Securing Stability: Legal Aid?s Lasting Impact A report by The Center for Community Solutions 1 Legal Ald Society of Clevelann Wear/?; THE CENTER FOR BUMMUNITY SOLUTIONS Table of Contents Introduction .............................................................................................................................................. 2 Overall Findings......................................................................................................................................... 6 Financial Stability .................................................................................................................................... 10 Family Stability ........................................................................................................................................ 18 Health Stability ........................................................................................................................................ 24 Housing Stability ..................................................................................................................................... 29 Educational Stability ............................................................................................................................... 37 Civic Involvement .................................................................................................................................... 41 Conclusion ............................................................................................................................................... 47 Appendix A: Survey ................................................................................................................................. 48 This report was prepared by a team from The Center for Community Solutions including: Emily Campbell, Associate Director and Williamson Family Fellow for Applied Research Emily Muttillo, Research Fellow Kate Warren, Research Associate Adam White, Policy and Research Assistant Emily Davis, Graduate Assistant Sam Sobol, Graduate Assistant June, 2018 2 Introduction There are significant differences between criminal law and civil law and the legal rights associated with each. Miranda rights, often recited in television shows, movies and other pop-culture entertainment, lead many people to believe that protection is assured for people who cannot afford legal help in the United States. But this is not true. These rights only apply in serious criminal cases. There is no constitutional right to free legal representation in civil cases, such as those dealing with health, safety, shelter, education and economic security. That is where civil legal aid makes an impact. Legal issues related to civil law often impact low-income individuals and families negatively and contribute to the perpetuation of poverty. Individuals and families face high stakes and dismal odds when they must navigate the civil legal system alone, without a lawyer. If they lose one civil case, additional legal problems, other challenges and expenses can quickly multiply. Civil legal assistance, like that provided by legal aid nonprofits in the United States, is meant to address these problems. Cases have clear outcomes, either favorable or unfavorable for each client. Civil legal assistance can have a direct impact, in foreclosures prevented, orders of protection granted, and benefits and income obtained. But the impact of legal aid assistance goes beyond those case outcomes and direct effects. Civil legal assistance is closely tied to improvements in stability for individuals and families, which has been shown to cause improvements to quality of life and the broader societal benefit. This study sought to examine the longer-term tangential, or indirect, impact of civil legal assistance especially those impacts that relate to broader societal good.1 Utilizing a mixed-methods approach to collect primary qualitative data, we found that the majority of former Legal Aid clients who responded reported an improvement in stability following their interactions with Legal Aid. Further, legal aid assistance has a lasting impact, and clients who worked with Legal Aid between two and five years ago were most likely to report at least one improvement in stability. About Legal Aid The Legal Aid of Society of Cleveland (serving Ashtabula, Cuyahoga, Geauga, Lake and Lorain counties) and Community Legal Aid (serving Medina, Portage, Stark, Summit, Mahoning, Trumbull, Columbiana and Wayne counties) are two independent nonprofit civil legal aid programs in Northeast Ohio. The 13 county area both organizations serve contains the cities of Akron, Canton, Cleveland and Youngstown and hundreds of smaller municipalities spread in rural, suburban and urban areas. The mission of The Legal Aid Society of Cleveland is, “to secure justice and resolve fundamental problems for those who are low income and vulnerable by providing high quality legal services and working for systemic solutions.” This is similar to the mission of Community Legal Aid, “through legal advocacy, we transform the lives of those in poverty to increase opportunities, fairness, and stability, for a stronger community and justice for all.” Both of these guiding statements shape the work of the organizations. For the purposes of this report, The Legal Aid Society of Cleveland and Community Legal Aid are collectively referred to as “Legal Aid.” Legal Aid represents clients in court and administrative hearings. Legal Aid also provides advice, brief assistance, and community education on legal rights. Legal Aid handles cases that affect basic needs 1 This report was commissioned by The Legal Aid Society of Cleveland and Community Legal Aid, who engaged The Center for Community Solutions to conduct the research. 3 such as health, shelter and safety, economics and education, and individual rights. Legal Aid helps individuals overcome the chaos brought on by legal troubles. Legal aid services allow clients to regain control of and stabilize their lives by securing the benefits they’ve earned, reducing violence and discrimination, and preserving dignity and independence. Legal Aid's attorneys practice in the areas of consumer rights, domestic violence, education, employment, family law, health, housing, foreclosure, immigration, public benefits, utilities and tax. Research Approach In order to assess this lasting impact, The Center for Community Solutions sought out clients who reached out to Legal Aid two or more years ago. More than 1,250 former clients responded to a survey which asked several open-ended questions about the client’s experience with Legal Aid and their lives since. The survey requested information about the client, the type of problem they sought assistance for, how Legal Aid helped and how their lives were impacted. The surveys were distributed by The Legal Aid Society of Cleveland and Community Legal Aid via email, text message, social media, and paper mail.2 Figure 1: Location of Survey Respondents by ZIP Code Because the response rate was higher than anticipated, the survey responses represent a rich source of qualitative data from former clients. Verbatim quotes from these responses are included throughout this report. Responses were assessed individually by researchers and the content was evaluated to see if it indicated an improvement in stability which was then categorized. Survey respondents could opt-in to be contacted for an interview to provide more details about their experiences with Legal Aid, and their lives since resolution of their legal problems. Interviews were conducted with 20 former Legal Aid clients. Interviewees were randomly selected from the pool of survey responses and were chosen to represent a variety of legal problems, counties of residence, and length of time since legal assistance. Case studies developed from interview conversations are included throughout the report. Interviews were analyzed using a model adapted from the Wenger-Trayner framework3 for promoting and assessing value creation. For the purposes of this report, the value analyzed is the impact of a legal intervention provided by Legal Aid on the individual and his or her family. 2 Although every former Legal Aid client had an equal chance of being included in the study, respondents likely do not represent a statistically valid sample of clients. 3 Wenger, E., Trayner, B., and de Laat, M. “Promoting and Assessing Value Creation in Communities and Networks: a Conceptual Framework.” Open University of the Netherlands, 2011. 4 On a parallel line of research, we conducted an extensive literature review that explored the assumptions that are necessary to believe the work of Legal Aid has a positive impact on clients. Through this, we sought to understand the documented links between the types of issues legal aid assistance addresses and societal goods such as civic participation, parent engagement, educational success and decreased reliance on public assistance. We specifically examined a variety of legal aid problem areas to learn what, if any, documented improvements for individuals, families or society could result. These areas included bankruptcy, civil protection from intimate partner violence, lead exposure in homes, tax issues, public benefits, housing loss or conditions, expungement, vital documents, immigration and education. Published research was reviewed for each area of practice to identify connections to one or more of the assumed benefits; family stability, housing stability, children’s educational success, health, financial stability and community and civic involvement. The body of this report is organized by the six areas of stability assessed. In each section, the report includes the data on reported stability by time since Legal Aid assistance; by problem area; and for certain problems, the share of people who experience different types of stability. These data are presented in the context of literature on each type of stability, and are illustrated with client quotes and case scenarios. 5 Overall Findings Finding: Legal Aid’s assistance has a long-term, lasting impact that allows individuals and families to secure stability in a wide variety of different areas. There are immediate, intermediate and long-term impacts of legal aid assistance. An understanding of these improvements provides some explanation of the mechanisms that enable some clients to experience stability improvements as a result of their interactions with Legal Aid. Figure 2: Phases of Legal Aid Impact In addition to the changes that occur from simply getting help with a civil legal problem, this study examines the impact of 11 legal problems on six areas of stability improvement, which are linked to benefits for individuals and society. Former clients attributed the improvements that have occurred in their lives since interacting with Legal Aid to the assistance they received. Overall, we found that 54 percent of clients who responded to the survey reported an improvement in at least one area of stability. Figure 3, below, defines the areas of stability and the number of clients who reported improvements in that area. Many described improvements in several stability areas. 6 “I felt helpless for a very long time until they came along and made me feel very hopeful.” (Client from Cuyahoga County, Family Problems, 2 to 5 years ago.) Figure 3: Areas of Stability Improvement Stability Improvement Area Financial Stability Number of Clients (n=1,267)4 314 Clients experienced improvements (25 percent)5 Definition Financial stability requires adequate and predictable income and sufficient financial resources. Income can be wages, retirement income, public benefits or disability benefits. Financial resources include assets and savings to cover unexpected expenses and access to affordable housing and other goods and services. Family Stability 189 Clients experienced improvements (15 percent) Family stability is the consistency of family activities and routines. In contrast, family instability is a chronically chaotic and unpredictable family environment. Indicators for family instability include residential mobility, rotating intimate relationships among adult primary caregiver, number of families a child has lived with, serious childhood illness and other recent negative life events including but not limited to job change, death and eviction. In one generally-accepted definition, health stability does not mean an individual is in perfect health, but rather his or her health is predictable, implying the proper conditions are in place to manage health. In addition to needing access to doctors, hospitals and pharmacies, environment and other social determinants play a crucial role in health stability. Health Stability 169 Clients experienced improvements (13 percent) Housing Stability 142 Clients experienced improvements (11 percent) Education Stability 29 Clients experienced improvements (2 percent) It is widely recognized that housing stability exists on a continuum, however, there is currently no standard or formal definition of that continuum. At the most basic level, the housing stability continuum spans from being homeless to having permanent housing. But merely looking at the extremes overlooks the struggle many Americans experience, often referred to by various terms that include housing insecurity, instability, insufficiency and risk of homelessness. A broad definition of educational success goes beyond measures of academic achievement, to include skill attainment, satisfaction, social and emotional development, access to trauma-informed classroom practices and inclusion in educationally purposeful activities. Civic Involvement 22 Clients Experienced improvements (2 percent) Civic behaviors are “activities oriented toward collective action, care, concern and development of others, as well as societal decision making and resource allocation.” This includes voting and political participation, volunteering and participation in voluntary associations and social groups. 4 A total of 675 clients reported at least one stability improvement. Number of clients refers to the number who reported a stability improvement, not the legal problem for which they sought assistance from Legal Aid. 5 7 Clients who received help with a variety of civil legal problems were included in this study. Case problem areas were placed in 11 distinct categories. The civil legal matters included in each category are defined in the table below. Figure 4: Definition of Civil Legal Problem Area Categories Number of Clients Legal Problem Area/ Area of Practice Who Responded (n=1,267) Family Problems: Adoption, custody, divorce, adult guardian, name 380 change, parental rights, paternity, domestic abuse Debt Problems: Bankruptcy, collections, repossession, garnishment 349 Housing Problems: Subsidized housing, homeownership, landlord/ 256 tenant, public housing, mobile homes, public utilities, discrimination, foreclosure, predatory mortgage lending Income and Benefits Problems: TANF6, Social Security, SSI7, SSDI8, 147 unemployment, veterans benefits, state and local income benefits Work-Related Problems: Discrimination, EITC9, taxes, employee rights, 75 wage claims Health Care Problems: Medicaid, Medicare, CHIP10, home and 56 community-based care, private health insurance, long-term care Discrimination and Individuals Rights Problems: Mental health, 42 disability rights, civil rights, human trafficking, criminal records expungement School Related Problems: Discipline, special education, IEP11, 504 38 plans, vocation education Fraud and Consumer Protection Problems: Predatory lending, 38 deceptive sales End of Life Planning Problems: Wills and estates, advance directives, 28 powers of attorney Problems for Children: Delinquency, neglect or abuse, emancipation, 17 minor guardian conservatorship Number Reporting Improvement in Stability 200 205 144 80 39 26 18 27 16 11 7 Stability improvements were found for at least one-third of clients who received help in each civil legal problem category. As shown below, in six of the 11 categories, more than half of former clients who responded reported at least one stability impact area. 6 Temporary Assistance for Needy Families Supplemental Security Income 8 Social Security Disability Insurance 9 Earned Income Tax Credit 10 Children’s Health Insurance Program 11 Individualized Education Program 7 8 Figure 5: Clients Who Reported a Stability Improvement, by Legal Problem Improved stability was most often seen in those issues related to the legal problem. For example, clients whose cases related to income and benefits and debt saw the greatest improvements in financial stability. However, stability improvements were also reported by individuals in areas unrelated to their original legal problem, with the most common happening between family problems and health stability. These intersections are described in greater detail in subsequent sections of this report. Figure 6: Share of Former Legal Aid Clients Who Reported a Stability Improvement Overall By time since Legal Aid assistance 60% 59% 50% 40% 53% 30% 47% 58% 51% 20% 10% 0% Less than 2 2 to 5 years 6 to 10 years 10 years or Years more Legal aid assistance has lasting impact. Across all problem categories, clients whose cases were resolved between two and five years ago were most likely to report a stability improvement. More than half of clients whose interaction with Legal Aid was more than a decade ago attributed changes in at least one stability area to civil legal aid assistance. Among this group of the oldest cases, improvements in family stability were most common. Nearly one-quarter of respondents whose case occurred 10 or more years ago reported improvement in family stability. Research indicates that family stability is particularly important to help children rebuild resiliency and overcome disadvantages like Adverse Childhood Experiences (ACEs). 