abstract. The Medical-Legal Partnership (MLP) model promotes the provision of direct legal services, interdisciplinary training, and public policy advocacy by lawyers situated in sites of medical care. Although scholars have called on MLPs to be more proficient in driving policy change, MLPs do not have a consistent record of doing so. But where they have achieved success, MLPs have done so by working in local coalitions. Building on this history, this Essay introduces a methodology of coalition building for MLPs to advance public policy goals more successfully and proposes metrics that MLPs can use to gauge their success. Through storytelling and analysis of our own experiences with coalition work in Connecticut and in Hawai’i, we document how coalition work can achieve policy wins. The Essay concludes with some observations regarding obstacles to coalitional practice and suggests that legal education and training will be essential to promoting this vision of public policy advocacy.

Introduction

The United States tolerates a staggering level of inequality—tied to racial, class, and gender hierarchies—that manifests in massive differentials in individual and community health between groups of people.1 Medical-Legal Partnership (MLP)—an interdisciplinary intervention conceived and innovated in Boston Medical Center, a safety-net hospital, during the 1990s2—seeks to respond to these discrepancies in community health with a three-legged approach: first, by providing preventative direct legal services to patients with health-harming legal needs;3 second, by fostering interdisciplinary professional education and training; and third, by engaging in structural and policy advocacy.4 MLP work brings lawyers together with doctors, nurses, social workers, and community health workers at healthcare sites that serve a designated community of patients, often defined by treatment group or geography.5 The lawyers, who are generally affiliated with legal aid or a law school clinic, address a wide range of legal issues, including housing stability (eviction defense, habitability, public-housing navigation), family law (guardianships, powers of attorney, domestic violence), income supports (employment law, state and federal public benefits, consumer protection), civil rights, and immigration/legal status. Many MLPs involve just a lawyer or two, while others include dozens of lawyers serving thousands of patients per year.

In a moment of increased attention to social determinants of health—the “conditions in which people are born, grow, work, live, and age”6—and as prominent voices warn against “conflating ‘health’ with ‘health care,’”7 it is no surprise that the MLP model has received much attention. For example, during the COVID-19 pandemic, scholars Gregg Gonsalves and Amy Kapczynski proposed large-scale federal funding for MLPs as part of a federal Community Health Core,8 and a version of the 2022 Build Back Better Act9 would have allocated five hundred million dollars to MLP work.10 Although this version of the Act failed in Congress, the first federal dollars specifically appropriated for MLPs were granted by the Administration for Children and Families in 2023,11 and additional MLP funding is contemplated in the Elder Justice Reauthorization and Modernization Act.12

At its core, the MLP model seeks to promote health justice, which Jamila Michener has defined as both an outcome and a process:

As an outcome, health justice reflects a vision—defined by and with people and communities in specific contexts—for what every person and community should have, irrespective of race, ethnicity, class, gender, or any other dimension of socially inscribed difference. As a process, health justice entails transforming existing economic and political institutions to make them more inclusive, responsive, and accountable, particularly in relation to the needs and demands of those who are consistently and systematically marginalized.13

MLPs nationally have already made strides toward this vision through the provision of direct legal services and by making interdisciplinary professional education and training the norm. However, fully actualizing Professor Michener’s vision of health justice will also require MLP practitioners to reconceptualize the manner in which we execute the third component of our mandate: structural and policy advocacy.

Since the COVID-19 pandemic and the uprisings of 2020, scholars have urged MLPs to focus more on advocating for policy change that is informed by racial justice and that builds community power and resilience in the face of systemic hostility and neglect.14 Dayna Bowen Matthew and Emily A. Benfer, for example, have called for a “massive expansion” of MLP resources to address systemic racial injustice.15 This Essay supports this call to action and argues that MLPs should pursue this type of systemic policy change by organizing within community coalitions.

MLPs already have achieved a handful of traditional policy wins. Matthew and Benfer cite examples of successful MLP policy advocacy in Chicago, Connecticut, New York, and Washington, D.C.16 And scholars have previously identified concrete MLP public policy wins, including police reform around U-Visas in Cleveland; housing-code inspections in San Mateo; home-health-agency-service legislation in Atlanta; language-justice advances in Kansas City; legal-aid funding in Syracuse; utility-shutoff protections in Boston; and advances in housing conditions in Washington, D.C.17

Notwithstanding these reported public policy wins, however, MLP policy advocacy has not been consistent and has not always been aimed at structural change. In 2012, Monica Carmean observed that while MLPs had made “tangible strides in their missions of direct service . . . and training,”18 the “examples of MLPs fighting for structural or systemic change are few and far between.”19 She concluded that “the biggest impact potential for MLPs would be achieved if they went beyond servicing individual cases and actually accomplished the systematic change they are called to advocate.”20 By the end of that decade, Joel Teitelbaum reported that “despite the emphasis on policy-level efforts, there is limited evidence of such activities taking place within most existing MLPs.”21

Where MLPs have been successful in public policy advocacy, these wins have one thing in common: every successful advocacy effort, no matter the substance of the issue, involved working and organizing in local coalitions. Community coalitions are “long-term collaborations that are composed of diverse organizations, factions, or constituencies that agree to work together to achieve a common goal.”22 Generally, these multiorganizational alliances are “built on complex relationships, maintained by specific structures and processes of communication, negotiation, and collective action, and sustained through dynamics of trust, mutuality, and collaboration.”23 They can be “investigated as a type of institutional arrangement used for social and political change.”24

The MLP form and purpose, an interdisciplinary collaboration aimed at improving population health, fits neatly into a public health tradition of community coalition work that is increasingly embraced at the grassroots and government levels.25 The partners that formally constitute MLPs—including doctors, social workers, nurses, attorneys, and case managers—are often already involved in various working groups, alliances, and coalitions that share information and work together to address individual and community health problems. After all, most MLPs are embedded in dynamic, community-based sites of care—like community health centers, free clinics, and safety-net hospitals—where the staff and patients are members of the same communities and participate in many of the same community institutions. In our experience, the more embedded the MLP, the better the platform for building relationships and growing networks of action and thought around health justice.

