurance, this change will have a significant impact on the people we work with every day.  However, while removing the ban was a significant and important step, the policy does not go far enough.

Medicaid replaced its exclusion with several exceptions and prohibitions that create unnecessarily burdensome requirements for low-income New Yorkers seeking fully-inclusive healthcare.  For example, Medicaid will not allow youth under the age of 18 to access hormone therapy despite a consensus among medical experts that young people and their healthcare providers are fully capable of understanding and addressing these medical needs.  The new policy also prohibits many procedures and surgeries that the Department of Health has deemed “cosmetic” but which leading medical experts in the field have deemed to be a vital part of transition for many.

Fortunately, groups like the Sylvia Rivera Law Project continue to fight against the Department of Health in court to remove these restrictions, and NYLAG continues to represent community members most impacted by these changes. We will continue to do this work until the prohibitions are removed and our clients are able to access the medically necessary care that they need to survive and thrive.

Additional information can be found on NYLAG’s website about the healthcare rights of TGNC people and what trans-related services Medicare and Medicaid will cover.

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Gender Identity & Justice for Transgender People

Ez Cukor Blog CardA version of this blog post was published by Huffington Post.

The first identity document most of us get is a birth certificate. At birth, the doctor looks at the external genitalia and labels a newborn male or female. This cursory survey controls whether an M or an F goes on the birth certificate. But really, we learn the baby’s sex later. All human beings have a core knowledge of their own gender, also known as their gender identity.

Gender identity is deeply rooted, most likely has a strong biological or genetic etiology, and cannot be changed. It is the dominant component of a person’s sex. Most people have a male or female gender identity that is aligned with the other components of sex typical of members of their sex, including chromosomes, hormones, and internal and external genitalia. For them, the practice of assigning sex, and then accruing a lifetime of identity documents based on the appearance of external genitalia, works out fine. But for transgender people, whose gender identity differs from the sex they were assigned, the assumption made at birth was incorrect. Many transgender people take steps to align their bodies with their gender identities, and to become socially and legally recognized as their true sex. Correcting the sex marker on identity documents is an important component of this process.

We are fortunate that in the past year several New York City and State agencies have reformed their policies for correcting the sex marker on identity documents they issue. The new standards are the result of years of advocacy by transgender people and organizations, including the Sylvia Rivera Law Project, Transgender Legal Defense and Education Fund, the Empire State Pride Agenda, the Audre Lorde Project, the New York Civil Liberties Union, and NYLAG. They replace policies that ignored the reality of transgender people’s lives by refusing to recognize their sex unless they could provide proof of genital surgery. They will make it possible for many more transgender people to get identification with a sex marker that reflects who they are.

The standard for determining one letter on the face of an ID is absolutely worth our collective time and attention. The old New York birth certificate and benefit card standards meant that many transgender people were never able to have accurate documents. Requiring a transgender person’s ID to reflect hir sex assigned at birth is not only inaccurate, it is often harmful. When transgender people are forced to present incorrect ID, they are subject to harassment, discrimination and accusations of fraud. A NYLAG client was denied care by emergency room staff who insisted, after seeing that one of her documents had a male gender marker, that she must be a man pretending to be a woman and would make other patients uncomfortable. Another client feared harassment and violence every time she used food stamps because, even though she is a woman, her benefit card says male. These are just two examples. A staggering 44% of transgender people have said they had been harassed, assaulted or asked to leave an establishment as a result of presenting identity documents with a sex designation that did not match who they are.

Updated Gender ID Rules in New York

Gender CheckboxThe New York State Department of Health will now correct the sex on an adult’s birth certificate based on her doctor’s affidavit that she has undergone “appropriate clinical treatment” for gender transition. The New York City Department of Health will accept certification that the requested “correction” is accurate “in keeping with contemporary expert standards regarding gender identity” from a variety of health professionals including physicians and licensed master social workers. When applying for a New York City Municipal ID (IDNYC), one can simply self-attest to the appropriate sex designation – male or female – or make no sex designation at all. In a similar vein, the Human Resources Administration removed the sex-designation entirely from the city’s Common Benefit Identification Card.