9 Financial Stability Finding: Working with Legal Aid impacts a client’s financial well-being for many years following a case, regardless of the type of legal problem the initial case addressed. Legal Aid focuses on employment, bankruptcy and income maintenance with the expectation that intervening in cases related to these areas will result in financial stability for the individual and his or her family. One definition of financial stability comes from United Way Worldwide (United Way). United Way states, “to achieve financial stability, families must have stable, adequate income as well as stable, adequate financial resources. Stable, adequate income is derived from a job that pays family-sustaining wages and public, employer and informal income supports and subsidies. Stable, adequate financial resources include savings and assets to cover unexpected expenses, affordable and accessible goods and services and safe, affordable housing.”12 An effective way to improve financial stability is to increase income. Income can be wages, retirement income, public benefits or disability benefits. However, accessing income and maintaining income can be challenging for individuals and families with multiple sources of instability in their lives. Figure 7: Share of Former Legal Aid Clients Who Reported a Financial Stability Increase Overall By time since Legal Aid assistance 30% 25% 25% 20% 15% 27% 22% 29% 20% 10% 5% 0% Less than 2 2 to 5 years 6 to 10 years 10 years or Years more One-quarter of former Legal Aid clients who responded reported an increase in financial stability. Clients who worked with Legal Aid as recently as a month ago, as well as those with legal cases from more than 10 years ago, experienced an increase in financial stability. These clients represent various types of cases, many not related to financial problems. Clients who sought help for a problem related to income, employment or benefits who had a positive case outcome saw an immediate impact. In the longer term, impact peaks six to 10 years after case resolution. This supports the assumption that working with Legal Aid impacts clients’ financial wellbeing for many years following their cases, regardless of type of legal problem addressed. 12 United Way Worldwide, “Achieving financial stability for individuals and families through integrated service delivery.” 2013. 10 Figure 8: Rates of Financial Stability Improvement by Legal Problem Debt Income and Benefits Work Related Health Care Discrimination Fraud End of Life Planning School Related Housing Family Problems Problems for children 44% 41% 39% 25% 24% 21% 18% 16% 14% 10% 6% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Clients reported the highest rate of financial stability when their initial case was related to finances, such as debt, income and benefits, work-related and/or fraud. It is notable that cases related to health care had a higher rate of increased financial stability than those related to fraud. Figure 9: Share of Clients Helped with Certain Legal Problems Who Experienced Stability Improvement The most common impact from civil legal aid assistance was financial improvement, which was often related to debt, income, benefits and work-related cases. These categories include bankruptcy, collections, repossession, garnishment, Temporary Assistance to Needy Families (TANF), Social Security, Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), unemployment, veteran’s 11 benefits, state and local income benefits, workplace discrimination, Earned Income Tax Credit (EITC), other taxes, employee rights and wage claims. In addition, numerous studies have linked increased income or access to public benefits with improvements in other aspects of well-being, including health, educational success and social inclusion. Clients who sought help for financial-related problems reported stability improvements in areas including health and housing stability. Low-income families with little to no savings likely receive the greatest immediate benefit from a legal intervention that prevents income disruption for the family. A study by the Urban Institute examined the impact of income disruption and financial instability on families, including those with low incomes. Families who lose a job are about twice as likely to miss housing and utility payments as families who do not lose a job. Loss of housing resulting from loss of income impacts children’s educational success and parents’ ability to find new employment.13 Most American families do not have enough savings to ease the blow of income disruption.14 Families with even a modest savings cushion of $749 who miss a utility payment, miss a housing payment or are evicted do not experience hardships to the same degree as those with no savings, regardless of income. When looking specifically at low-income families, the study found the higher the savings, the less hardship the family experienced when an income disruption occurred. Research indicates that financial stability impacts nonfinancial aspects of an individual’s life. Participants who worked with in Financial Empowerment Centers who worked to open “Just feeling there was hope somewhere bank accounts, improve credit, reduce debt and gave me the strength to address [my] increase savings reported a reduction in stress, gambling problem. Worked!! Thank you, improved emotional health, higher confidence and selfsaved my life. Did not want to be that efficacy and a development of decision-making and person.” negotiating skills. An evaluation of Financial Empowerment Centers found that working towards (Client from Cuyahoga County, Housing and financial stability augments social service programs and Utilities, 2 to 5 years ago) improves client outcomes in those programs.15 Improvement in financial stability was most common for clients who received help with debt problems, including bankruptcy. Legal Aid provides assistance in this area through brief advice clinics and by representing clients in bankruptcy court. Filing for bankruptcy can lead to financial stability improvements long after the bankruptcy has been granted. For instance, one study compared those who were granted Chapter 13 bankruptcy to those in similar financial situations who filed for but were not granted bankruptcy. The study found that, over the course of the first five years after filing, those who received bankruptcy earned on average around $5,000 more annually than those that did not.16 13 McKernan, S.M., Ratcliffe, C. Braga, B. Kalish, E.C. “Thriving Residents, Thriving Cities: Family financial security matters for cities.” Urban Institute, 2016. 14 Ibid 15 “An Evaluation of Financial Empowerment Centers” Cities for Financial Empowerment Fund, 2017. 16 Dobbie, W., & Song, J. “Debt Relief and Debtor Outcomes: Measuring the Effects of Consumer Bankruptcy Protection.” American Economic Review, 2015. 12 This research also found that employment was 3.5 percent higher over a five-year period for those granted bankruptcy than it was for those whose bankruptcy was rejected.17 Other research has shown ties between bankruptcy and the other areas of stability. “It had a major impact, I was able to People who are granted bankruptcy protection rebuild my credit. The bankruptcy has were 20 percent more likely to stay in the jobs since fallen off my credit report, and they had before filing, 20 percent more likely to stay in the now I have an awesome credit score.” same industry and 17 percent more likely to stay in the same state than those who were not granted bankruptcy (Client from Cuyahoga County, Debt, More than protections.18 Bankruptcy could decrease the likelihood 10 years ago) that the family will have to move, thereby fostering housing stability. However, the effect of bankruptcy on one’s ability to remain in the same house is unclear. A survey of other studies on this topic found that, on average, a person who files for bankruptcy delays the foreclosure process for one year, but that 30 percent of those who file for bankruptcy still end up losing their homes to foreclosure.19 The health effects of filing for bankruptcy have been “Being able to get the studied by researchers who measure both direct and bankruptcy filing relieved a lot indirect measures of health. For instance, a number of stress in my life!” of publications use bankruptcy declarations as a way of gauging whether or not a person was in financial distress. (Client from Summit County, Results of declaring bankruptcy are mixed. One example Debts, Less than 2 years ago) found that cancer patients who declare bankruptcy have an increased risk of mortality.20 However, it is unlikely that the act of declaring bankruptcy actually led to an increased chance of death amongst cancer patients. Instead, a declaration of bankruptcy is used to measure a person’s overall financial stress, leading the authors to conclude that “severe financial distress…after cancer diagnosis appears to be a risk factor for mortality.”21 17 Dobbie, W., & Song, J. “Debt Relief and Debtor Outcomes: Measuring the Effects of Consumer Bankruptcy Protection.” American Economic Review, 2015. 18 Ibid 19 Li, W. “Residential Housing and Personal Bankruptcy, Business Review.” Federal Reserve Bank of Philadelphia, 2009. 20 Ramsey, S., Bansal, A., Federenko, C., Blough, D., Overstreet, K., Shankaran, V., & Newcomb, P. “Financial Insolvency as a Risk Factor for Early Mortality Among Patients With Cancer.” Journal of Clinical Oncology, 2016. 21 Ibid 13 Interview Case Study A: Bankruptcy About five years ago, Ms. K. contacted Legal Aid for advice about her financial situation. She was recently divorced and had accumulated credit card debt that she was unable to pay. She expected Legal Aid might give her some advice about how to handle the creditor or find help with bankruptcy but was pleasantly surprised that Legal Aid took on her case. She had lost her job just before the divorce, and although she had found new employment, she did not have benefits and said “things didn’t come together as quickly as [she] hoped” after the divorce. She was struggling to pay rent and bills, and all her child support payments were going to credit card bills. Legal Aid was able to help her obtain what she considered a positive resolution by declaring bankruptcy. She said this enabled her to pay for food and necessities. She was no longer stressed about losing her car, and she wasn’t harassed by creditors. Ms. K. describes the time after working with Legal Aid as very freeing. She said her lawyer was excellent to work with and lifted a lot of the burden. Her lawyer also referred her to other services, such as EITC, and gave her information on student loan payments. Since filing for bankruptcy, Ms. K. has been able to slowly rebuild her credit and open some credit cards. If she hadn’t resolved this issue, she would have been more stressed and worries she would have had to figure out a way to pay a lawyer out of pocket, which would have been challenging. Overall, the most positive impact to come out of working with Legal Aid was “getting to restart everything.” She is now employed as a home nurse, where she interacts with many low-income families and has made referrals to Legal Aid. While financial distress may increase mortality on the whole, evidence has shown that, for those in financial trouble, declaring bankruptcy may actually improve outcomes. The five-year mortality for those who were granted bankruptcy is around 2 percent lower than for those who did not receive bankruptcy protections. This effect is especially drastic amongst those who are older than age 60. For those older than age 60, the five-year mortality of those who are granted bankruptcy is 17.6 percent lower than it is for those who are not.22 It is interesting to note that, in the same paper, filing for Chapter 13 bankruptcy has a statistically insignificant effect on the annual income of those older than age 60.23 The fact that declaring bankruptcy decreases mortality, but may not impact earnings provides more evidence for the idea that mortality is linked to stress, and there is evidence “I was diagnosed with cancer and subsequently that declaring bankruptcy reduces lost my employment. It was a great relief to have stress. According to other research, 84 this resolved. I have no resource other than social percent of debtors reported feeling “very security!” stressed” before filing for bankruptcy. Afterwards, 35 percent of debtors reported (Client from Summit County, Debts, 2 to 5 years ago) having that feeling.24 The results of these studies indicate that stress alleviation may be a mechanism to explain the health stability improvements described by former Legal Aid clients who were helped with debt problems. 22 Dobbie, W., & Song, J. “Debt Relief and Debtor Outcomes: Measuring the Effects of Consumer Bankruptcy Protection.” American Economic Review, 2015. 23 Ibid 24 Porter, K. “The Pretend Solution: an Empirical Study of Bankruptcy Outcomes.” Texas Law Review, 2011. 14 Another area related to financial stability where Legal Aid helps clients is to gain access to tax credits and income support benefits. One of the most utilized income supports for working families is the Earned Income Tax Credit (EITC). The Center on Budget and Policy Priorities estimates that the EITC lifted approximately 5.8 million people out of poverty in 2016 and “I have fibromyalgia and my husband has spinal reduced the severity of poverty for issues, if we had cuts to that grant, I don't know 25 an additional 18.7 million people. how we could have survived” During the 2016 tax year, the average credit (Client from Mahoning County, Income & Benefits, Less amount for a family with children was $3,175, than 2 years ago) the equivalent of an additional $265 in monthly wages. In a study conducted at The Ohio State University shortly after the EITC was last expanded in the 1990s, researchers estimated EITC recipient families with children under age 18 experienced a 10 percent increase in disposable income and a 27 percent reduction in poverty attributable to the credit.26 More broadly, the researchers estimated that the EITC resulted in a 15 percent reduction in the overall child poverty rate in America. Further, the EITC has been shown to increase employment, particularly among single mothers. A comprehensive study showed that the EITC was responsible for nearly two-thirds of the rise in labor force participation among single mothers between 1984 and 1996, when the credit was expanded.27 Increases in income from the EITC can reasonably be expected to have a positive effect on family wellbeing, particularly if the extra income is used for things that help children, like books, quality daycare or preschool or moving to a better neighborhood.28 In addition to tax benefits, access to income supports can impact an individual long after they have received the benefit. A recent study found that participation in safety net programs during childhood, specifically SNAP, increase a women’s selfsufficiency in adulthood. Women who benefited from safety net programs at a young age saw increased educational attainment, earnings and income.29 Families who are able to supplement their earned income through public assistance create opportunities for their children’s future success. 