Still, community embeddedness and familiarity with coalitional work are not sufficient on their own. An MLP lawyer has to decide to be more than a traditional lawyer and choose to be a community activist willing to be organized into “networks of relationship and interdependency” and willing to share their “hoard of social capital.”26 MLP lawyers who want to win public policy battles must be willing to organize and be organized into the coalitions that can achieve structural change.

This Essay builds on the MLP literature that discusses “patients to policy,” a term that MLP practitioners use “to describe a policy trajectory” through which harmful policies are identified and reforms are designed and advocated for.27 The Essay offers practical guidance on how to do this advocacy—namely, through community coalition work. It is not surprising that the “how” is often absent in the literature because this work, when done well, centers the voices and power of traditionally excluded communities—not the institution of the MLP or traditionally centered professionals like doctors and lawyers. We posit that because community organizing is about the collective and not the individual, and because engaging in coalition work often means uplifting other organizations alongside your own, those of us doing this work are often behind the scenes and therefore less visible. If the goal is to uplift the work of affected communities, then their voices and strategies and leadership—indeed, their power—should rightfully be at the fore. This work may be less visible, but it should not be invisible. As the MLP network finds its footing in the policy realm, we seek to shine light on how the unique interdisciplinary MLP model is ideally positioned to advance community coalition work.

The Essay argues that MLP practitioners must organize within community coalitions to become more effective advocates. This democracy-enhancing work28 requires a focus on building and sharing power, elevating and accepting the leadership of community coalition partners, and holding ourselves and others accountable. The Essay proceeds in two Parts. In Part I, we build on the established “patients to policy” model of MLP public policy advocacy by introducing our model of coalition work for MLPs, drawing from the community coalition action theory, law and organizing literature, and Marshall Ganz’s model of organizing practice. We also propose metrics that MLPs can use to evaluate their own successes with coalitional work. In Part II, we provide two concrete examples of coalitional campaign work from our own MLP practices in Hawai’i and Connecticut and measure our successes and failures vis-à-vis those metrics. Finally, we conclude by describing some potential structural barriers to doing coalitional work in MLPs and by offering ideas on how to teach coalitional public policy advocacy to law students in MLPs.

I. from “patients to policy” to community coalitions

Since the inception of the MLP model, practitioners have endeavored to engage in the critical prong of policy work and systemic advocacy.29 However, the “patients to policy” approach that is predominant in the MLP literature has not provided much guidance on how to move from identifying policy needs to achieving policy wins. This Part seeks to fill that gap by arguing that MLP lawyers should help organize local coalitions around discrete policy campaigns that build towards systemic reform.30 Such community collaborations are necessary because no stakeholders are more committed to winning than the community members impacted by health-harming policies. While we cannot pretend that we, as MLP lawyers, have the same stake in these policy fights as directly impacted people, practitioners still have a role to play.

A. The MLP Mandate of “Patients to Policy”

The most comprehensive description of how MLPs should approach public policy is a chapter in the first and only MLP casebook, Poverty, Health and Law: Readings and Cases for Medical-Legal Partnership.31 The editors dedicate a chapter to “[s]trategies for [p]olicy [c]hange,” laying out the opportunity for systemic change “on behalf of vulnerable populations that could be brought about by legal and health professionals working together in medical-legal partnership.”32 The authors also debut the now-ubiquitous phrase “patients to policy,” which refers to the process of identifying harmful policies and then designing and advocating for reforms.33

In developing this “patients to policy” approach, the casebook focuses on the core inquiries for MLP practitioners contemplating policy advocacy: identifying key stakeholders in the MLP context; recognizing basic tactics and strategies that are available; and taking advantage of the special insights that the legal and medical sides might bring to the work.34 For example, with regard to stakeholders, the authors identify various parties that will have vested interests in many policy fights and therefore must be accounted for, including state, local, and federal governments; the general public; lobbyists and interest groups; professional and industry associations with recognized expertise; and government-relations offices of hospitals and law firms that have institutional gravitas and long-term relationships with policymakers.35 Likewise, the casebook authors advocate for an important outcome of collaboration whereby MLP healthcare providers “are more likely to understand the interaction between social and legal systems and patient health,” and MLP attorneys “are able to reframe their legal work in terms of patient health and well-being.”36

While we agree with the general framework advanced by the authors, the “patients to policy” approach does not sufficiently emphasize that the primary stakeholders in any advocacy work should be the impacted community members and their organizations. MLPs engaged in policy advocacy must start by building relationships with community stakeholders and centering their voices, policy solutions, and organizing strategies. Only if an MLP is able to build those relationships, align on strategic goals, and build a coalition can it have the structure and ongoing commitment to participate in the advocacy activities described by the casebook authors. These “grassroots and grasstops organizing” activities—such as preparing and presenting testimony, phone and text banking, calling and facilitating meetings, furnishing speakers, assembling educational materials, circulating petitions, contacting legislators, and engaging in press work—can then be carried out by practitioners in organized coalition.37 How then do we, as MLP attorneys, engage in organizing local communities and move beyond the traditional “patients to policy” approach to realize the MLP goal of systemic change?