These new policies are a step in the right direction. Among them, however, the IDNYC’s is the model that other city and state agencies should adopt. The IDNYC policy respects transgender people’s bodies and right to self-determination. It is also the best way for everyone to have an accurate sex marker on their identification. As noted, the modern scientific understanding is that gender identity is the determinative component of a person’s sex. Having a male gender identity is what makes a man a man, and having a female gender identity is what makes a woman a woman. A transgender woman is a woman, full stop. Any medical or social steps she takes to be more typically female are not making her into a woman; they are aligning her body and appearance with the fact that she is a woman. By allowing New Yorkers simply to certify to the sex marker that corresponds to their gender identity, the IDNYC model makes correct identification possible from the start for men and women.

By contrast, policies that set the sex marker any other way create superfluous barriers for transgender people. Many standards rely on certification from a health care provider such as a physician, nurse practitioner or mental health care provider to make the correction. Obtaining such certification is burdensome and sometimes impossible. Many transgender people are forced to postpone necessary medical care due to cost or discrimination. 19 percent reported being refused medical care because of being transgender. A majority reported having had to educate their health care providers about transgender health care. In some cases correction is only possible with a court order acknowledging the person’s gender. Not all courts will issue such an order. In jurisdictions that will, there are significant hurdles, including access to a competent attorney, monetary costs, and the indignity and loss of privacy experienced by having one’s gender adjudicated. Furthermore, transgender people are disproportionately likely to be very low-income, navigating homelessness and unemployment, and facing devastating levels of discrimination.

Globally, there is precedent for recognizing transgender people’s sex/gender based on their own certification. Since 2012, Argentina has allowed transgender people to change the sex designation on their birth certificates and national identity cards simply by making a sworn statement. In 2014, Denmark became the first European country to recognize transgender adults’ sex/gender based on their own attestation when it amended the requirements for correcting one’s gender in the country’s social security system. In 2015, Malta adopted legislation allowing adults to self-determine their legal sex by making a sworn statement before a notary and prohibiting requests for medical information. Later in the year, Colombia approved a similar procedure for transgender people to correct the sex on their government-issued identity documents. Ireland’s parliament has just sent an analogous bill to the president, who is expected to sign it. IDNYC, however, is the first government identification in the United States to look at the individual’s statement rather than relying on third-party certification.

IDNYC’s sex marker policy is a truly laudable policy. Simply allowing individuals to attest to their sex ensures accurate identification for transgender men and women. The option of having an ID without a sex designation means that people who do not fit into binary sex categories are not forced to choose between two inaccurate options. It’s time for other jurisdictions to catch up to New York City and a rapidly growing list of countries in removing unnecessary barriers to obtaining accurate identification for transgender men women.

The views expressed in this article are the author’s own, not those of the New York City Commission on Human Rights.

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When an Attorney Is the Best Medicine

Randye RetkinBeth Breslin

A version of this blog post was published by Huffington Post.

Laura, a single mother with breast cancer, no income, and no medical insurance, was over $300,000 in medical debt. While her doctors addressed her cancer, they could do little to help her deal with the devastating financial consequences of her illness. Fortunately, Laura’s doctor referred her to a nonprofit that provides free legal services to low-income people living with cancer. Her attorney was able to get her approved for Social Security Disability, and eventually Medicaid, which retroactively covered all of her medical bills.

Laura’s story is not unusual. People living with cancer face daunting legal and economic challenges. Many struggle with insurance disputes, obtaining public benefits, housing, loss of employment, future care and custody planning of minor children, and estate planning. And the ramifications of cancer have a particularly disproportionate and destructive effect on uninsured, low-income, and at-risk populations.

The National Cancer Legal Services Network (NCLSN) was established in 2009 to increase the availability of legal services for people like Laura. By connecting cancer patients with legal services, the NCLSN works to lift their legal burdens, allowing them to focus instead on their medical care and improving their quality of life.

Cancer is the second leading cause of death in the United States. In 2020, there will be an estimated 18.1 million cancer survivors in the US – 30 percent more than in 2010. Half of all men and one-third of all women in the United States will develop cancer at some point in their lives. While the five-year survival rate for all diagnosed cancers has increased, the rate of cancer diagnosis – as well as the overall societal and individual costs of cancer – also continues to rise.