25 “Took care of a lot of bills for the time until I found a new job. Before I couldn't even come up with bus fare to look for work.” (Client from Summit County, Income & Benefits, 2 to 5 years ago) Center on Budget and Policy Priorities, “Policy Basics: The Earned Income Tax Credit.” 2018. Kim, R. Y. “The Effects of the Earned Income Tax Credit on Children's Income and Poverty.” Journal of Poverty, 2001. 27 Meyer, B. and Rosenbaum, D.T. “Welfare, the earned income tax credit and the employment of single mothers.” Quarterly Journal of Economics, 2001. 28 Dahl, G., & Lochner, L. “The Impact of Family Income on Child Achievement: Evidence from the Earned Income Tax Credit.” American Economic Review, 2012. 29 Hoynes, H., Whitmore Schanzenbach, D., Almond, D. “Long-run impacts of childhood access to the safety net.” American Economic Review, 2016. 26 15 Though little conclusive research exists on the long-term health effects associated with shifts in income, several studies have found that families who receive the EITC or certain other income transfers are significantly more likely to self-report healthier children, as well as better mental health for mothers and children.30,31 Additional research has uncovered promising findings relating to specific health outcomes for EITC recipients. One such study that analyzed Current Population Survey data from the U.S. Census Bureau and found that low- to moderate-income single mothers who were ineligible for the EITC were 1.4 times more likely to not have health insurance for their children than low- to moderateincome single mothers who were eligible.32 Increased income has also been linked to improved birth outcomes and a lower risk for infant mortality. Researchers found that, in general, higher household income is marginally associated with earlier prenatal care and higher birth weight. It also is associated strongly with a reduced likelihood of tobacco use and increased likelihood of attending a well-child check-in the first month after birth.33 These improvements were found even after researchers controlled for possible confounding variables including marital status, annual hours worked, number of dependent children, educational attainment, physical and mental health, the child’s gender and race. The EITC has also been found to improve the lives of recipients by enhancing feelings of citizenship and social inclusion, according to the findings from 115 in-depth interviews with EITC recipients.34 Further, accessing income supports builds social capital through relationships and improved quality of life. Through the process of applying for and receiving a public benefit, an individual creates a new relationship with a social service agency. Often, these agencies offer additional services that support families, or they can provide referrals to assistance agencies. Developing a relationship with a caseworker can offer the family an opportunity to seek additional assistance or guidance from a trusted source. Studies have shown that accessing one benefit often leads to enroll in multiple benefits.35 Receiving multiple benefits increases overall income and provides the family with opportunities to spend time and resources on interests beyond obtaining basic needs. While EITC is just one of many benefit programs Legal Aids works with, it has been studied extensively and it is reasonable to assume that at least some of the proven impacts of EITC are present for other income supports. Civil legal aid assistance can reduce barriers to employment, such as having a criminal record. In this study, expungement cases are included in the discrimination and individual rights problems category. In an interview-based study of 53 expungement seekers in Illinois, only 13 percent of participants reported being employed in the formal economy. Fifty-eight percent were unemployed and 28 percent had 30 Ibid Hamad, R., & Rehkopf, D. “Poverty, Pregnancy, and Birth Outcomes: A Study of the Earned Income Tax Credit.” Paediatric and Perinatal Epidemiology, 2015. 32 Arno, P., Sohler, N., Viola, D., & Schechter, C. “Bringing health and social policy together: The case of the earned income tax credit.” Journal of Public Health Policy, 2009. 33 Hamad, R., & Rehkopf, D. “Poverty, Pregnancy, and Birth Outcomes: A Study of the Earned Income Tax Credit.” Paediatric and Perinatal Epidemiology, 2015. 34 Sykes, J., Kriz, K., Edin, K., & Halpern-Meekin, S. “Dignity and Dreams: What the Earned Income Tax Credit (EITC) Means to Low-Income Families.” American Sociological Review, 2015. 35 Moffitt, R., “Multiple Program Participation and the SNAP Program.” University of Kentucky Center for Poverty Research Discussion Paper Series, 2014. 31 16 “under-the-table” jobs in the unregulated “gray” economy.36 This is illustrative of the limitations to economic opportunity that face those seeking expungement. The study found that participants faced blocked opportunities in employment, along with housing and education, regardless of the severity of their criminal history. The following case study demonstrates the positive impact expungement can have on employment opportunities, increased financial stability and the desire to set goals. Interview Case Study B: Expungement Ms. D. graduated from college with a culinary degree, but every time she applied for a job her criminal record prevented her from getting a position. Ms. D. worked with a lawyer at Legal Aid to have charges from 20 years ago removed from her record. Having that record was stressful, and one mistake she made decades ago impacted her ability to support her family. Her lawyer was able to get most of the charges removed, however one charge still remains. Ms. D. was able to get a higher paying, more rewarding job; if she had not worked with Legal Aid she believes she would be working in a fast food restaurant without the option to be promoted. Her goal now is to have the final charged removed and open up her own business. While there is limited research on direct outcomes for those who have successfully had their criminal records expunged or sealed, recent research shows promising results. A 2018 study tracked participants in a records-clearing clinic in Alameda County, California, and found employment rates among participants increased by five to 10 percent within three years after the intervention.37 Average real earnings increased by nearly $6,000. The authors noted that clients typically entered the program after years of suppressed earnings. Another study estimated that when jobseekers with criminal records are given the opportunity to build rapport with an employer, the negative effects associated with a criminal record on job applications are reduced by approximately 15 percent.38 In other words, these jobseekers see better outcomes when they are given the opportunity to make an impression in person, whereas they may have been immediately screened out had they been required to report criminal history in the application stage. Overall, financial stability was the most common area where former clients reported stability improvements. These took the form of better jobs, higher wages or the ability to make ends meet. For some legal problems, such as interventions that secure benefit eligibility, resolve tax issues or increase payments, the impact is direct. A substantial number of clients whose legal problem was related to financial matters also indicated an improvement in health, a more indirect impact. 36 Ipsa-Landa, S., & Loeffler, C. “Indefinite Punishment and the Criminal Record: Stigma Reports Among Expungement-Seekers in Illinois.” Criminology, 2016. 37 Selbin, J., McCrary, J., & Epstein, J. “Unmarked? Criminal Record Clearing and Employment Outcomes.” The Journal of Criminal Law and Criminology, 2018. 38 Pager, D., Western, B., & Sugie, N. “Sequencing Disadvantage: Barriers to Employment Facing Young Black and White Men with Criminal Records.” The Annals of the American Academy, 2009. 17 Family Stability Finding: Legal Aid’s impact on family stability appears to increase over time no matter the original reason a client sought assistance from Legal Aid. Family stability can be defined as the consistency of family activities and routines.39 In contrast, family instability is described as a chronically chaotic and unpredictable family environment. Indicators for family instability include residential mobility, rotating intimate relationships among the adult primary caregiver, number of families a child has lived with, serious childhood illness and other recent negative life events including, but not limited to, job change, eviction and death.40 Family instability often is associated with low-income families as many of the impacts of living at or near poverty can result in a chaotic environment. However, research shows that poverty does not automatically mean family instability. Through multiple avenues of casework, Legal Aid services can reduce chaotic experiences including “It helped maintain our normal residential mobility, volatile relationships and day-to-day existence.” rotating custody arrangements that lead to family instability. Interventions by Legal Aid that result in (Client from Stark County, Income & eliminating a single instance of instability in an otherwise Benefits, 2-5 years ago) stable family will likely have an immediate positive result. On the other hand, Legal interventions for a single instance of instability in a family living in a constant state of disorder will have a very short-term impact with little to no intermediate or long-term impact. This is because the persistent instability overrides moments of stability. The longest and most powerful impact on family instability occurs when a case outcome results in a complete and permanent removal of the source of persistent instability. The resulting benefits of stability will have a cumulative effect as the families are able to develop routine and structure in the absence of chaos. In the survey of former Legal Aid clients, 15 percent of respondents reported a family stability improvement, regardless of the legal problem for which they sought help. The impact of Legal Aid’s work on family stability appears to increase over time. While 11 percent of clients who worked with Legal Aid less than two years prior to this study reported a family stability improvement, 24 percent of clients who worked with Legal Aid 10 or more years ago experienced increased family stability. 39 Masha Y. Ivanova & Allen C. Israel. “Family Stability as a Protective Factor Against Psychopathology for Urban Children Receiving Psychological Services.” Journal of Clinical Child & Adolescent Psychology, 2010. 40 Ackerman, B. P., Kogos, J., Youngstrom, E., Schoff, K., & Izard, C. “Family Instability and the Problem Behaviors of Children from Economically Disadvantaged Families.” Developmental Psychology, 1999. 18 FIGURE 10: Share of Former Legal Aid Clients Who Reported a Family Stability Improvement Overall By Time Since Legal Aid Assistance 25% 24% 20% 15% 15% 15% 10% 19% 11% 5% 0% Less than 2 2 to 5 years Years 6 to 10 years 10 years or more When the client’s legal problem was directly related to family problems such as adoption, custody, divorce, adult guardian, name change, parental rights, paternity and domestic violence, the rate of family stability improvements was higher than when the case was not related to a family problem. Fiftythree percent of Legal Aid clients helped with family problems experienced a positive change in stability after receiving services. More than a third of clients experienced a family stability improvement and 20 percent also indicated a health stability improvement as a result of working with Legal Aid to resolve their family legal problem. Figure 11: Rates of Family Stability Improvement by Legal Problem Family Problems Problems for Children End of Life Planning Health Care Debt Fraud Housing Discrimination Income and Benefits School Related Work Related 36% 29% 14% 9% 9% 8% 8% 7% 7% 5% 1% 0% 5% 10% 15% 20% 25% 30% 35% There were also strong ties between people who received help for problems with children, such as delinquency, neglect or abuse, emancipation and minor guardian conservatorship, and family stability improvements. 19 40% Figure 12: Share of Clients Helped with Certain Problems Who Experienced Improved Stabilty Many of the events considered to be Adverse Childhood Experiences (ACEs) that have links to poor health outcomes are also related to the conditions that result in family instability. These include abuse, neglect and household dysfunction. Eliminating the conditions that lead to ACEs will likely increase family stability and decrease poor health outcomes. Improving family stability also helps build the types of child-adult relationships proven to have a buffering effect that mitigate the impact of ACEs and toxic stress. Civil legal aid assistance directly impacts ACEs by helping victims of intimate partner violence obtain orders of protection and other arrangements that remove abusers from the house. “My life was positively impacted first of all by its continuance, since I was in mortal danger when I left. I found an apartment, some physical and mental space to call my own. I got some alimony and managed to retrieve about half of my household goods. Then I worked for about a year until I was unable to walk. Then I got treated for my old injuries. Now I can walk again.” (Client from Ashtabula County, Family Problems, 2 to 5 years ago) Those who inflict intimate partner violence and other abusive behaviors in a family setting often use techniques to maintain control of the family members. These techniques include denial, rationalization, minimization and assigning blame.41 By manipulating information and situations to their benefit, abusers are able to maintain or regain control of the family power. A family’s stability is at risk of disruption when the sense of reality is distorted by a powerful individual. This prevents the development of routines and traditions associated with stability. Furthermore, repeated individual instances of abuse create an unpredictable environment of chaos that is not consistent with family stability. A recent study examined self-sufficiency among women who had experienced intimate partner violence and sought civil legal services for assistance. Researchers found that study participants reported a 19 percent increase in income between intake and one year later. This finding is contrary to earlier studies of survivors of intimate partner violence which typically have showed a decrease in economic self-sufficiency. Women in the study also reported an increased 41 “I moved on with my life, divorced, got an excellent job and restarted my life again. Working now for a great company and am grateful for Legal Aid.” (Client from Cuyahoga County, Family Problems, 6 to 10 years ago) Whiting, J. B., Oka, M., & Fife, S. T. “Appraisal distortions and intimate partner violence: Gender, power and interaction.” Journal of Marital and Family Therapy, 2012. 