B. Reimagining MLP Lawyers as Community Coalition Builders

The notion that direct-services lawyers should engage in organizing work is nothing new. In fact, in the last few decades, practitioners and legal academics have written about “how transformative theories can influence the practice of law itself: the day-to-day activities of lawyers who interact with clients, their communities, and the legal and political systems that affect everyone’s lives.”38 In this Section, we draw from community coalition action theory (CCAT), developed by Professors Frances D. Butterfoss and Michelle C. Kegler, to explain how MLP attorneys can use basic community-organizing concepts and skills in forming community coalitions to move beyond “patients to policy.” As CCAT envisions, coalitional development can be subdivided into three stages—formation, maintenance, and institutionalization.39 Here, we discuss the role that MLP lawyers can play in each of these stages.

During the formation phase, practitioners should strive to bring people together and establish norms, rules, and operating procedures for the coalition.40 In a profession that “largely acts as the private army of corporations, the carceral state, and/or the elites who benefit from both,”41 rather than for our client populations, rebellious-lawyering literature—including Gerald López’s seminal book, Rebellious Lawyering: One Chicano’s Vision of Progressive Law Practice—provides a practical foundation for our vision of organizing for public policy advocacy.42 Coauthor Dina Shek has previously described rebellious lawyering’s role in Hawai’i’s MLP work:

Rebellious lawyering calls on us to break through the trappings of our professions, to listen to and value the narratives and problem-solving of subordinated people, and to develop relationships of shared power and decision-making with the clients and communities we serve. This work demands a fundamental shift in attitude; it requires the belief that poor and marginalized people have the capacity to assess the effects of racism and economic deprivation and the right to lead their own communities and shape their own futures. Anything less, according to Eric Yamamoto, “undermines the notion of justice through legal process. It pulls law away from racial justice.”43

Pragmatically, this approach means taking seriously our relationships with communities and their organizations. We must recognize that when we pursue a concrete public policy goal, we are organizing and being organized into “networks of relationship and interdependency”44 that extend far beyond our own office and will determine the success of our advocacy. In his review of Rebellious Lawyering, Angelo Ancheta observed: “[P]rogressive lawyers are community activists who have legal training. As activists, they do much more than represent clients in legal proceedings . . . Lawyers organize community members . . . train others . . . use the media, the policy-making process, and the legal system to advocate for their clients.”45 But how do we use organizing to form coalitions?

There is no single right way to organize. A good place to start is with the work of Marshall Ganz. According to Ganz, “the five key practices of organizing” are “telling stories, building relationships, structuring teams, strategizing, and acting.”46 We propose that each of these practices should be used by MLP attorneys while organizing and being organized into community coalitions.

For example, “What brings you here?” might be the first question an organizer would ask during coalition formation. Organizing practitioners intentionally use stories to build one-on-one relationships and maintain a shared commitment to our common purpose. Ganz refers to this process of coming together as “association—not simply aggregation—that makes a whole greater than the sum of its parts.”47 This level of collaboration is not typically taught in law school, but it is particularly relevant for MLP policy practice. Ganz offers, “Through association we can learn to recast our individual interests as common interests, identify values we share, and envision objectives that we can use our combined resources to achieve.”48 At the same time, MLP attorneys should not be afraid to tell our own stories, especially “stories of sources of our own values,” that communicate why we are called to participate and develop leadership, why we hope to help mobilize this particular community, why we seek coalition, and what compels us to act.49 MLP lawyers all have a professional and personal story worth telling: very few of us view our MLP work as simply “a job,” but as part of our vocation and our calling. And some of us come from, have ties to, and face similar challenges as our constituent communities. We need to share that, find our common ground, and make specific commitments to others on the same path. Importantly, sharing our stories and building relationships here is not only intended to create friendships, but also to build collective capacity to both strategize and act.

The second stage of CCAT coalition development is the maintenance stage. Once a coalition is formed and begins to engage in outward-facing collective activity, MLP practitioners must then help maintain the coalition. In this phase, coalitions begin to identify policy goals, take concrete actions, acquire resources, and achieve concrete results.50 Coalitions must collectively strategize to find their “theory of change,” which Ganz describes as identifying “how we can turn what we have (resources) into what we need (power) to get what we want (achieving goals).”51 To carry out this theory of change, any coalition will require structure with defined, interdependent roles and explicit expectations for participation.52 Many coalitions have several committees, all of which do crucial work. But these committees cannot include everyone. Therefore, while the MLP lawyer should retain control over legal work within their expertise—such as drafting model legislation, analyzing the merits of legal objections that have been raised against a policy change, and providing “know your rights” trainings before direct actions—they must surrender control of other major tasks to community members and directly impacted people. This is a well-known professional challenge for many lawyers, and it means the MLP lawyer might not get to be involved in every negotiation with policymakers, be in every meeting, or take part in making every decision. It may be more important that other leaders—especially community leaders—step up at those crucial points, either because they have a more direct stake or because they have more capacity. This not only ensures that we prioritize the voices of those most impacted by the policy change, but it also helps develop and expand collective capacity.

Finally, the third stage of CCAT coalition development is the institutionalization stage. After the coalition has achieved a short-term policy win or faced an important defeat, the coalition must then confront new challenges—implementing the policy win, developing new capacity to revisit the problem, or embracing new policy advocacy campaigns altogether. In this institutionalization phase, coalitions become sustainable.53 Long-term sustainability requires coalitions to engage in a comprehensive evaluation of both the successes and the failures of their past activities and of the capacity for future coalitional action. It is these metrics to evaluate coalitional maintenance and institutionalization, therefore, that we turn to next.