For patients with or without insurance, cancer is an expensive disease. The National Institute of Health projects that by 2020, direct medical costs alone will be at least $158 billion, an increase of 27% over ten years. Soaring medical expenses mean patients often have difficulties in covering living expenses, such as housing and groceries. One survey of cancer patients found that among survivors, 27% reported at least one financial difficulty and 37% reported needing to modify their work lives due to cancer. These costs can also impact a patient’s recovery; according to a survey conducted by the Association of Oncology Social Work, 54% of cancer patients struggled to afford treatment, while 29% of patients delayed prescriptions due to financial pressures and 22% skipped doses of their medication. Patients with financial hardships due to cancer are more likely to rate their physical and mental health as poor, as compared to those who did not have financial hardships. Cancer patients with major financial challenges are also likely to suffer from depression and anxiety.

How Legal Services Can Help

Legal services attorneys, working in partnership with health care professionals, can help to address a range of the nonmedical issues that stand in the way of improving a person’s cancer prognosis and life expectancy. Chief among these is working to identify healthcare coverage options, securing coverage, and helping patients deal with insurance providers when disputes arise. An attorney can also help patients facing eviction, foreclosure or unemployment, secure Social Security Disability and other benefits, address matters related to consumer debt, and help with estate and end-of-life planning, as well as guardianship and child custody issues.

The work being done by the NCLSN and its member organizations is having a profound impact on patients and their families. An earlier study (2006) of cancer patients who received legal assistance through our LegalHealth (a division of the New York Legal Assistance Group) yielded auspicious results: 75% of patients interviewed said legal assistance reduced stress, 50% reported that receiving legal assistance had positive ramifications on their families and loved ones, 45% said legal assistance positively affected their financial standing, and 30% of participants reported that legal assistance helped them maintain their treatment regimen.

Legal assistance helps patients help themselves. People who received legal services became better advocates on their own behalf, better able to face and conquer subsequent challenges. Healthcare systems benefit as well. When an attorney acts as a part of the healthcare team, doctors are not burdened with issues outside of their expertise, and are able to focus on a patient’s health. Healthcare institutions and practices benefit financially when their patients are not struggling with various legal issues. Patients may miss medical appointments and treatment, impacting efficiency and productivity, in addition to compromising care. And by assisting clients in obtaining health coverage, legal services help to move uncompensated care paid for by the hospital to compensated care paid for by insurance companies.

Cancer alone makes anyone vulnerable. Simultaneously coping with cancer and a serious legal matter can have catastrophic effects on patients and their families. Although we have made great progress and seen steady growth, there are still tremendous opportunities to expand this proven model to more communities across the country.

Read NCLSN’s newest publication: The Cancer Cliff, Addressing legal issues that stand in the way of cancer care.

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What the Recent SCOTUS Ruling Means for New Yorkers

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Anya Mukarji-ConnollyBrian Esser

The historic United States Supreme Court ruling that has legalized same-sex marriage sends a strong message of equality across the country – but that same equality does not exist for many LGBTQ families In New York State, who continue to be denied adequate legal protections.

In 2008, when NYLAG first began providing services to low-income LGBT community members in New York City, much of our work involved drafting wills and health care proxies for clients who were unable to marry their partners, and helping non-biological parents adopt their children to ensure they had legal parental rights recognized under the law.

The passage of New York State’s Marriage Equality Act, in 2011, was a significant milestone. But spousal rights stopped at the border, and could not protect families created in New York who travelled or moved to states where their marriages were not recognized. The bill also did not help families created before the parents married or whose children were raised by non-biological parents unable to marry or adopt. And, despite equal access to marriage and family courts in New York, we still see clients who face barriers to full equality, such as being denied orders of protection or shelter based on the nature of their relationships.

Limited Impact on Parental Rights

In New York, a child born to a married couple is presumed to be the legal child of both parents. For lesbian couples, this means that if one parent gives birth to a child while married to her same-sex partner, her spouse is presumed under the law to be the second parent and will be added to the child’s birth certificate. Until the recent SCOTUS ruling in Obergefell, these families were not guaranteed that their parental rights would be recognized in states that refused to recognize same-sex marriages from New York.

After Obergefell, the non-biological parent should be entitled to the presumption of legal parentage based on the marriage in every state. We do not know yet whether all states will apply this presumption equally.

The Supreme Court’s decision protects married couples, who are now free to travel and live where they choose. But it is important to keep in mind that marriage rights and parental rights are two separate issues. Marriage rights are about the relationship between two adults. The legal relationship that a parent has with a child may be affected by whether he or she is married to the child’s other parent – but it may not.