20 ability to provide “extras” for their families such as travel and entertainment.42 Being able to provide traditions and routines with extra resources contributes to family stability as well. Witnessing intimate partner violence can have long-lasting negative impacts “My children and I left an abusive father and on young children as they reach husband. Now w/ an amazing man that treats adolescence. These children can display the children and I very well. Currently back in antisocial behavior like violence including felony school for medical billing and coding. The kids assault (gang fights, having the idea of seriously are doing great.” hurting or killing a person, hitting a non-family member, sexual assault), minor assault (hitting (Client from Wayne County, Family Problems, 6 to or threatening to hit a parent, supervisor, 10 years ago) coworker), status offenses (running away from home, poor school attendance, drinking alcohol, getting suspended) and delinquency (theft, disorderly conduct and other related behaviors).43 These types of behaviors are disruptive to the family environment and can greatly reduce family stability. In addition, children who witnessed a sustained level of intimate partner violence are more likely to experience depression and anxiety. The longer the violence persists through recurring instances of abuse, the stronger the correlation with poor mental health outcomes. The impact is lessened when family supports are consistently present.44 These findings indicate an intervention, such as a civil protection order against the abusive individual, could lessen the impact of witnessing violence and protect against negative health outcomes. Witnessing intimate partner violence during childhood has been shown to have a negative impact on economic well-being. A study examining the financial health of children who witness familial violence found increased costs of more than $50,000 due to increased health care needs, increased involvement in crime and productivity losses. It is estimated that around 60 percent of children who witness intimate partner violence also experience maltreatment, which carries a set of outcomes that would likely increase the lifetime costs beyond $50,000. The study recommends prevention programs and interventions to remove the risk of witnessing violence as a way to reduce individual and societal costs.45 One such intervention is civil protection orders like those Legal Aid helps clients obtain. It is increasingly acknowledged by those who work with children that ACEs such as abuse, neglect and household dysfunction result in negative health and academic outcomes. An article from 2008 outlined how a student who has experienced trauma will experience barriers to academic success in a classroom environment that does not employ trauma-informed educational practices. 46 Legal Aid can 42 Harltey, C.C., Renner, L.M. “Economic self-sufficiency among women who experienced intimate partner violence and received civil legal services.” Journal of Family Violence, 2018. 43 Sousa, Sousa, C., Herrenkohl, T. I., Moylan, C. A., Tajima, E. A., Klika, J. B., Herrenkohl, R. C., & Russo, M. J. “Longitudinal study on the effects of child abuse and children's exposure to domestic violence, parent-child attachments, and antisocial behavior in adolescence.” Journal of Interpersonal Violence, 2010. 44 Kennedy, A. C., Bybee, D., Sullivan, C. M., & Greeson, M. “The impact of family and community violence on children’s depression trajectories: Examining the interactions of violence exposure, family social support, and gender.” Journal of Family Psychology, 2010. 45 Holmes, M.R., Richter, F.G.C., Votruba, M.E., Berg1, K.A., Bender A.E. “Economic Burden of Child Exposure to Intimate Partner Violence in the United States.” Journal of Family Violence, 2018. 46 Oehlberg, B. “Why schools need to be trauma informed.” Trauma and Loss: Research and Interventions, 2008. 21 help improve the likelihood of educational success for children who have experienced trauma by facilitating placement into appropriate school settings. “Helped put us on the path of health, stability & growth. We (the children & I) In addition to consistent supportive survived and are thriving in big part due to relationships, the stability of family life is intertwined the assistance from Legal Aid! The kids and with the stability of housing. It is generally easier to I are all doing so well! I celebrated 2 years create order, routine and tradition (the markers of of sobriety. Thank you all for your part in family stability) when the physical space where family our families [sic] recovery, rebuilding and members gather is safe, secure and stable. Stability healing process.” can come from a variety of housing situations including homeownership, market rate renting and (Client from Stark County, Family Problems, Less housing subsidies. Based on research conducted on than 2 years ago) housing and family stability, it can be argued that legal assistance that increases housing stability will likely lead to longer periods of family stability. While not all families who seek legal assistance for family problems experience housing instability, 12 percent of former clients who experienced a family stability improvement also reported a housing stability improvement. By working to improve their family dynamics through legal intervention, clients were able to also improve their ability to maintain safe, affordable housing. Interview Case Study C: Divorce Ms. S worked with Legal Aid about eight years ago to get help filing for a divorce. Ms. S had previously worked with Legal Aid and remembered her good experience with her lawyer and reached out to the same lawyer to help free her from a violent relationship. Ms. S was seeking to divorce her husband who was abusive toward her and her children. Her lawyer helped obtain a restraining order against her husband and file for divorce. Her husband posted a notice with the court that he intended to sue Ms. S for half of her worth. Ms. S received support from Legal Aid during this process and said that from the moment she first contacted her lawyer, she knew she would “finally be free” and it was a relief “knowing she (her lawyer) had my back.” Ms. S’s husband passed away before the divorce was final. When describing what life was like without her husband, she said the most important thing was, “I can be me again. I got me back.” After filing for divorce, she was able to do simple things like take walks in the park and help her elderly neighbors out. She was also able to begin the process of healing relationships with her children. Ms. S has made changes in her own life and said, “I would never let myself get myself in that situation again.” She also helped her son who is separated from his wife understand the process of filing for divorce and recommended he reach out to Legal Aid for assistance. Those who were helped with family problems also reported a financial stability improvement. Stable sources of income and resources provide an opportunity for families to enjoy a level of consistency in providing basic needs. Participation in SNAP (Supplemental Nutrition Assistance Program also referred to as food stamps) has been shown to reduce poverty, particularly for working families or those who 22 experience short stints of unemployment.47 “It kept my family together and let me With the added resources provided by SNAP continue my education to get my degree.” and other public benefits, families are able to maintain routines and traditions. Parents who (Client from Cuyahoga County, Housing and experience the economic stress associated with living in Utilities, 2 to 5 years ago) poverty are more likely to experience conflicts with partners and hostility towards their children.48 Persistent conflict within a family is disruptive to the routines and patterns that are emblematic of a stable family. Therefore, maintaining assistance through income supports and benefit programs can help maintain family stability. One study from 2005 found that among low-income parents, lacking financial stability created a barrier to marriage, even when the couple continued their relationship.49 The process of immigrating is particularly disruptive to family routines and familiarity. As a family settles into a new home, a return to the routines and traditions that had been previously a part of daily life can help establish a sense of stability. Even when some level of stability has been established, undocumented immigrants often live in fear of that stability being disrupted. Deportation has considerable and lasting impacts on the children of those who were deported. Children experience a major disruption in their familial routines when a member is removed, especially if it happens unexpectedly. A study by the Urban Institute found that six months after deportation, children continued to experience both behavioral and emotional changes including disrupted sleeping, crying, anger, aggression, withdrawal and a heightened sense of fear.50 Immigrants may struggle to find stable employment or access to benefit programs without proper documentation. Jobs they are able to obtain are not likely to pay high wages, provide health care or have consistent schedules. A study looking at the impact of naturalization for young male immigrants’ employment prospects found that those who naturalized gained access to public sector jobs, white collar jobs, union jobs and higher wages,51 basically for those able to obtain proper documentation, more stable and higher paying jobs become accessible. A study of undocumented Latino students found those who did not find a path to further their education and legally participate in adult life were at risk for poverty and hardship into adulthood.52 Civil legal interventions that enable families to maintain routines and establish supportive interpersonal relationships can improve family stability. These effects are often long lasting, as indicated by research and comments from former Legal Aid clients. 47 Wheaton, L., Tran, V. “The Antipoverty Effects of the Supplemental Nutrition Assistance Program.” Urban Institute, 2018. 48 Rand D. Conger, Xiaojia Ge, Glen H. Elder, J., Frederick O. Lorenz, & Ronald L. Simons. “Economic Stress, Coercive Family Process, and Developmental Problems of Adolescents.” Child Development, 1994. 49 Gibson-Davis, C.M., Edin, K., McLanahan, S. “High hopes but even higher expectations: The retreat from marriage among low-income couples.” Journal of Marriage and Family, 2005. 50 Chaudhary, A., Capps, R., Pedrosa, J.M., Casteneda, R. M., Santos, R. M., & Scott, M. M. “Facing our future: Children in the aftermath of immigration enforcement.” The Urban Institute, 2010. 51 Bratsberg, B. Ragan, J.F., Nasir, Z.M. “The Effect of Naturalization on Wage Growth: A Panel Study of Young Male Immigrants.” Journal of Labor Economics, 2002. 52 Abrego, L.J. Gonzales, R.G. “Blocked Paths, Uncertain Futures: The Postsecondary Education and Labor Market Prospects of Undocumented Latino Youth.” Journal of Education for Students Placed at Risk, 2010. 23 Health Stability Finding: Some former Legal Aid clients reported a health stability improvement regardless of the legal problem they initially sought assistance to solve, but the impact on health stability peaks two to five years after case resolution. There are many facets of health that contribute to an individual or family achieving stability. Health stability does not mean an individual is in perfect health, but rather their health is predictable.53 This implies the proper conditions are in place to manage health. These conditions would include access to medical services, such as those provided by doctors, dentists and mental health professionals, in facilities like doctor’s offices, health clinics, hospitals, ambulances and, for some, within their homes. In addition to needing access to doctors, hospitals and pharmacies, an individual’s environment plays a crucial role in the stability of health. Recently much attention has been given to the social determinants of health. Healthy People 2020, a program of the U.S. Office of Disease Prevention and Health Promotion, defines social determinants of health as “the conditions in the environments in which people are born, live, learn, work, play, worship and age that affect a wide range of health, function and quality-of-life outcomes and risk.”54 Healthy People 2020 identifies five key determinants that influence health; economic stability, education, social and community context, health and health care, and neighborhood and environment. Within these categories, interventions by Legal Aid can increase access to health services and create a positive impact on these determinants. Thirteen percent of former Legal Aid clients reported an increase in health stability regardless of the legal problem they sought assistance to solve. Many clients reported an immediate improvement in mental health, most often via a reduction in anxiety. The impact on health stability peaks two to five years after case resolution. This supports research that suggests the removal of issues that result in legal problems can improve health outcomes and that the benefit is cumulative over time. After five years, impact on health stability decreases. This could be a result of multiple barriers low-income individuals and families face and when it comes to accessing appropriate and affordable care. Another explanation could be that as time passes, the client who sought assistance for a non-health related issue no longer associates gains in health with their legal outcome. 53 Stability. (n.d.) Mosby's Dental Dictionary, 2nd edition, 2008. Office of Disease Prevention and Health Promotion, “Social Determinants of Health.” Centers for Disease Control and Prevention, https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health. 54 24 Figure 13: Share of Former Legal Aid Clients Who Reported an Increase in Health Stability Overall By Time Since Legal Aid Assistance 18% 16% 13% 16% 14% 12% 12% 10% 13% 8% 8% 6% 4% 2% 0% Less than 2 2 to 5 years 6 to 10 years 10 years or Years more Nearly half of clients who sought assistance with a legal problem directly related to health care experienced an increase in at least one area of stability. For this study, health care problems included issues with Medicaid, Medicare, CHIP, home and community-based care, private health insurance and long-term care. Experiencing a health stability improvement appears to correspond with gains in family and financial stability. More than a quarter of those with health stability improvements also indicated progress in family and financial stability. These findings support research that financial stressors negatively impact health. “It made a stressful situation a lot easier to handle, although I am not in much of a better situation. Financially, it is a relief getting out of that problem with the help of Legal Aid. I live a different lifestyle now than I did before this issue.” Legal interventions can lead to health improvements through the removal of a barrier or a lessening of persistent stress. Many of the issues faced by the Legal Aid’s clients have been shown to have links to chronic health conditions. (Client from Trumbull County, Housing & Utilities, Less than 2 years ago) 25 Figure 14: Rates of Health Stability Improvement by Legal Problem Health Care Family Problems End of Life Planning Income and Benefits Debt Problems for Children Work Related Fraud Discrimination Housing School Related 27% 20% 18% 15% 13% 12% 11% 8% 7% 7% 5% 0% 5% 10% 15% 20% 25% 30% The connection between the resolution of family problems and health was stronger than any other nonhealth problem area, with one-in-five clients for Family Problems reporting an improvement in health. At least 10 percent of clients said their health improved for seven different problem areas – ranging from income and benefits, to problems for children and end of life planning. Figure 15: Share of Clients Helped with Certain Problems Who Experienced Stability Improvements Many problems that civil legal assistance addresses have been linked to positive health outcomes. One example is family problems and civil protection orders. A large body of research exists that looks at the impact of intimate partner and domestic violence on the physical and mental health of survivors. A literature review detailed the increased instance of conditions such as injury, chronic pain, gastrointestinal issues, sexually-transmitted diseases, depression and post-traumatic stress disorder among survivors compared to peers who did not experienced abuse.55 Intimate partner violence has also been linked to nearly every system within the body, and the study explains that violence leads to “adverse health outcomes affecting the brain and nervous system, cardiovascular system, gastrointestinal system, genitourinary system, immune and endocrine system, reproductive system, adverse pregnancy outcomes and other health outcomes” including poor mental health outcomes.56 The 55 Campbell, J. C. “Health consequences of intimate partner violence.” The Lancet, 2002. Black, M. C. “Intimate Partner Violence and Adverse Health Consequences: Implications for Clinicians.” American Journal of Lifestyle Medicine, 2011. 