C. Proposed Metrics for Coalition Maintenance and Institutionalization

MLP practitioners are serious about leveraging MLP’s potential for the “systemic change [we] are called to advocate.”54 In order to do so through durable coalition work, we need planning and assessment tools to maintain and institutionalize the coalitional formation that this Essay has promoted. The goal is to assess the extent to which the policy work promotes community power55 and builds democracy-enhancing spaces for meaningful reform to occur.56 In this Section, we offer tailored metrics, drawing from the CCAT literature, that MLP practitioners can use to evaluate public policy advocacy efforts. We developed these metrics through story sharing and structured discussions between the two coauthors about our respective policy work. We found ourselves circling around these metrics and key questions as we asked each other what went well, what could have been better, and what was still left to be done. We offer below one outcome of this process.

1. Concrete Policy Change

An important metric in evaluating a coalitional campaign for policy change is whether the policy win was achieved. This can be evaluated simply by measuring whether the law, regulation, or administrative policy the coalition targeted was changed in the way the coalition desired. To be clear, even without a legal win, policy campaigns can achieve significant advances in building community power and other democracy-enhancing outcomes, as addressed below.

2. Implementation of Policy Change

Winning a right on paper is not enough. A successful coalition must also pursue and monitor the successful implementation of the change. One advantage of MLP work is that our direct services inform our interdisciplinary education, which informs our policy work, which in turn is re-assessed by our experiences providing direct services. So, for example, if an MLP successfully advocates for a law that establishes certain rights on paper, but the rights are not exercised or enforced, the MLP will find out quickly from the patient-clients we serve. Ensuring that policy wins have traction on the ground requires having some sense of what implementation success looks like, especially from the perspective of affected communities.

3. Improving Coalition Capacities Through Interorganizational Relationships

Coalitional work is difficult work and can lead to as many interorganizational disputes as it does moments of unity. But experiencing either can lead to improved relationships, and improved coalition capacities in the future, if care is taken to maintain and nurture those associations. As such, monitoring the strength of relationships and trust within and between organizations is key. We should also assess whether and how relationships were reactivated for other campaigns, whether we engage in difficult conversations, and how we plan actions together to build, strengthen, improve, and heal relationships.57

4. Developing New Intraorganizational Capacities

MLP practitioners should use coalitional work to strengthen MLPs internally. As indicators of strength, practitioners should look to whether new internal working relationships formed, whether morale was boosted, whether new committees formed, and whether work stayed on track.

5. Elevating New Leaders and Organizers

Coalitional campaigns should be built to identify and elevate new leaders. These might be people who move from participating to active organizing, or people who step into more public roles from more private ones. MLP attorneys should be able to identify these emerging leaders from impacted communities and ensure that they are fully able to participate in the coalition. This can be accomplished, for example, by ensuring that speaking opportunities are shared with community members, elevating new organizers and leaders from impacted communities, and tracking whether community members have sufficient material support—for example, transportation, childcare, and training—to participate in these policy campaigns.

6. Changing the Public Narrative

Organizers recognize that changing the public story around health-harming social policy and the people it affects is an essential piece of winning on policy. Because of the high stakes of public communication, advocates should pay special attention to including directly impacted people and their organizations in an iterative decision-making conversation about terminology, messaging, slogans, and media narratives.

7. Prioritizing Community-Led Strategizing

MLP practitioners should prioritize coalitional work that elevates the leadership of directly impacted community members, especially leadership that arises from grassroots and democratic organizations. To start, practitioners should identify the points at which strategic decisions were made by the coalition and who participated in that decision-making. With the goal of developing processes that are iterative, flexible, and inclusive, we should identify and assess supports for the involvement of directly impacted people in those key decision-making points, not just lawyers and lobbyists.

8. Promoting Sustainable and Forward-Looking Organizational Structures

The health-justice movement needs organizational structures capable of creating both immediate and long-term impact. In most discrete policy campaigns, there is a high likelihood that the coalition will cease to exist once a win is achieved. We therefore should consider whether we need to build a long-term coalition that survives beyond a single campaign. When we prioritize and support the capacity of impacted communities—people with the most direct stake in the struggle—their ongoing organizing is almost certain. Assessment questions might include whether new coalition structures and roles were created, strengthened, or institutionalized. For example, a new group might be formed and named to continue the coalitional policy work, or existing organizations might create new positions to formalize their systemic advocacy work. These actions should promote the long-term participation of directly impacted community members.

9. Striving to Improve Relationships with State Actors

We enter coalitions to build our collective capacity to influence those in power, so we have to evaluate campaigns in part based on the state of our relationships to power. We must remind ourselves to judge state actors and other decision makers based on whether they are taking concrete actions to further community coalition goals. Put simply, actions speak louder than words. We should keep track of who is holding key relationships and how directly impacted community members are included in key conversations. We must reject tendencies to objectify community members or use them as props or window dressing.

10. Reducing the Power of Adversaries

Every health-promoting policy campaign worth undertaking has adversaries, whether out in the open or behind the scenes. To strengthen our coalition, we need to weaken our adversaries’ ability to limit our wins. An adversary could be an actor, a group of actors, an institution, or a structural barrier, like white supremacy. It is essential to include diverse coalition members in determining who or what is the adversary and in identifying how power is operating.