In all states, including New York, the legal presumption of parentage afforded to married parents is a presumption that can be challenged. And some states make it very easy to challenge that presumption with evidence that the spouse is not genetically related to the child. To protect a non-biological, non-adoptive parent, it is advisable that the family use an anonymous sperm or egg donor or, if a known donor is used, that the family and the donor enter into a valid donor agreement. It is advisable to obtain a second-parent adoption when using an anonymous donor, but it is an absolute must when a known donor is used.

Having a non-biological, non-adoptive parent’s name on a child’s birth certificate doesn’t protect that parent if the parentage is challenged in court. A birth certificate is not a definitive statement of parentage: only an adoption or parentage order will ensure protection.

In the days following the SCOTUS ruling, NYLAG has been hearing from clients who want clarification about just what the decision means for their families. Following are answers to several common questions we are being asked:

My partner and I are not married, but I adopted our son after he was born (my partner is the biological mom). Is my second-parent adoption still valid or do we need to get married? Your second-parent adoption is safe. Obergefell doesn’t address the rights of unmarried same-sex couples at all. In New York, the only way for a non-biological parent in an unmarried couple to obtain parental rights to a child whose pregnancy they planned together, and who is a co-parent of the child, is through a second-parent adoption. New York has allowed unmarried partners to adopt jointly for many years, and this right remains. These adoption orders are recognized in all 50 states.

Can my partner and I now adopt in all 50 states? Yes, but you probably have to be married. Obergefell doesn’t specifically address state laws that forbid same-sex couples from adopting, such as Mississippi, which by statute does not allow two people of the same gender to jointly adopt. Texas and Louisiana do not allow two parents of the same sex to appear on a child’s birth certificate. The Supreme Court did not directly address differential treatment of same-sex and different-sex married couples in its decision. However, it is hard to imagine how states will continue to justify discriminatory treatment of LGBTQ families in the future. Some states, even a state like New Hampshire that has had same-sex marriage for many years, require the adoptive parents to be married in order adopt jointly.

My husband and I want to adopt internationally. Will that be allowed now? Each sending country makes its own rules about what families it will permit to adopt. These rules are unaffected by the Supreme Court’s decision. Currently, South Africa and Brazil are the only countries with international adoption programs that knowingly place children with same-sex couples. If you are able to adopt individually, you would be able to complete a second-parent adoption once you brought your child home to the United States.

What’s Next?

The LGBTQ community is diverse, including families with biological children, adopted children, families raising nieces and nephews, single parents, parents who choose not to marry, multiple-parent families, co-parents who are not romantic partners, and multiple configurations of the above. Unfortunately, despite significant legal advancements and full marriage equality, too many of them still have no legal recourse or protections. There are efforts in New York to close part of this legal gap. The Child-Parent Security Act, which has been pending in the New York legislature for several terms, offers a set of reforms that will allow people to be recognized as parents with full rights. We look forward to the day when the State gives LGBTQ families the same rights as every New York family to secure and strengthen the parent-child bond.

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A Compromise Leads to Equitable, Sensible Divorce Reforms

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Kate Wurmfeld

Yesterday the New York State Senate, in a unanimous vote, joined the Assembly in approving a bill that represents a landmark in the reform of New York State’s domestic relations law. A.7645/S.5678, a compromise to a bill introduced in the last session, sets forth new guidelines for how temporary and post-divorce maintenance and spousal support awards are calculated.

The bill balances the sometimes conflicting concerns of low-income New Yorkers, including victims of domestic violence, with those of families of higher income. This was achieved largely because of the process by which it was drafted.

In an attempt to arrive at a compromise on maintenance guidelines, Justice Jeffrey Sunshine, chair of the NYS Unified Court System’s Matrimonial Practice Advisory and Rules Committee, informally brought together lawyers from different interest groups, including the Family Law Section of the New York State Bar Association, the New York State Maintenance Standards Coalition (including attorneys from NYLAG), the Women’s Bar Association of the State of New York, and the New York Chapter of the American Academy of Matrimonial Lawyers. Over a period of several months, the group was able to work through their differences and arrive at a reasonable and fair compromise that resulted in A.7645/S.5678.

The legislation builds on earlier successful matrimonial law reforms in the State introduced in 2010: the passage of no-fault divorce; the introduction of a provision strengthening attorney’s fees for the non-moneyed spouse; and the adoption of formulas for calculating temporary maintenance awards.