56 26 impact of the violence upon survivors increases with each instance of abuse so that the more abuse one endures, the worse health outcomes they are likely to experience.57 Legal interventions that are successful in removing the source of abuse are likely to have a positive impact on health outcomes as long as the abuser remains away. “It was such a blessing. I now get my food stamps and my life saving Medicaid that provides me with my health care and prescriptions.” (Client from Medina County, Income & Benefits, 2 to 5 years ago) Food insecurity also has links to health. Legal Aid assists clients in obtaining or maintaining income and benefits, including SNAP58. Accessing SNAP has been shown to improve health outcomes, while lifetime chronic hunger can lead to various negative health effects. Children ages 10 to 15 experienced poor general health outcomes associated with food insecurity whereas youth ages 16 to 21 saw impacts related to chronic conditions and asthma. 59 The more often a person experiences food insecurity, the more exacerbated their health conditions are likely to become. 60 Clinical evidence has linked food insecurity to diabetes and hypertension among low-income working-age adults.61 The study also found food insecure older adults maybe more likely to underreport a diagnosis of diabetes. Diabetes was more strongly associated with food insecurity than hypertension, particularly high levels of food insecurity. By accessing SNAP, individuals and families are able to reduce the impact of food insecurity by lessening personal incidences of household food scarcity. When individuals lack access to income support programs, they may experience conditions that lead to poor health outcomes. When supports are in place, health improves. For instance, food security has a statistically significant positive impact on children’s health. A recent study found that previous research may have underestimated the causal “It gave me the strength to keep fighting to relationship between food insecurity and 62 survive the cancer without the burden of poor health outcomes. Income support financial stress.” programs like SNAP and WIC (Women, Infants, and Children) directly increase food available (Client from Cuyahoga County, Income and to a beneficiary while other income supports either Benefits, 2 to 5 years ago) provide cash or release financial resources to purchase food. A study on the long-term impacts of safety-net programs found that children who had access to such programs from the prenatal period to age five had significant reductions in metabolic syndromes in adulthood including obesity, high blood pressure, heart disease and diabetes.63 57 Bonomi, A. E., Thompson, R. S., Anderson, M., Reid, R. J., Carrell, D., Dimer, J. A., & Rivara, F. P. “Intimate partner violence and women’s physical, mental, and social functioning.” American Journal of Preventive Medicine, 2006. 58 Supplemental Nutrition Assistance Program 59 Kirkpatrick SI, McIntyre L, Potestio ML. “Child Hunger and Long-term Adverse Consequences for Health.” Archie of Pediatric and Adolescent Medicine, 2010. 60 Ibid. 61 Hilary K. Seligman, Barbara A. Laraia, Margot B. Kushel. “Food Insecurity Is Associated with Chronic Disease among Low-Income NHANES Participants.” The Journal of Nutrition, 2010. 62 Gunderson, C. Kreider, B. “Bounding the effects of food insecurity on children’s health outcomes.” Journal of Health Economics, 2009. 63 Hoynes, H., Whitmore Schanzenbach, D., Almond, D. “Long-run impacts of childhood access to the safety net.” American Economic Review, 2016. 27 Evidence suggests that another benefit program, Supplemental Security Income (SSI) reduces negative impact of disability. A study that included an examination of SSI benefit amount changes between 1990 and 2000 and the level of disability in older adults in Census data indicated that more generous SSI benefit levels lead to reductions in disability. A $100 increase in SSI led to reduction in mobility limitations for the total older adult population of about one-half of a percent.64 Legal Aid works with clients to access SSI and other public benefits and to maintain payment levels. The importance of student health outcomes is evident in a study that examined the health of adolescents and their plans to continue their education beyond high school. Students who identify themselves as healthy are more likely to have intentions to go to college. Eighty-five percent of adolescents in very good/excellent health planned to go to college whereas only 77 percent in good health and 75 percent in fair to poor health intended to go to college.65 Quality of housing is considered a social determinant of “I'm less stressed. I was scared I'd health. Researchers cite several studies that show poor be homeless. It relieved so much.” housing conditions such as lead paint can cause considerable emotional distress and significantly reduces family (Client from Lorain County, Housing well-being.66 The fact that issues such as lead paint, mold and & Utilities, Less than 2 years ago) fire hazards are more common in older, less-expensive housing has caused others to argue that there is a link between poor housing, social inequality and health problems. In fact, one study goes so far as to state that, “the most important antecedents of human health are not medical care inputs and health behaviors (smoking, diet, exercise, etc.) but rather social and economic characteristics of individuals and populations.”67 Among adult populations, housing instability is negatively associated with poor health behaviors. Compared to peers who obtained housing stability, experiencing housing instability was associated with not having a usual source of care, postponing needed medical care, postponing medications, increased emergency department use and more hospitalizations.68 The intersection of housing and health is explored in greater detail in the Housing section of this report. 64 Herd, P., Schoeni, R.F., House, J.S. “Upstream Solutions: does the Supplemental Security Income Program Reduce Disability in the Elderly?” Milbank Quarterly, 2008. 65 Sentell, T. “Adolescent-rated health and intention to attend college: variation by race/ethnicity and levels of health status.” Race and Social Problems, 2012. 66 Mueller, E. & Tighe, J.R. “Making the Case for Affordable Housing: Connecting Housing with Health and Education Outcomes.” Journal of Planning Literature, 2007. 67 Dunn, J. “Housing and Health Inequalities: Review and Prospects for Research.” Housing Studies, 2000. 68 Kushel, M.B., Gupta, R. Gee, L., Haas, J. “Housing instability and food insecurity as barriers to health care among low-income Americans.” Journal of General Internal Medicine, 2006. 28 Housing Stability Finding: Eleven percent of former clients reported a housing stability improvement regardless of the legal problem that lead them to Legal Aid, but this stability appears to fluctuate and declines at the 10-year mark. It is widely recognized that housing stability exists on a continuum, however, there is currently no standard or formal definition of that continuum. At the most basic level, homelessness and permanent housing represent the beginning and end of the housing stability continuum. This dichotomy overlooks the struggle many Americans experience, often referred to by various terms including housing insecurity, instability, insufficiency and risk of homelessness. The space between homelessness and housing permanence is quite familiar to many low-income individuals and families. Indicators of housing instability include difficulty paying housing expenses such as rent, mortgage and utilities, denial of affordable housing due to poor credit, eviction threats or notices, moving frequently and living in overcrowded conditions. “I was able to continue paying my Regardless of a precise definition or system of house payments and utilities on time measurement, the results of housing insecurity, and ease into final retirement.” instability or insufficiency have been documented by multiple sources and are tied to areas where Legal Aid’s (Client from Mahoning County, Work civil legal assistance has an effect. Legal Aid’s housing work Related Problems, 6 to 10 years ago) includes fighting against housing discrimination, increasing access to subsidized housing, increasing opportunity for homeownership, reducing risk of foreclosure and helping individuals facing eviction. Each of these areas can have impact on the stability of family, housing, education, health, finances and community involvement. Eleven percent of former clients reported a housing stability improvement, regardless of the legal problem that lead them to seek assistance from Legal Aid. Unlike some other type of stability, housing stability improvements appear to fluctuate in the period following civil legal assistance. Housing stability improvements were most common for people who received assistance from Legal Aid between two and five years ago. 29 Figure 16: Share of Former Legal Aid Clients Who Reported a Housing Stability Improvement Overall By Time Since Legal Aid Assistance 16% 14% 12% 10% 11% 8% 6% 4% 2% 14% 12% 10% 7% 0% Less than 2 2 to 5 years 6 to 10 years 10 years or Years more Twenty-one percent of people who had a housing stability improvement also experienced a financial impact, and 15 percent reported a family stability improvement. This aligns with the literature that suggests that housing is closely related to financial issues and family stability. Among clients who were helped with a housing issue, 37 percent expressed that their housing stability improved. A secondary indicator of the housing stability of former clients comes from the fact that so many replied to a survey mailed to the last known address Legal Aid had on file. Due to eligibility requirements, Legal Aid services are confined to the low-income population, a group which is often expected to be transitory. Figure 17: Rates of Housing Stability Improvement by Legal Problem Housing 37% Fraud 13% Debt 9% Work Related 8% End of Life Planning 7% Income and Benefits 7% School Related 5% Family Problems 3% Discrimination 2% Health Care 2% 0% 5% 10% 15% 20% 25% 30% 35% 40% Fifty-six percent of clients who sought assistance specifically for problems related to housing experienced at least one stability improvement. The greatest share, nearly 40 percent, reported a housing stability improvement, and 14 percent reported a financial stability improvement. Housing 30 problems include issues related to subsidized housing, homeownership, landlord/tenant, public housing, mobile homes, public utilities, housing discrimination, foreclosure and predatory mortgage lending. Figure 18: Share of Clients Helped with Housing Problems Who Experienced Stability Improvements If families experience low levels of housing “My children and I would of [sic] been instability and a civil legal aid intervention improves homeless and it was a very stressful. their situation, their stability is likely to be And depressing time for me.” maintained for a period of time. If housing instability is more complex and civil legal aid intervention (Client from Cuyahoga County, Housing & removes some, but not all, sources of the instability, we Utilities, less than 2 years ago) would not expect to see sustained impact. A single threat to housing security may be overcome by legal intervention, but as the challenges or problems stack upon each other, interventions alone may not be enough to prevent housing instability. For instance, preventing the loss of a housing subsidy would increase housing security. But, if that same individual also has a poor landlord/tenant relationship and has been unable to access need care for their behavioral health issues, only restoring the housing subsidy is not likely to be effective in the long term. The case studies below demonstrate the variations in impact legal intervention can have on housing stability. In the first case, the client sought assistance through a voucher program after her rent had increased. Legal Aid successfully reduced her payments so she could maintain housing. Her housing instability resulted from a lack of financial stability, which the client indicated was ongoing. Thus, it seems likely that if this client experiences another complication that disrupts her voucher assistance in the near future, she will experience housing instability. Interview Case Study D: Subsidized Housing Ms. M contacted Legal Aid because she needed assistance with a change in her rent payments to the local housing authority in 2016. She rented an apartment with a Section 8 (Housing Choice Voucher Program) voucher, which required her to pay rent based on her income. Her payments went up more than they should have based on her income, and she couldn’t afford the rent. The increased payments caused her to have to come up with more money for rent, which meant she had trouble affording other basic necessities, such as food. She met with a Legal Aid attorney right away, and although her case had a positive outcome (she no longer has needed to make rent payments since the case was resolved), she does not feel that she learned skills that would help her handle an event like this in the future. She stated that she is glad that she doesn’t need to rely on family to help her pay rent, but she does not have a job and has not identified goals for her future as a result of working with Legal Aid. 31 In a second case, the client experienced housing instability as the result of a health issue that led to financial instability. The intervention provided by Legal Aid returned the client to the stable level of housing the client had enjoyed prior to the disruption caused by high medical costs. As her health stabilized, her financial situation improved, and she is no longer at risk for housing instability. Interview Case Study E: Foreclosure Ms. G. experienced a health crisis that consumed a substantial amount of time and financial resources. During this period, she fell behind in making mortgage payments and received a foreclosure notice. Ms. G. contacted a private attorney for assistance who suggested she reach out to Legal Aid. Once she began working with Legal Aid she felt an “ease of mind” for a situation that was “devastating.” Going through medical treatment was difficult enough, and worrying about losing her home made it even harder. Ms. G.’s lawyer took care of all the paperwork and was able to work out a modification that allowed her to keep her home. Ms. G explained that working with Legal Aid changed her life, as she was able to maintain housing during her treatment and return to work once her health stabilized. Without Legal Aid, she imagines she would be further in debt, would need to file bankruptcy and be in financial ruin. She also was able to focus on her health without further stress. One thing Ms. G. appreciated was that Legal Aid was discreet, and she was able to keep her problems private from her other family members. Housing assistance through government subsidies is a key tool for many low income families to achieve housing stability. Subsidies in Ohio come in a variety of forms including buildings subsidized by the U.S. Department of Housing and Urban Development (HUD), rent voucher programs, subsidies for specific populations such as veterans and those living with HIV/AIDS and subsidized housing for older adults and adults with disabilities. Access to housing is protected by the Fair Housing Act, which prohibits discrimination based on race, color, national origin, religion, sex, familial status and/or disability. Clients that Legal Aid assisted with housing issues reported improvements in health. This connection has been demonstrated in other studies that show housing instability has major impact on health, including mental health. The Michigan Recession and Recovery Study found that more than 30 percent of respondents recently experienced some type of housing instability and many reported negative health outcomes. A policy brief from the National Poverty Center identified key findings of the report: “Respondents who were behind on their mortgages or who had gone into the process of foreclosure were more likely to self-report fair/poor health and to have had a recent anxiety attack than mortgage holders without any recent housing instability. Those behind on rent were more likely to meet criteria for major or minor depression than renters with no housing instability. Respondents who moved due to cost in the past three years were substantially more likely to report an anxiety attack than those with no recent housing instability.”69 69 National Policy Center, “Policy Brief Housing Instability and Health: Findings from the Michigan Recession and Recovery Study.”2012. 