II. our stories of mlp coalitional work

Having outlined our vision for MLP coalitional work, we recount two stories from our own work as examples of MLP coalitional work. Section II.A tells our first story, from Hawai’i, which involves a long-term successful coalitional effort to fight the racist exclusion of Micronesian community members from Medicaid and other public benefits. Section II.B tells our second story, from Connecticut, which involves a more recent and ongoing coalitional effort to ensure that every person returning home from incarceration leaves with proper identification. In each of these examples, we not only illustrate that MLPs can effectively engage in public policy advocacy through coalitional work, but we also highlight our successes and failures by applying the preceding metrics.

A. Hawai’i’s Fight to Restore Medicaid for Micronesians

1. The Campaign

In Hawai’i—home to an estimated twenty-four thousand Micronesian migrants58—the Medical-Legal Partnership for Children in Hawai’i (MLPC-HI) has spent recent months educating patients, clients, fellow advocates, and community members about new federal benefits flowing from renegotiated treaty agreements called the Compacts of Free Association (COFA). These bilateral agreements between the United States and three Pacific nations—the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau—were embedded in the Consolidated Appropriations Act of 2024 and signed into law on March 9, 2024.59 The COFA Amendments Act grants MLPC-HI’s Micronesian clients and patients access to numerous federal programs including Supplemental Nutrition Assistance Program, Temporary Assistance for Needy Families, Supplemental Security Income, Federal Emergency Management Agency, and other benefits such as Veterans Affairs healthcare benefits and in-state tuition at all U.S. colleges and universities.60 This previously available group of entitlements had been stripped away by the 1996 Welfare Reform Act,61 a move that was justified, before and after, with racist and classist rhetoric.62 As attorneys from MLPC-HI share community updates about these critical benefits programs, they are also taking the time to share and celebrate the story of the long, difficult coalitional work that made this public policy advance possible. This is that story.

The fight to restore Medicaid benefits for Micronesians started in Hawai’i in August of 2009. The state’s Med-QUEST Division (Hawai’i’s Medicaid program) sent letters to Micronesian residents enrolled in Medicaid that read, “Aloha, Hawai’i’s economy has slowed. The State must decrease spending. The health benefits you are receiving from the Department of Human Services (DHS) will end on August 31, 2009.”63 The state began moving seven thousand Micronesian beneficiaries, including many MLPC-HI clients, to a new state-funded health insurance plan called Basic Health Hawai’i, which provided barebones coverage for a population known to have high healthcare needs.64 One MLPC-HI client was undergoing a kidney-transplant evaluation when she was told the new program would not cover transplant costs. Because she could not cover the costs herself, she was removed from the transplant list.

MLPC-HI was invited to join a fight already being mobilized by Micronesian organizations and public health allies, as well as local impact-litigation attorneys led by the Hawai’i Lawyers for Equal Justice.65 The protracted legal fight began at a rapid pace—with a preliminary injunction blocking the state’s limited insurance program on its first day—but became a five-year struggle spanning two gubernatorial administrations and ending with a Ninth Circuit loss66 and the U.S. Supreme Court denying review of the case.67 This legal battle was the backdrop for Micronesian communities to organize, testify, protest, and put pressure on the Governor and state officials, including through a powerful sit-in at the Governor’s office by the women of Micronesians United.68 While the legal battles ultimately allowed the state to implement a second-rate health program for its Micronesian residents, Micronesians themselves built and led the movement for an ultimate “federal fix.”

Throughout the eleven-year policy fight to restore federal Medicaid benefits, MLPC-HI was privileged to be invited into community spaces and to co-organize with Micronesian residents, including by forming the COFA Community Advocacy Network (COFACAN).69 In the earliest days of organizing COFACAN, MLPC-HI staff engaged in extensive story sharing and learned from their Micronesian partners that what mattered most was not necessarily the healthcare cuts, but rather the constant discriminatory language embedded in the healthcare fight and reflected in everyday racism.70 This “racial noise”71 of discriminatory narratives manifested in everything from anti-Micronesian “jokes” on morning radio72 to racist portrayals of Micronesians in social media,73 as well as in discrimination in classrooms, on playgrounds,74 and in healthcare settings.75

The coalition needed to change the public narrative. MLPC-HI intentionally employed empowering language in presentations, resolutions, media outreach, and academic work. And as MLPC-HI proceeded with this coalitional policy work, it shared platforms and speaking opportunities with partners. For example, as the non-Micronesian MLPC-HI attorney was frequently asked to speak to professional, student, and advocacy groups about “Micronesian issues,” she chose her opportunities carefully and frequently consulted with Micronesian partners to identify and support Micronesian speakers in her stead. Every engagement was an opportunity to shift the narratives (including teaching that people are not “issues”) and to ensure that the coalition elevated the voices of directly impacted partners, and not just the voices of the lawyers.

A struggle over competing state resolutions addressing COFA healthcare exemplified the battle over the public narrative. On March 12, 2015, Hawai’i’s House of Representatives introduced two resolutions with very different language. One resolution called for a “task force to investigate and coordinate the provision of medical, educational, housing, and social services to migrants from Freely Associated States.”76 This resolution spoke of the “significant financial impact” of the “cost of migrants,” and its drafters chose to include clauses saying, “there are high rates of tuberculosis, hepatitis B, and syphilis reported among migrants from the Freely Associated States.”77 The language repeated the common rhetoric of cost and disease burdens. Conversely, another bill urged the U.S. Congress to “restore federal healthcare funding for U.S. residents present under the Compacts of Free Association, in recognition of their unique historic and ongoing sacrifices and contributions to the United States of America and to the world.”78 That resolution highlighted Micronesian contributions and military sacrifices and U.S. responsibilities.79 This language was based on and echoed a previous resolution drafted by members of COFACAN to address the federal Medicaid policy fix. In this 2013 resolution, the coalition introduced positively framed language to urge “the United States Congress to include resident citizens of the freely associated states” as “qualified aliens” under the Welfare Reform Act in recognition of “their unique historic and ongoing sacrifices and contributions to the United States of America.”80