Temporary maintenance standards have been especially welcome for low-income New Yorkers seeking a divorce. (Last year alone NYLAG received 1,178 calls about divorces.) The standards protect economically vulnerable spouses, allow litigants and lawyers to anticipate eventual court-ordered awards and thus settle cases without lengthy litigation, and assist those unable to pay for representation in obtaining needed financial awards.

Victims of domestic violence in particular have benefited from temporary maintenance rules, which have dramatically shorted the time it takes to receive a temporary award from as much as six months to just a few weeks. The law also enables parties to predict (as has long been the case with child support) how much temporary maintenance will be paid or received. For victims of domestic violence this predictability means the difference between staying with an abusive spouse and having the courage – and the means, to leave.

By expanding standards to post-divorce maintenance awards, A.7645/S.5678 will further streamline the divorce process and ease the burden on our judicial system, leading to more consistent awards, an increase in settlements and reduced litigation. Moderate- and low-income spouses who cannot afford an attorney will be able to use a simple formula to calculate legitimate claims for maintenance. The less-moneyed spouse who sacrificed her earning potential to support the more-moneyed spouse’s career, raise children, or care for elderly relatives will be compensated for the contributions she made to the wellbeing of her family.

On behalf of our clients and in the interest of matrimonial reform for all, I want to thank Judge Sunshine, the sponsors of the bill, Assemblywoman Helene E. Weinstein and Senator John J. Bonacic, along with Senator Ruth Hassel-Thompson, for their leadership and support. We urge Governor Cuomo to sign this bill when it arrives on his desk later this month. It will finally provide the consistency and predictability desperately needed in determining economic awards for vulnerable spouses in divorce proceedings, and more efficiently resolve matrimonial actions for families in New York State.

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SSI Restoration Act Will Strengthen Benefits for Poor and Disabled Americans

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Michelle Spadafore_This week, U.S. Senators Sherrod Brown (D-OH) and Elizabeth Warren (D-MA) and Representative Raul Grijalva (D-AZ) reintroduced a long overdue bill to strengthen and modernize Supplemental Security Income (SSI) benefits that are critical to the wellbeing of elderly, disabled, and blind Americans, including 1.3 million children.

As Senator Warren said when she introduced the bill last year, “SSI is a critical program that helps millions of our poorest and most vulnerable citizens keep their heads above water.” I’m very pleased to join Senator Brown to introduce the SSI Restoration Act, which will help strengthen SSI for families who rely on these essential benefits.”

The Supplemental Security Income Restoration Act (HR 2442/S 1387) would fix key elements of the SSI program that currently make life difficult for millions of low-income disabled and elderly individuals. Most of the SSI eligibility rules have not been updated since 1972 – when Richard Nixon was in the White House. After decades unchanged, the program is woefully out of step with the economic realities faced by the vulnerable Americans it was created to protect. For example, a beneficiary is only allowed to receive a maximum of $20 from other sources (such as a pension) without having their benefits reduced. The cost of living today is more than 5.5 times what it was in 1972, when you could buy a loaf of bread for 25 cents and a gallon of gas for 52 cents. The SSI Restoration Act would permit individuals to receive up to $112 monthly without a corresponding loss in benefits.

The bill will also increase the amount of money recipients can save for emergencies such as medical bills, and home and car repairs from the current cap of $2,000 to $10,000 ($15,000 for couples).  Often an illness or other unexpected expense can cause an individual to be temporarily unable to pay bills, leading to a slight excess in accumulated benefits. Currently, if their bank account goes over $2,000 on the first of the month – even by $1 – disabled and elderly recipients lose their only means of support.

The SSI benefit rate for an individual living alone is $820, which is rarely sufficient to pay for even a studio apartment in New York City. Often an elderly individual’s adult child will assist him or her in meeting rental responsibilities each month by paying $100 or $200 directly to the landlord. Under the current program, the monthly benefit is reduced whenever someone receives food or housing for less than fair market value from another person, including family members. The reintroduced bill eliminates this harsh provision.

According to a 2013 Economic Policy Institute Briefing Paper, 48 percent of the elderly population in the United States (roughly 19.9 million people) is “economically vulnerable,” defined as having an income that is less than two times the supplemental poverty threshold (SPT). SPT is a poverty measure that the Census Bureau has adopted in recent years that takes a more comprehensive look at what it actually costs to live than the traditional federal poverty line.