32 A study that researched unstable “Returned our credit rating to a realistic level housing among renters found that saved our home and probably our marriage caregivers and children experience restored our faith in the justice system allowed us adverse health outcomes related to housing to retire only a few years later than planned instability. Each instance of housing removed the stress so my husband could heal instability increased the negative health from a massive heart attack.” outcomes. Measures of housing instability, such as being behind in rent or having (Client from Summit County, Housing & Utilities, 6 to multiple moves in a short time span, resulted 10 years ago) both in caregivers and children having a higher likelihood of reporting fair/poor health. Caregivers also had an increased risk of maternal depressive symptoms and children had increased odds of lifetime hospitalizations and risk of falling behind on developmental milestones. Caregivers and school-age children in unstable housing also were more likely to experience food and utility insecurity, which have direct negative impacts on health and wellbeing. 70 Children younger than three years old living in insecure housing also have increased risk of poor health, diminished weight and developmental challenges. Housing subsidies can mitigate the impact of poor health related to housing and food insecurity.71 The Urban Institute describes some of the negative effects of housing instability on children, including a family’s inability to provide basic necessities, frequent school moves, high rates of absenteeism, low test scores, increased family stress and the exposure of children to prenatal and early childhood toxic stress/trauma72. One study stated that, “Housing instability presents barriers to the maintenance of “After my divorce was finally final, I was able to family routines and rituals,”73 a move on with my life and my kids. The legal marker of family stability. Achieving assistance I received for my housing issue was able family stability is very difficult without to stop AMHA from evicting myself and my family of housing stability, though many parents go to 8 (2 adults, 7 children) which would have left us great lengths to provide some consistency homeless on the street!” and stability during times of housing insecurity. (Client from Summit County, Family Problems, 2 to 5 years) A common marker of housing instability is moving multiple times in a short period of time. In a study of urban students, researchers found that residential mobility correlates with a decrease in reading scores if the move happens during kindergarten through second grade, when reading formation occurs. Math scores also suffered for those students who experience residential moves. Together these findings indicate that residential moves, including those due to eviction or foreclosure, are likely to have a negative impact on 70 Sandel M, Sheward R, Ettinger de Cuba S, et al. “Unstable Housing and Caregiver and Child Health in Renter Families.” Pediatrics, 2018. 71 Meyers A, Cutts D, Frank DA, et al. “Subsidized Housing and Children's Nutritional Status Data from a Multisite Surveillance Study.” Archives of Pediatrics and Adolescent Medicine, 2005. 72 Cunningham, Mary K. “Reduce poverty by improving housing stability.” Urban Institute, 2016. 73 Mayberry, L. S., Shinn, M., Benton, J. G., & Wise, J. “Families Experiencing Housing Instability: The Effects of Housing Programs on Family Routines and Rituals.” The American Journal of Orthopsychiatry, 2014. 33 a child’s educational success.74 Removing the need for multiple moves through legal assistance has the potential to improve educational outcomes for both young children and adolescents. Many low-income families and individuals benefit from the stability that housing subsidies provide, whether that is “I have a forever home.” through public housing projects, senior high-rises or housing vouchers. Researchers propose a number of factors unique to public (Client from Cuyahoga housing that could lead to positive outcomes when compared to free County, Debts, Less than 2 market low-income housing. Public housing is more structurally sound, years ago) and regular certification of the quality of the dwelling is required. When families can afford rent they are able to achieve housing stability and reduced mobility. The reduction of a rent burden increases available financial resources for other basic needs such as food. Parents in public housing may also experience less financial distress and psychological burden as a result of housing insecurity which, in turn, can reduce the potential adverse impact on children.75 While subsidized housing does appear to have a positive impact on the economic stability of low-income individuals and families, the impact is not enough to move them out of poverty. However, there is evidence to suggest that the longer a child lives in subsidized housing, the greater the economic impact in adulthood. Children who live in public housing and voucher-assisted housing have higher earnings as young adults compared to low-income children who have not lived in subsidized housing. For males, each year spent in subsidized housing increased their annual income as young adults (age 18 to 26) by $508 for public housing and $256 for voucher assisted housing. For females, each year spent in subsidized housing increased annual income by $488 for public housing and $468 for voucher-assisted housing. It appears subsidized housing has the most positive impact on earnings for females from nonHispanic black households.76 Civil legal assistance that enables individuals to remain in housing supported by public assistance should allow them to realize similar benefits. For those without subsidized housing, a major area of work for Legal Aid in recent years relates “I was able to stay in my home with to foreclosure and eviction. Owning a home is a an affordable note. Was a really huge quintessential marker of reaching the “American relief off my shoulders.” Dream.” It can also be a means to increasing financial security. Analysis suggests homeownership, “remains (Client from Cuyahoga County, Housing & very beneficial for most families, offering both financial Utilities, 2 to 5 years ago) gains and a chance to build wealth,” particularly for those who will retain ownership long enough to recover transaction costs and can take advantage of cyclical markets.77 Home ownership gives low-income families an opportunity to build wealth and increase their financial security. Accessing and maintaining 74 Voight, A. Shinn, M., Nation, M. “The longitudinal effects of residential mobility on the academic achievement of urban elementary and middle school students.” Educational Researcher, 2012. 75 Newman, S. and Harkness, J. M. ”The long term effects of public housing on self-sufficiency.” Journal of Policy Analysis and Management, 2002. 76 Anersson, F., Haltiawanger, J.C., Kutzbach, M.J., Palloni, G.E., Pollakowski, H.O., Wienberg, D.H. “Childhood housing and adult earnings: a between siblings analysis of housing vouchers and public housing.” NBER Working Paper Series, 2016 77 Goodman, L.S., Mayer, C. “Homeownership and the American dream.” Journal of Economic Perspectives, 2018. 34 homeownership for these families may require intervention from community supports in order to obtain appropriate financial products and avoid predatory lending. The Institute for the Study of Social Change describes the impacts to families displaced by foreclosure. Similar to eviction, the very nature of foreclosure requires moving, which is disruptive to family routine regardless of the reason for moving. Legal Aid works with families to prevent foreclosure and eviction. When a move is a result of foreclosure, an individual will also suffer from poor credit, which greatly reduces options for purchasing a new home “If I lost SSDI, my son and I would be or passing a credit check to rent in the future. Those homeless. I am in quite a bit of debt. who experienced a foreclosure or eviction may split Not only did the debt clinic help with up their family and send children to whomever has two lawsuits, it also has given me space for them. Family stability is very difficult to maintain tools and confidence to face my across multiple temporary households. Moving out of the debt.” community may be the only option for these families, particularly if their home had been in an area with high (Client from Lake County, Income & market rents. Leaving a physical community often means a Benefits, 2 to 5 years ago) loss of social supports at a time when any available support 78 is highly valued. Legal Aid can help renters with landlord/tenant issues including conditions issues, which can improve the quality of housing in which children live. Lead exposure is just one example. The negative effects of lead poisoning, especially in regards to the effect on the mental development of children, have been well documented. Despite this, many communities in Northeast Ohio lag behind in abating lead paint hazards in homes. In 2018, Legal Aid was successful in procuring a court order that requires the City of Cleveland to place warning placards on homes that have a known lead hazard.79 While this may have limited benefits for those who already suffer from lead poisoning, it will provide significant benefits to both the future residents of those homes and society as a whole. Several studies have developed a societal cost-benefit analysis for lead abatement. Generally, the results have shown that it is to the financial benefit of society to implement a strict lead abatement policy. Using a strategy that links earnings to IQ to lead, researchers found that lead exposure could cost the cohort of American five-year-olds in 2002 a total of $43.4 billion in net present value of lost earnings. They also looked at three other diseases related to environmental factors: asthma, childhood cancer and neurobehavioral disorders. Weighing for the percent of each disease that is due to environmental factors, they found that the total cost of illnesses caused by environmental factors for that cohort of five-year-olds is $54.9 billion.80 By this measurement, lead poisoning makes up 79 percent of the annual costs for children who have major childhood illnesses linked to environmental factors. In another study, researchers compared lead abatement costs to the benefits of decreased health care and special education spending and increased earnings for children who may live in the house after the 78 Martin, A.J. “After Foreclosure: The displacement crisis and social and spatial reproduction of inequality.” UC Berkeley: Institute for the Study of Societal Issues, 2010. 79 Dissell, R., & Zeltner, B. “Court order requires Cleveland to placard hundreds of lead hazard homes this month.” Cleveland Plain Dealer, 06 June 2018. 80 Landrigan, P.., Schechter, C.., Lipton, J., Fahs, M., & Schwartz, J. “Environmental Pollutants and Disease in American Children: Estimates of Morbidity, Mortality, and Costs for Lead Poisoning, Asthma, Cancer, and Developmental Disabilities.” Environmental Health Perspectives, 2002. 35 hazard is discovered. This was done across two neighborhoods, one that required “strict” enforcement, in which lead abatement was required when a hazard was recognized, and one that required “limited” enforcement, in which enforcement failed to ensure that lead abatement would occur once a hazard was recognized. Considering all of these factors, “strict” enforcement would save society $45,360 per building abated compared to “limited” enforcement.81 Housing vouchers or other assistance can have a transformative impact on low-income family stability if families are able to move out of neighborhoods with extreme poverty into less economically distressed areas. However, research suggests the long-term impact of a move to a better neighborhood is dependent on age, with adolescents seeming to have more adverse outcomes following any residential move.82 Children under age 13 who experienced a move out of high-poverty public housing into a census tract with less than 10 percent poverty had higher incomes as young adults and were significantly more likely to attend college and attend better colleges than their peers who remained in subsidized housing in high-poverty neighborhoods. This cohort was also more likely to live in better neighborhoods as adults and less likely to become single parents. However, children between the ages of 13 to 18 years old when their families moved into lower poverty neighborhoods did not have a positive long-term economic impact into adulthood. This led the authors to conclude that “providing subsidized housing vouchers to move to lower-poverty areas produces larger benefits for younger children.”83 By providing families with access to housing subsidies, preventing foreclosures and other actions that result in a housing stabilization, civil legal assistance has an impact on the health of individuals in the family. The largest benefits will be experienced by family members with the longest stretches of stability. 81 “Brown, M.J. (2002). Costs and Benefits of Enforcing Housing Policies to Prevent Childhood Lead Poisoning.” Medical Decision Making, 2002. 82 Metzger, M. W., Fowler, P. J., Anderson, C. L., & Lindsay, C. A. “Residential mobility during adolescence: Do even “upward” moves predict dropout risk?” Social Science Research, 2015. 83 Chetty, R. Nedren, N., Katz, L.F. “The effects of exposure to better neighborhoods on children: new evidence from the Moving to Opportunity experiment.” American Economic Review, 2016. 