Another coalition partner, the Micronesian Health Advisory Coalition (MHAC), formed in response to the Hawai’i Medicaid cuts and took the state to another type of court by organizing the All Mike Basketball Tournament.81 This sports event was initially organized “to help defray the costs of the Attorney fees for the Basic Health Hawai[’]i litigation and to bring our Micronesian communities together in a healthy event.”82 The tournament raised money for the ongoing litigation, educated communities about the policy issues and legal updates, and provided valuable health education and resources. The “All Mike” brought together Micronesians, Marshallese, Palauans, and other Pacific Islanders, and raised nearly eight thousand dollars to support the lawsuit.83 It became an annual event and still works to serve current justice and community needs.84

The work of COFACAN, MHAC, and the “All Mike” tournaments shifted the focus of who controlled the message and the movement of the Medicaid policy struggle. MLPC-HI followed the community’s lead in much of the organizing and community education. And MLPC-HI staff shared leadership and networking opportunities in support of our shared goals. The coalition’s strong relationships and ongoing communication with key congressional leaders kept the policy movement alive well after the litigation ended. In December 2020, after an eleven-year policy fight in Hawai’i, Senator Mazie Hirono ensured that the U.S. Congress included Medicaid restoration for Micronesians in the federal CARES Act.85 Today, MLPC-HI continues to work alongside the coalition members and congressional staff to educate the public about Medicaid access and to ensure full implementation of the additional federal benefits restored in March 2024.86

2. Measuring the Campaign’s Success

In Hawai’i, the Micronesian community won the significant policy victories of restoring Medicaid benefits in 2020 and other federal benefits in 2024. While litigators were integral in the early days of the legal fight in Hawai’i, it was the community coalition of Micronesian-led organizations working with community lawyers (like MLPC-HI) that redefined the policy goals and strategies to success. The implementation of these federal benefits is proceeding, but not without challenges and continued vigilance. MLPC-HI works with the same coalition members who fought for these policy changes, including national COFA advocates, to monitor and address implementation challenges on the ground. This includes sharing advocacy stories, meeting and working with state benefits administrators, and expanding our coalition of partners committed to successful implementation.

MLPC-HI built long-lasting relationships during the Medicaid campaign with Micronesian community leaders, church leaders, and advocates, through years of close collaboration. This included sharing personal stories (sharing why we care in order to align our values and goals) and side-by-side organizing on this campaign and others. MLPC-HI’s primary health center partner was a key site for organizing work, leveraging both professional and community networks within the organization to achieve civic engagement and public policy success. The Hawai’i campaign also forged strong relationships with local, state, and federal officials, and Micronesian leaders were always at the table.87 Still, not all personal and professional relationships endured, and at times we simply embraced the value of showing up and showing grace, knowing that we all have a role to play in the struggle.88

While formal organizations were established and strengthened through Hawai’i’s Medicaid fight, ad hoc structures like COFACAN served as an appropriate vehicle for rapid responses to organizing and outreach needs. In later years, COFACAN was less active and primarily endured as a Facebook group. Recently, a new generation of young Micronesian activists in Hawai’i have asked to use the COFACAN name and structures for new organizing and outreach efforts and to share current social justice messages. Throughout the campaign, MLPC-HI worked to elevate Micronesian leaders and support their advocacy skills and opportunities, including creating a salaried staff position for a Micronesian advocate who was mentored by the Medicaid campaign organizers.

Our primary goal was Medicaid restoration, but our primary adversary was the deeply embedded structural racism of the state. As described earlier, the Hawai’i campaign directly confronted racist narratives designed to marginalize and undermine Micronesian demands for equality. Coalition members also addressed power imbalances by having frank discussions about racial dynamics in Hawai’i, structural barriers, and representation. Ultimately, because the coalition was centered around Micronesian people directly impacted by the target policies, we continue to see organizing and policy successes coming from this ever-expanding circle. With community-centered coalitions, the advocacy doesn’t stop after the win.

B. Connecticut Transitions State ID Campaign: “No ID, No Second Chance”

1. The Campaign

Transitions MLP in New Haven, Connecticut, is located within Transitions Clinic, a primary-care clinic serving people returning home from incarceration, as part of a national network that exists in fourteen states and Puerto Rico.89 Transitions is a small academic MLP staffed on the legal side by an attorney and several law students who screen new patients for civil legal needs and provide advice, brief service, and representation under the supervision of the attorney. The students also provide formal and informal presentations on legal determinants of health for medical staff in the clinic and in the larger health-system community.

From the MLP’s earliest days, doctors at the clinic brought to the MLP attorney’s attention that the lack of reliable state identification for formerly incarcerated patients was a major barrier to housing, employment, and public benefits. Law students at the MLP began meeting patients who did not have identification and learned firsthand how the lack of official identification hamstrung patients’ capacity to simply survive. We set about researching the issue of state identification and quickly learned that people all over the country are discharged from carceral facilities without proper identification.90 We struggled with the same question that Transitions patients and state legislators face: how, in the twenty-first century, are we sure enough about a person’s identity to lock them up, but not sure enough to issue a functioning ID?