This number will only continue to climb as the massive population of baby boomers enters their “golden years” with limited savings and assets to support them through retirement.

My colleagues and I who staff NYLAG’s Disability Advocacy Project see the overwhelming challenges faced by the poor and disabled individuals we serve every day. The Supplemental Security Income Restoration Act is by no means a cure-all, but it will provide some long overdue relief for millions of Americans, and deliver on a promise we made them 40 years ago.

What can you do to help? You can email U.S. Senator of New York Charles Schumer or contact him by phone to let him know that you support the bill, and encourage him to co-sponsor the legislation.

Where can you find more information? Justice in Aging (formerly the National Senior Citizens Law Center), which supports the legislation, has posted an excellent overview and additional materials to their website.

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Why Your Credit Score Matters

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Doug Ostrov Blog CardA credit score is an often overlooked but vitally important indicator of financial health. Much like getting an annual medical check-up, monitoring your credit score regularly means you can catch and deal with problems early on.

Personal finance guru Suze Orman urges her readers to earn a “gold star” by getting their credit scores above 720. As she explains in her “Ridiculously Easy Financial To-Do List:”

“Your credit score affects the interest rates you’re offered on credit cards and loans, can be used to vet your job application, and in some states may influence your insurance premiums. So your credit reports, which determine your FICO score, need to be up-to-date and correct (mistakes abound). A score of at least 720 (the range is 300 to 850) earns you a gold star.”

She is right. Credit scores determine the interest rates and premiums you pay, including the interest you will pay on car loans, home loans, and student loans. And, yes, nearly half of all employers in the U.S. check the credit histories of job applicants, and use the information to make hiring decisions. This practice is both unfair and an illegitimate predictor of job performance.

Luckily, however, in New York City employment credit checks are about to become far less common. Yesterday Mayor de Blasio signed a bill to restrict the use of credit scores as a basis for hiring. While the bill exempts a number of professions, such as police officers, national security professionals and those bonded by the city or state, it is still the strictest such law in the nation.

This is a positive development for our city. NYLAG’s Consumer Protection Project submitted testimony before the City Council Civil Rights Committee strongly supporting the bill. Job-related credit screenings often target minorities, students and immigrants, who have been long victimized by predatory and deceitful lending practices that lead to mounting debt and poor credit. The use of credits checks prevents people who are willing to work hard from getting the jobs they need to get back on their feet and avoid further debt.

NYLAG’s Financial Counseling Division was launched in 2009 in response to the global financial crisis to help clients navigate through short term financial crises and plan for long term financial stability. This often includes helping them understand the importance of their credit scores and reports, and how to fix mistakes, prevent and recover from fraud and identity theft, and establish or improve damaged credit. The economic recession, which impacted people from every rung of the economic ladder, illuminated the fact that most people could benefit from  improved access to financial literacy resources and professional financial guidance to help them better manage their financial lives. Even as the economy improves, the need continues. Last year NYLAG was able to expand services to help empower students and low-income New Yorkers to manage their student loan debt and finances through outreach at community based organizations and CUNY colleges across the city.

Protecting Yourself From Consumer Banking FraudIn partnership with the Muriel F. Siebert Foundation, NYLAG launched Learn Money, a financial literacy website that provides people with the basic tools of personal finance. The site provides a starting point for people looking for information about managing their money, controlling spending, investing for the future, protecting assets, and maintaining good credit.

Our clients have told us countless stories of how damaged credit has affected their lives – often over relatively small amounts of money. According to a recent report from the Consumer Financial Protection Bureau, more than half (52%) of accounts in collection are medical bills. The median amount unpaid on medical collections $207 and average is $579. The bottom line is: always get proof of every bill you pay – medical bills especially. Otherwise a small unpaid bill (that you think you paid but was perhaps never processed, or was processed incorrectly by a medical billing office) can end up haunting you and your credit score.

Starting over after a major financial crisis can seem like an insurmountable task. But it can be done. You can work to eventually correct a mistake, rebuild your score, and stabilize your credit. It just takes time. And at the very least – if the new employment credit checks bill does what it purports to do – New Yorkers won’t have to worry quite as much about paying for those mistakes for years to come when it comes to applying for a job.

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