36 Educational Stability Finding: Only two percent of former Legal Aid clients reported an educational stability improvement, however one-in-five clients who had an education improvement also reported positive impacts on family stability or housing stability. Legal Aid plays a role in guaranteeing children receive mandated services that provide the physical, social and emotional academic environment so each student has the opportunity to achieve educational success. A broad definition of educational success goes beyond measures of academic achievement, to include skill attainment, satisfaction, social and emotional development, access to trauma-informed classroom practices and participation in educationally purposeful activities. Students with disabilities, those with limited English proficiency, those suffering from chronic health conditions, immigrants and other vulnerable populations benefit from interventions by community advocates, including Legal Aid, to ensure their schools provide the supports and services they are entitled to receive. Families who seek to gain access to “free “Sons [sic] behavior resolved, he appropriate public education” as outlined in graduated HS with a year of AP credit, the Individuals with Disabilities Education Act went to University (in final year) via (IDEA) may need legal assistance to achieve compliance honors program with substantial aid from a school district. A student with an identified resulting in zero loans and already disability should be granted an individualized education admitted to grad school. Convinced all plan (IEP) or Section 504 Plan, which guarantees the this would have been much harder and student will not be discriminated against (504) and will less likely with an expulsion on his have special education accommodations for his or her record.” disability (IEP). Parents and guardians may turn to Legal Aid if they do not feel the school is meeting the needs (Client from Cuyahoga County, School of a student, either by not recognizing the disability or Related Problems, 6 to 10 years ago) by not adhering to the IEP or 504 plan. Legal Aid also plays a role in educating parents about how to advocate on behalf of their child. Students with special health care needs and emotional, behavioral or developmental problems experience a greater threat to school success than their peers.84 An IEP increases the likelihood that a student with learning, behavioral and/or emotional disabilities will stay in the school system through high school graduation. A study that examined educational attainment among adolescents with disabilities found greater financial well-being related both positively and significantly to the likelihood that children finish high school.85 The study also found that children with serious disabilities were more than 50 percent less likely than children without disabilities to complete high school. Progress in education stability was less common than other areas, with only 29 clients or 2 percent reporting an improvement. However, one-in-five clients who had an education improvement also a 84 Bethell, C., Forrest, C. B., Stumob, S. Gombojav, N. Carle, A. Irwin, C.E. “Factors promoting or potentially impeding school success: disparities and state variations for children with special health care needs.” Maternal and Child Health Journal, 2012. 85 Shandra, C.L., Hogan, D.P. “The education attainment process among adolescents with disabilities and children of parents with disabilities.” International Journal of Disability, Development and Education, 2009. 37 family stability improvement and 10 percent had a housing stability improvement. Many people with children said that Legal Aid’s assistance with a housing problem allowed them to keep their children in a school of their choice, preventing disruption in their children’s education. Figure 19: Rates of Educational Stability Improvement by Legal Problem School Related 42% Discrimination 7% Problems for Children 6% Housing 3% Work Related 1% Debt 1% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% School-related legal problems were most closely associated with education stability improvements. School related problems include issues related to discipline, special education, IEPs, 504 plans and vocational education. Even though it represented a relatively small number of former clients, 71 percent of Legal Aid clients who sought assistance with school-related problems reported a stability improvement. Figure 20: Share of Clients Helped with School Related Problems Who Experienced Stability Improvements A student and his or her family who seeks and receives assistance from Legal Aid to obtain appropriate interventions through an IEP or 504 plan will have the immediate benefit of an educational environment that takes the student’s needs into account. This stability often continues throughout the student’s education. Services provided by Legal Aid that result in an introduction of an academic, social or behavioral intervention, or in the enforcement of a previous intervention, have the potential to have lasting impacts as the student transitions into adulthood. The impact is strengthened by further interventions, including academic, behavioral and emotional, whether provided by Legal Aid or another entity. Conversely, if beneficial interventions are not continued, the impact of the civil legal aid service will be lessened over time. 38 The following case study illustrates the role legal intervention can play in a student’s educational success. Informing parents about their children’s educational rights and working directly with the school benefits children who need additional support, services or alternative placements to be successful in a school setting. In this case study, the parent’s employment stability was also challenged by the situation with her child’s school. Interview Case Study F: IEP Every day, Ms. D. would receive a phone call from her son’s school requesting that she pick him up. Every day, she would leave work at lunch, get him and drop him off at her mom’s house. Ms. D twice requested that the school evaluate him to determine if he was eligible for special education services. They refused both times, and instead suggested her son attend school on a reduced schedule, with a daily dismissal at noon. Ms. D. explained that she needed to work and while her boss was very understanding, this arrangement was unworkable. Around this time, Ms. D reached out to Legal Aid for assistance. Her lawyer explained that her son had a right to education and empowered Ms. D. to say no to the school’s suggestions if she wasn’t comfortable with their ideas. Ms. D felt an immediate sense of relief as her lawyer helped her better understand the process for getting her son the services he needed. The lawyer “stepped up, took charge, she fought back” and showed Ms. D how to fight for her son’s educational rights herself. The school agreed to an evaluation and he began to receive the services he needed to be successful in a classroom environment. In addition to her son receiving appropriate educational interventions, Ms. D. explained that the experience changed how she approached her son. Immediately after she started working with Legal Aid, she had a sense that “it’s okay, he is not a bad kid.” She explained that she used to get mad at him all the time, but now understood that some of his behaviors are outside of his control. With the interventions in place for her son, Ms. D. no longer gets daily calls, no longer has to leave work midshift and has the mental space to address other issues in life beyond her son’s education. Legal Aid often provides immigrants assistance in navigating the educational systems to ensure their children are properly enrolled and receive the services they need from preschool through high school. Children of undocumented immigrants experience academic withdrawal as they transition into adulthood. This is especially true during adolescence as these individuals experience barriers related to their status when they attempt to engage in typical adolescent behavior including part-time work and obtaining a driver’s license. At this point, children who had previously been integrated into society through school come to realize they are not like their citizen peers. During this time period, intervention from a trusted adult can help prevent early exit from the educational system.86 Educational attainment establishes ties to positive health outcomes including life expectancy. The opportunity to advance through high school and beyond has a significant impact on the remainder of an individual’s life. The difference in life expectancy between someone with less than a high school education and someone with 86 “My son is doing a lot better now. He is thriving in school and on a social level. I needed that extra income for him so I can pay for tutoring and special programs etc.” (Client from Stark County, Income & Benefits, 2 to 5 year ago) Gonzales, R.G. "Learning to be Illegal: Undocumented Youth and Shifting Legal Contexts in the Transition to Adulthood.” American Sociological Review, 2011. 39 a graduate degree is 12 years.87 One study found “[Legal Aid helped] greatly because I that each increment of completed education (less would've had to move which would than high school, high school only, some college, have resulted in having to move my kid bachelor’s degree, graduate degree) is associated with an out of school where he is doing good.” incremental improvement in physical health score. The study noted that the difference in physical health score (Client from Summit County, Housing & between a bachelor’s degree and graduate degree is not Utilities, 6 months ago) significant. This indicates the completion of a bachelor’s degree is a breakpoint where educational attainment no longer improves health outcomes.88 Although fewer clients reported an education stability improvement overall, those who were helped with school related problems were particularly likely to report at least one stability improvement. In addition, research links educational stability for children to financial stability and health in adulthood. 87 Kaplan, R.M. “Behavior change and reducing health disparities.” Preventive Medicine, 2014. Kaplan, R. M., Fang, Z. Kirby, J. “Educational attainment and health outcomes: data from the medical expenditures panel survey.” Health Psychology, 2017. 88 40 Civic Involvement Finding: Only two percent of clients reported a civic involvement improvement. Individuals who received Legal Aid help with a discrimination and individual rights problem were most likely to report a civic involvement improvement. Much of Legal Aid’s work is done with the assumption that solving their clients’ legal problems will allow them to become more civically engaged in their communities and strengthen democracy. Civic engagement is the outer ring of the ripple effect Legal Aid initiates by helping its clients. Civic behavior has been defined as “activities oriented toward collective action, care, concern and development of others, as well as societal decision making and resource allocation.”89 Civil legal aid services can reduce barriers to community engagement. Research has shown that barriers to civic engagement included lack of time, family care issues and divorce, problem neighbors, lack of community groups and isolation due to recent move or lack of transportation.90 Legal interventions to remove “I'm now a productive member of society barriers that consume individuals’ time can working full time and looking forward to increase the likelihood of civic engagement. reuniting with my child.” (Client from Stark County, Discrimination, 2 to 5 Only 22 clients, representing 2 percent of the total, years ago) reported an improvement in civic involvement. Examples included voting, helping neighbors and being engaged in community activities thanks to Legal Aid assistance. Individuals who received civil legal help with a discrimination and individual rights problem were most likely to report an improvement in civic involvement. This problem category included issues related to mental health, disability rights, civil rights, human trafficking and criminal records expungement. In contrast to many other stability areas, civic involvement improvements were reported less frequently. 89 McBride, A.M., Sherraden, M.S., Prtizker, S. “Civic engagement among low-income and low-wealth families: in their words.” Family Relations, 2006. 90 Ibid. 41 Figure 21: Rates of Civic Involvement Improvement by Case Area Discrimination 12% Problems for Children 6% Health Care 2% Income and Benefits 1% Work Related 1% Debt 1% Family Problems 0.8% Housing 0.8% 0% 2% 4% 6% 8% 10% 12% Figure 22: Share of Clients Helped with Discrimination Problems Who Experienced Stability Improvements In a study focused on low-income individuals, the researcher found that access to social and human capital resources increased when an individual was socially engaged. Access to those assets could be parlayed into educational and employment opportunities, and the odds of being employed increased over time for those who were civically engaged. Civic engagement that involved long-term opportunities were more economically beneficial for participants than short-term or episodic engagements. Long-term civic engagement more often led to building relationships and networks that provided access to information about employment and education opportunities. However, that study found that increased civic engagement often could not overcome structural barriers faced by lowincome individuals such as transportation, housing insecurity, poor local economy, discrimination and incarceration.91 91 Benenson, J. “Civic Engagement and Economic Opportunity Among Low-Income Individuals: An Asset-Based Approach.” International Society for Third-Sector Research, 2017. 42 Becoming civically engaged can be beneficial “My son is healthy mentally and physically. to low-income individuals, particularly if they His presence has pushed me to be more are able to develop relationships across class active part of the community.” and racial divides. These relationships can build social capital and lead to economically-beneficial (Client from Summit County, Problems for opportunities. However, the barriers associated with Children, 2 to 5 years ago) having incomes close to the poverty threshold come into play both in becoming civically engaged and in turning developed social capital into true economic mobility. Interview Case Study G: Immigration A friend suggested Mr. R contact Legal Aid for help with adjusting his residency status. He connected with a lawyer who assisted him in the complicated process of obtaining the proper residency documentation. Mr. R explained that having documentation has been life-changing. He is now able to look for employment which will allow him to financially support his family. He is able to travel without worrying about being unable to return to his new home. He no longer is worried about being accused of being in the country illegally and feels the freedom to be more involved in the community, including in his religious community Going through this process helped Mr. R understand that community involvement really makes an impact, because he saw firsthand how the work of Legal Aid directly impacts people’s lives. He described the importance of Legal Aid to the immigrant community, especially their help in obtaining the proper documentation. Mr. R explained, Legal Aid is able to intervene with the tools to obtain the documentation necessary for immigrants and refugees to move beyond survival into stability. Immigrants and refugees face many obstacles to establish stability for themselves and their families in their adopted residences. Recent newcomers to this country who do not speak English fluently may find themselves unable to receive services they need. This may impact their ability to obtain health insurance, stable housing, educational services and income supports. Although government agencies, including schools, are required to provide translation and interpretation services, immigrants and refugees may not be aware of the process for requesting these services. They may also not be aware of how to file a complaint if they have not been provided appropriate services. Civil legal services and guidance may be necessary to obtain the language services guaranteed under federal law. In addition to language, a newcomer’s legal status can impact their ability to become a stable, contributing member of the community. Visa processing, deportation hearings, naturalization and citizenship are areas where Legal Aid can be effective in advocating for decisions that result in a positive impact on an immigrant’s or refugee’s stability. Legal Aid’s legal interventions, and other free legal services, can reduce the impact “Now a proud U.S. Citizen.” language barriers and immigration status can have on (Client from Mahoning County, those who come to this country. As suggested in the Family Problems, 2 to 5 years ago) case study above, assisting an individual or family in obtaining proper documentation can have a long-lasting impact on income, housing stability, health and education. Despite the lack of former clients who reported improved civic engagement, there are several civil legal problem areas where other research indicates a relationship to community involvement. One is photo 43 identification. Lacking photo