Partnering with a network of reentry service providers, advocates, and organizers that had relationships with the MLP, we found that community members had fought this battle many times and were so exasperated by their repeated efforts that they did not even want to talk about it. In fact, community members had twice succeeded in passing legislation that they thought would fix the problem in theory, but that did not in practice. This was an example of how demoralizing a “paper win” can be.

The law students and the MLP attorney met internally as a team and decided to create a survey, which they distributed to providers to give to their clients. The purpose of the survey was to gather information about the frequency of people returning to community without identification, to find compelling stories, and to deepen working relationships with other providers. Meanwhile, we identified legislation from other states and connected with groups in California and New York working on the same issue. A Transitions Clinic partner connected our MLP to a staff attorney with Root and Rebound, a public-interest law firm focused on reentry that had worked closely on the language of a similar bill in California. Transitions staff and patients began to involve themselves in the advocacy, participating in meetings with legislators, talking at community events, and persuading longtime New Haven community partners at the Reentry Roundtable (an open forum for reentry service providers and advocates) that the issue, while frustrating, was still important.

The Transitions Clinic MLP began to build relationships at the state level, specifically around the ID issue. The clinic presented the issue to, and gained support from, member organizations of the Justice Reinvestment Coalition—which focused on using money saved by prison closures to fund communities decimated by incarceration—as well as the Recovery for All Coalition, which joined labor, faith, and community partners to focus on programs and policies that promote racial equity and tax fairness. Transitions MLP represented the clinic in this outreach and relationship-building work, with the dual motive of passing ID legislation and also educating more people about the importance of community-health-worker funding—an issue that was already being driven by another organization, Health Equity Solutions.91 MLP students also educated patients one-on-one about our legislative campaign and continued to speak at community and other public events.

As a result of these activities, a New Haven legislator, who had passed ID legislation in the past, decided to champion an ID bill.92 He raised the bill in committee, and Transitions staff and some former patients went to the Connecticut state capitol in Hartford to talk to individual legislators and meet coalition partners in person. At a committee hearing packed with testimony from the coalition, we learned that even the “law and order” committee members wanted new legislation to pass, and eventually the bill passed through the legislature unanimously.93 By this point, our momentum carried us well past our own organization’s top priority. After our ID legislation passed, we participated in direct action as our labor coalition partners fought for healthcare funding. In an unforgettable moment, one of our MLP medical champions volunteered to take arrest at the state capitol in support of better pay for healthcare workers.94 Her willingness to sacrifice for a coalition partner, even after our immediate goal had been reached, embodied to us a capacity for solidarity and a desire to pursue “a vision—defined by and with people and communities in specific contexts—for what every person and community should have,”95 that went beyond any one issue or cause.

The MLP is now advocating for the bill’s implementation, having determined next steps based on information from community meetings, new relationships inside the Department of Corrections, and new patients on clinic days. The energy from the campaign is still tangible, with community health workers and researchers from clinic persistently pushing MLP towards implementation advocacy and asking, “When are we going back to Hartford?”

2. Measuring the Campaign’s Success

Using our metrics identified in Section I.C, the Connecticut coalitional campaign has been a mixed success. The state ID coalitional campaign built on narrative-change work done by previous criminal-justice-reform advocates, who had popularized the idea that Connecticut should be a “second-chance society.” Organizers built on that phrase by repeating the slogan “No I.D. means no second chance.” While the coalition succeeded in passing new legislation, we are only beginning the implementation campaign to make the new identification law a reality. And we cannot truly say that through this campaign we have reduced the overall power of our principal adversaries—namely, those within the carceral system who benefit from punitive or neglectful practices like failing to provide effective reentry into the community.

But there are many positive takeaways. The campaign strengthened relationships between Transitions MLP, the healthcare-workers union, and the ACLU Smart Justice project, and it forged a new relationship with the Recovery for All Coalition—although it is not yet clear whether all of the organizations will continue to work on implementation. Additionally, the campaign built new internal capacity by sparking the establishment of an internal advocacy committee that aligns internal Transitions Clinic advocacy efforts and brings new people into that work, including formerly incarcerated community health workers, doctors, and researchers. That was possible because many individuals from Transitions Clinic and MLP stepped into roles of greater responsibility at various points during the coalitional work. Further, the Transitions Clinic deepened its relationship with the co-chairs of the state Judiciary Committee and built new, productive relationships with frontline Department of Correction workers in charge of state ID procurement. Overall, while the effects of this coalitional effort still remain to be fully seen, it is clear that success will depend on whether the process of pushing for implementation continues to build new relationships and new leaders, whether we can put an ID into the hands of every Connecticut resident leaving incarceration who wants one, and whether our advocacy can be a model for other states.

Conclusion: Obstacles, Pedagogy, And A Final Story

As this Essay has highlighted, MLP practice is a great fit for public policy advocacy through coalition—but that is not to say that this work is easy. The first and largest obstacle to doing this work consistently is the “shoestring” funding available for MLP work,96 both on the individual-program level and nationally. Most MLPs are understaffed for the volume of work that needs to be done.97 Additionally, many MLPs are initiated with specific grants or health-system expectations, which set metrics based primarily on individual patients served, legal matters handled, or even cost savings. Federal funding for MLPs, especially through the Legal Services Corporation that funds most legal aid programs, often carries severe restrictions on advocacy and organizing work.98 While this is not necessarily incompatible with MLP practitioners organizing in coalitions, it incentivizes individual client work over policy change work.99

Another issue is the limiting effect of institutional affiliation. For example, in New Haven, the Transitions MLP Clinic is affiliated with both Yale University and the Yale New Haven Health system—the two largest employers in the city, with their own interests and their own troubled histories.100 These institutional affiliations strengthen our credibility with some community actors and greatly weaken our credibility with others—particularly multiracial working-class constituencies within the city that have struggled to assert themselves vis-à-vis powerful community institutions, like the university and the hospital, over issues like medical debt,101 property taxes,102 and labor organizing.103 Furthermore, in the case of our medical partners in the health system, we are, without question, constrained in the advocacy we can do that would be directly adverse to their interests. For example, our Transitions MLP could never ethically represent a patient against one of the Transitions Clinic providers in a malpractice suit because we would struggle with divided loyalties. As lawyers, we would face a similar challenge with involving ourselves in a policy fight directly adverse to the interests of our medical partner, even if the ethical rules might not strictly forbid it. We are fortunate to work with health systems that have expressed an understanding, through word and action, that health justice will benefit their institutions, but we have not yet had to test the limits of that understanding on any issue.

We argue for MLP coalitional public policy work from our place as MLP lawyers, situated among social-service providers, community leaders, state actors, and large institutions. We believe this is the best method available to us to achieve policy success for our patient populations. While we agree that the “countervailing power of workers and other constituencies has been . . . undermined by the gradual shift away from mass-member organizations to professionalized nonprofit advocacy groups,”104 we hope that the way we are doing this work—conscientiously building constituencies for health justice that include member-led grassroots organizations—will facilitate rather than depress community participation in mass organization or other political work. We are open to being proven wrong. But there are now thousands of MLP lawyers working across the United States, and we believe many already “[use] their skills in more proactive and holistic ways” and “see their role as that of conscious tacticians—not saviors or bystanders.”105 Our national MLP network of 450 sites across forty-nine U.S. states is well-positioned both to engage in local coalitions and to organize for national reform. Indeed, the Hawai’i Medicaid campaign always carried a “Medicaid for All” vision and goal. And in Connecticut, the campaign for state IDs for formerly incarcerated people includes the work of individuals and organizations advocating more profound, abolitionist, change. We hope the MLP national network—itself a potentially powerful coalition—will continue to grow and organize in ever more expansive ways, linking our local policy work to national movements for change.

Legal education has an important role in making this possible. “Lawyers must know how to work with (not just on behalf of)” the poor and marginalized.106 A coalition-based approach to public policy advocacy is extremely teachable, and versions of its lessons have been passed down for generations through community, labor, and faith institutions around the country and the world. Important traditional lawyering skills like legislative drafting, public speaking, and drafting testimony in the context of policy campaigns are already featured in many clinical programs.107 There are now increased calls for law schools to incorporate organizing training into the clinical curriculum, as we see with the development of new centers like New York University’s Law and Organizing Lab.108 Surging areas of legal scholarship, such as law and political economy, recognize and promote the role of law and organizing.109 Finally, law student workers have organized their own unions and other organizations to change the conditions under which they teach, research, and edit journals like this one.110 We believe that if there was ever a generation of law students interested in learning and teaching actual organizing skills, and not content to leave that capacity on the shelf, it is the current one. We invite more discussion, from students, practitioners, teachers, and researchers, about how to develop assessment and planning metrics for MLP policy work.

As clinicians, we believe that practice is the best way to learn. In these grassroots activities, students will probably be reliant on relationships built by their instructors and past students to find their way into the work, and it may be difficult for a one-semester student to experience the full range of MLP practice. The academic calendar has proved to be a challenge for students who have worked with us, as coalitional activities tend to go on all year round. And while we are the permanent representatives of our organizations at that table, students can gain valuable experience by joining coalitional meetings, meeting key stakeholders, and building relationships through the work.

Students who believe themselves to be effective community advocates may find themselves humbled by the challenges, conflict, and even suffering inherent in genuine coalition work. On the flip side, students who ordinarily avoid meetings like the plague may find their vocation in this work. As Bernice Johnson Reagon pointed out, we “don’t go into coalition because [we] just like it.”111 No—inspired by organizers like the women of Micronesians United fighting for lifesaving Medicaid benefits, we go into coalition because we want more justice for more people.

We offer a final policy lesson and story from the Hawai’i Medicaid struggle. While we may not all have an equal stake in every fight, we are all bound together. We organize like our lives depend on it because they do. When the Micronesian women organized a sit-in targeting an obstinate state governor hell-bent on implementing healthcare cuts, coalition leader Innocenta Sound-Kikku led the group in a Chuukese song that exemplifies the best elements of coalitional work for change. It is a deeply democratic song from a people mobilizing for health justice and unapologetically fighting to “sustain[] a common bond of history, heritage, and attendant human connection through compassion.”112

Ach etto esapw usun pakutang
A atai fonu o pwun o ira,
Sa eto sipwe chok chufengen
Sipwe chu ren pwapwa
Pwapwa o tipeuw tong fengen
Tipewu enlet tong fengen
Epwe cho nonomw lon lefilach

Our being here is not like the destruction of a bomb
[That] destroys land earth and the trees
We come so we can just meet
We’ll meet in joy
Joy and common understanding and common love
Understanding in true common compassion
That must bind us together.113

James Bhandary-Alexander is a clinical lecturer at Yale Law School and the legal director of the Medical-Legal Partnership program at the Solomon Center for Health Law & Policy. Dina Shek is a faculty specialist at the William S. Richardson School of Law (University of Hawai’i at Mānoa) and the legal director of the Medical-Legal Partnership for Children in Hawai’i. The authors would like to thank our staff, students, and community partners who work every day with dignity, purpose, and joy, in the face of many challenges. We are extremely grateful to the editors of the Yale Law Journal for their excellent work in editing this piece.