identification may present a barrier to full participation in civic life. Legal Aid can assist clients in obtaining photo identification and other documents. Most of the research into the impact of possessing a photo ID relates to voter participation. Unfortunately, there is conflicting evidence as to whether more “I can vote now!” stringent photo ID requirements for voter registration or at the 92 polls has an impact on voter participation. The attention on (Client from Cuyahoga voter ID requirements may lead some in Ohio to believe that County, Immigration, 2 they need a valid from of photo ID to vote, even though the state allows to 5 years ago) other forms of identification to be used at the polls. Therefore, a lack of a photo ID should not automatically cause disenfranchisement in this state. A greater barrier to civic participation could be the fact that a photo ID is requested, and sometimes required, to enter many government buildings, including court houses and city halls. This presents challenges for those residents who have government business to conduct, but lack a photo ID. In Rhode Island, a policy to bar entrance to courthouses to “I got my license and was able to people without a photo ID resulted in an get to work and drive myself “extremely detrimental impact on people who had wherever I needed to go.” a legal obligation to be in court, such as a criminal 93 defendant or witness under subpoena.” Those who (Client from Cuyahoga County, Debts, attempt to enter Cleveland City Hall without photo ID can more than 10 years ago) be met by a city employee and personally escorted into the building. A birth certificate is often needed in order to obtain photo ID. But a photo ID is required to enter the buildings where one can obtain copies of birth certificates. Proof of identity and employment authorization are needed to obtain legal employment. Although other forms of ID are accepted by the IRS, employers may ask to see a driver’s license and Social Security card, as those are the most common forms of identification. Yet obtaining a government-issued photo ID carries costs. The U.S. Government Accountability Office found that the direct cost to obtain a driver’s license is as high as $58.50,94 presenting a financial barrier to those living in deep poverty. Obtaining photo identification makes it easier to travel, access services and participate in civic life. Unlike many of the problem areas addressed by Legal Aid, photo IDs are binary – you either have one, or you do not. Lacking a photo ID can be a barrier, yet the impact of gaining a photo ID is usually short-term. Civic involvement for former clients also has the potential to improve due to domestic violence issues addressed by Legal Aid. People who have experienced intimate partner violence are less connected to their communities than those who have not been subject to partner abuse. In a study examining social connectedness among female victims, researchers found the longer a woman was subjected to intimate partner violence, the less likely she was be active in voluntary community groups or to trust people in the community. Thirty-seven percent of women in the control group reported not being active in groups compared to 47 percent of women who had endured intimate partner violence for 10 years or more. 92 United States Government Accountability Office, “Issues Related to State Voter Identification Laws.” 2014. National Law Center on Homelessness and Poverty. “Photo Identification Barriers Faced by Homeless Persons: The Impact of September 11.” 2004. 94 United States Government Accountability Office, “Issues Related to State Voter Identification Laws.” 2014. 93 44 Similarly 23 percent of women who had reported no abuse did not trust people in the community compared to 35 percent who had been in an abusive situation for three to 10 years.95 These results suggest interventions that prevent or quickly end abusive relationships can increase community involvement in voluntary groups and allow those who have experienced, or were at risk, of violent relationships to develop trust in their communities. Being a civically engaged member of the community generally means following the laws and adhering to social norms. Evidence points to lead poisoning as a factor that may affect one’s likelihood to be a lawabiding citizen. Recent scholarship has shown a relationship between exposure to lead and increased criminal activity. Young people between the ages of 12 and 18 who had been arrested have been shown to have had, on average, lead levels that were more than 7 times higher than those who had not been arrested. The authors of the study also note that the difference in lead levels are even higher amongst those who do not have other risk factors for “delinquent behavior,” such as living in two-parent homes and having parents with higher education levels.96 Time lag analysis studies have found a correlation between lead and crime. One such study compared preschool blood-lead levels to crime rate 10 to 25 years later across nine different countries and found a highly significant relationship between pre-school blood lead levels and the rates of a number of different types of crimes, including burglary and assault. There is also considerable evidence that the sharp decline in juvenile murder rates seen in the 1990s could be associated with the decreased frequency of lead exposure amongst those born in the 1970s.97 Among other benefits, decreasing lead exposure in a home will decrease the likelihood that children in that residence will commit crimes as they get older. Legal Aid helps people address lead and other housing condition issues. If lead hazards decrease throughout the community, the community is likely to see an associated decrease in crime 10 to 20 years in the future.98 Improved housing stability also has been linked to civic involvement. A recent study found that homeowners are significantly more likely to vote in local and national elections and join neighborhood and civic groups.99 Providing opportunities for low-income households to join the American tradition of purchasing a home can strengthen the community as the household becomes more civically engaged. A study examining civic engagement of people in low-income neighborhoods who became homeowners found a significant increase in community involvement as they moved from renting in the same neighborhood to owning a home.100 95 Bonomi, A. E., Thompson, R. S., Anderson, M., Reid, R. J., Carrell, D., Dimer, J. A., & Rivara, F. P. “Intimate partner violence and women’s physical, mental, and social functioning.” American Journal of Preventive Medicine, 2006. 96 Needleman, H., McFarland, C., Ness, R., Fienberg, S., & Tobin, M. “Bone lead levels in adjudicated delinquents: A case control study.” Neurotoxicology and Teratology, 2002. 97 Nevin, R. “Understanding international crime trends: The legacy of preschool lead exposure.” Environmental Research, 2007. 98 Stretesky, P. & Lynch, M. “The Relationship between Lead and Crime.” Journal of Health and Social Behavior, 2004. 99 McCabe, B.J. “Are homeowners better citizens? Homeownership and Community Participation in the United States.” Social Forces, 2013. 100 Manturuk, K., Lindblad, M., Quercia, R. “Homeownership and civic engagement in low-income urban neighborhoods: a longitudinal analysis.” Urban Affairs Review, 2012. 45 A growing body of evidence suggests people “It meant I could stay – where my comfort are more likely to be civically engaged when level was my dream home – gives you a the engagement involves a homogenous sense of worth and pride.” group with which they identify. The more different they are from those around them, the less (Client from Mahoning County, Housing & likely they are to participate. The homogeneity could Utilities, 2 to 5 years ago) be associated with any number of factors including race, education, income, religion, ethnicity or political affiliation. Housing interventions that result in a family or individual moving into a community where they have little to no feeling of commonality with their neighbors are likely to result in less civic engagement than if the housing intervention maintains a similar environment of homogeneity or relocates to an environment with existing similarities. Therefore, it is unlikely that low-income families that belong to minority groups will become more civically engaged if they use vouchers to move into a residential area with low minority representation. If a legal intervention allows families to stay in a community where they have existing familiarity and commonality, they are more likely to become civically engaged with groups of people similar to themselves.101 Lack of trust of new neighbors can be overcome as individuals who regularly talk with their neighbors are less influenced by the racial and ethnic character of their surroundings than people who lack such social interaction. Families who move into new neighborhoods will develop stronger ties to their communities if they are actively welcomed into the community. 101 Stolle, D., Soroka, S., Johnston, R. “When does diversity erode trust? Neighborhood diversity, interpersonal trust and the mediating effect of social interactions.” Political Studies, 2008. 46 Conclusion Stability improvements that clients attribute to civil legal aid assistance are common, persistent and widespread. Other research has demonstrated links between the types of problems civil legal assistance addresses and a range of benefits for individuals, families and society. The results of this research display that various aspects of stability or instability are closely related. When asked open-ended questions, many former Legal Aid clients identified aspects of stability that had improved due to civil legal aid assistance that were unrelated to the civil legal problem for which they sought help. As shown below, ties between financial stability and non-financial matters were particularly strong. In addition, the number of clients who worked with Legal Aid on a problem unrelated to health issues, but reported a health stability improvement, further confirms the ties between health and social determinants such as housing, education and financial stability. Area of Practice School Related Debt Housing Income and Benefits Family Problems Work Related Health Care Discrimination Fraud Problems for Children End of Life Planning Total Percent who Financial Clients Experienced Stability Stability Improvement 38 349 256 147 380 75 56 42 38 17 28 71% 59% 56% 54% 53% 52% 46% 43% 42% 41% 39% 16% 44% 14% 41% 10% 39% 25% 24% 21% 6% 18% Family Stability Health Stability Housing Stability Education Stability Civic Involvement 5% 9% 8% 7% 36% 1% 9% 7% 8% 29% 14% 5% 13% 7% 15% 20% 11% 27% 7% 8% 12% 18% 5% 9% 37% 7% 3% 8% 2% 2% 13% 0% 7% 42% 1% 3% 0% 0% 1% 0% 7% 0% 6% 0% 0% 1% 1% 1% 1% 1% 2% 12% 0% 6% 0% The types of financial and family stability improvements that were most often reported by clients have been shown to help break cycles of poverty. Based on our extensive literature review and primary qualitative data we collected, it is reasonable to conclude that civil legal aid assistance has a long-term impact that allows individuals and families to secure stability. 47 Appendix A: Survey Dear former Legal Aid client, In the past, you have accessed Legal Aid services to help solve a problem. We hope our legal assistance resulted in a positive outcome for you. We are currently in the process of determining how effective our services have been in making a difference in our clients’ lives. We are looking for people who received help from Legal Aid one or more years ago to share their experiences. This survey will help us identify individuals who are interested in sharing their stories. Please take a moment and complete this survey and mail it back to us in the enclosed postage paid envelope. To show our appreciation, we will be raffling off two $50 gift cards. All survey responses will be kept confidential. Thank you, Colleen Cotter Executive Director The Cleveland Legal Aid Society Steven McGarrity Executive Director Community Legal Aid 48 What County did you live in while receiving assistance from Legal Aid?      Ashtabula Cuyahoga Geauga Lake Lorain      Medina Portage Stark Summit Other (please specify) _____________     2 to 5 years 6 to 10 years More than 10 years Other (please specify) _____________ How long ago was it that you worked with Legal Aid?    Less than a month 1 month to 6 months 6 months to 1 year What kind of problem did you ask Legal Aid to help resolve?            Debts (bankruptcy, collections, repossession, garnishment) Fraud/Consumer Protection (predatory lending, contracts, deceptive sales) School-related problems/Education (discipline, special education, IEP, 504 plan, vocation education) Work-related problems/Employment (discrimination, EITC, taxes, employee rights, wage claims) Family problems (adoption, custody, divorce, adult guardian, name change, parental rights, paternity, domestic abuse) Problems for children (delinquent, neglected/abused, emancipation, minor guardian conservatorship) Health care or health services (Medicaid, Medicare, CHIP, Home and community based care, private health insurance, long term care) Housing and Utilities (subsidized housing, homeownership, landlord/tenant, public housing, mobile homes, public utilities, discrimination, foreclosure, predatory mortgage lending) Income and Benefits (TANF, Social Security, SSI, SSDI, Unemployment, Veterans Benefits, State and local income benefits) Discrimination and Individual Rights (mental health, disability rights, Civil rights, human trafficking, criminal records expungement) End of Life Planning (Wills and estates, advance directives, powers of attorney) Please briefly describe the services Legal Aid provided to you or your family. 49 What happened with regard to the problem you were facing? Were the services you received from Legal Aid helpful to reaching a resolution? In what ways did the resolution of that problem impact your life? We are seeking former clients for more detailed follow-up interviews. We are looking for a good mix of people, and not everyone will be selected. Anyone who participates in an interview will receive a small gift card as a thank you. All information will be kept anonymous, and will not be used for other purposes unless you give us permission to share it. Are you willing to be interviewed by a researcher from The Center for Community Solutions?   Yes No We will use the contact information below to reach you if you are selected in the gift card drawing, or for a follow-up interview. All contact information will be kept confidential, unless you give us permission to share it, and will not be used for other purposes. Name _________________________________________ City/Town _____________________________________ State/Province __________________________________ Zip Code_______________________________________ Email Address __________________________________ Phone Number _________________________________ The Center for Community Solutions may need to compare some survey responses with case information kept by Community Legal Aid and The Legal Aid Society of Cleveland. Please read the statements below and select YES or NO to indicate if you give permission to share your information. The Center for Community Solutions may share my survey response, including my name and contact information, with the Legal Aid program that helped me, either Community Legal Aid or The Legal Aid Society of Cleveland.   Yes No The Legal Aid program that helped me, either Community Legal Aid or The Legal Aid Society of Cleveland, may share with the Center for Community Solutions information about my pat case (s). I understand that if I have a current, open case with the Legal Aid no information will be shared about my current case.   Yes No Thank you for completing this survey! If you have any questions about this survey, please contact Emily Muttillo at emuttillo@communitysolutions.org or 216-781-2988 ext 211. If you want to apply for legal help with a new problem, please contact Community Legal Aid (330.5354191) or The Legal Aid Society of Cleveland (216.861-5500) 2