Special thanks to the “Healthy Together Medical-Legal Partnership for Improving Asthma in Southeast DC” team for sharing their reflections and learnings on their BUILD Opportunity Fund Award in this blog. BUILD awardees were eligible for ad hoc funding awards to catalyze efforts in policy, data, system change, and/or health equity that complemented their ongoing efforts to support community health.

Every year, more than 12,000 children across Washington, DC struggle with asthma. Their struggles are all too often linked to something that can be solved – like unhealthy housing. Take one child for example – a boy named Messiah.

When Children’s Law Center met Messiah, he was a regular visitor in the emergency room. Messiah and his family lived in an unsafe, mold-ridden home. His mother, Ms. Henderson, reached out to her landlord over and over again with no results.

“We had problems with the AC unit, the air filter had never been changed, we had a mice infestation, there were holes in the walls,” she recalls.

These unhealthy housing conditions exacerbated Messiah’s chronic asthma and led to frightening, dangerous asthma attacks.

The Children’s Law Center team took legal action to make sure Ms. Henderson’s landlord completed the appropriate repairs—repairs that were so critical for her family’s health and safety. Today, he feels better—and is no longer a regular in the ER.

The Analysis: Avoiding Costs for Government-Funded Healthcare

Since 2002, Children’s Law Center’s Medical-Legal Partnership – Healthy Together – has been able to reach many children like Messiah. But not nearly enough.

Children living in wards 7 or 8 – DC’s  lowest-income neighborhoods – are 20 times more likely to end up in the ER for asthma than a child living in wealthier ward 3. Even with the strength of Healthy Together and the BUILD DC team which includes Children’s Law Center, Children’s National and DC Health, there are far too many families and children who still need legal services to help them navigate needed housing repairs.

Children’s Law Center Executive Director pictured with Karen M. Dale, Market President for AmeriHealth Caritas District of Columbia (DC)

That is why it is so critical to build new, innovative models that can serve even more families.

To do that, Children’s Law Center partnered with Children’s National and two managed care organizations, AmeriHealth Caritas District of Columbia and Health Services for Children with Special Needs, Inc. (HSCSN), to share data and conduct an analysis that quantified the return-on-investment for legal services. The team looked at cases over the past three years to understand what costs are being avoided every time a child stays healthy and out of the hospital because repairs were made or a family was relocated to a healthier home.

In order to access and share the data needed, Children’s Law Center enlisted pro bono support from Ropes & Gray LLP. The firm helped Children’s Law Center navigate the complexities of health care law, and ensured the nonprofit legal services organization became HIPAA compliant. This gave Children’s Law Center the ability to receive the data and complete the complex analysis.

The ground-breaking research uncovered impressive results: When the Healthy Together medical-legal partnership successfully intervenes, government-funded healthcare costs are reduced by $10,000 on average during the first 18 months.[1]

How? Take for example the typical costs for asthma-related emergency room visits, hospitalizations and other medical supports. For a child in DC – a child like Messiah – these costs can range from $400 to $68,000 or more.

Moving from One to Many

As a result of the Opportunity Fund award from the BUILD Health Challenge, Children’s Law Center finalized the return-on-investment analysis and used it to establish a pay-for-performance, outcome-based contract with AmeriHealth Caritas DC – the first of its kind in the nation.

Here’s how it works: Any time Children’s Law Center represents a child who has AmeriHealth as insurance, AmeriHealth will pay Children’s Law Center about half of what it averages on cost avoidance – for up to 50 cases during the first year of the agreement.

Karen Dale, Market President for AmeriHealth Caritas DC, explains why this is a win-win for families and her business. “When someone doesn’t have to take their child to an ER, that unnecessary cost is removed from the health care system, and that is really a business case for having a lawyer as part of the health care team,” she said.

The goal is for children with asthma in the District to require fewer medical interventions over time.

Children’s Law Center is now sharing what they’ve learned with others. Also with thanks to support from the BUILD Health Challenge Opportunity Fund, the Children’s Law Center team is creating a toolkit to support other medical-legal partnerships as they explore creating similar data-sharing models.

The toolkit will include a number of components such as:

  • A summary on the return-on-investment analysis including the steps and critical relationships needed – such as working with managed care organizations and healthcare systems – to develop data-sharing systems.
  • Specific, practical guidance on lessons learned, including an overview of different types of outcome-based contracts and models that are available and the pros and cons that Children’s Law Center uncovered as they worked with AmeriHealth Caritas DC to develop its contract.
  • Other case studies and resources that proved useful in conducting the analysis and forging the AmeriHealth Caritas DC partnership.

Looking Ahead

The team is preparing an academic paper describing the analysis which will be submitted to a peer-reviewed journal, but it’s already being used to improve the health of even more children and families across the District – and the country.

In addition to supporting more legal cases through the AmeriHealth Caritas DC contract, Children’s Law Center used the analysis and data in its testimony for the DC Council’s budget and oversight hearings with a goal to inform upstream solutions to the issues that impact children and families in DC. The testimony sparked an interest from the Chair of the DC Council’s Committee on Housing and Neighborhood Revitalization and has led to subsequent conversations that are useful in educating a key policymaker about the impact of housing on health.

Additionally, Children’s Law Center presented the impact of the work at the National Center for Medical-Legal Partnerships Summit and will be sharing the toolkit with medical-legal partnerships nationwide. They are continually conducting more analysis to understand what other data and trends can be used to inform more efficiencies and partnerships.

As for the BUILD Health team in DC, they are continuing to help children and families like Messiah’s, while also looking to craft similar cost-sharing arrangements with other managed care organizations across the city.


[1] Stevens, Holly R.; Goodman, Tracy.; Alberti, Philip, M.; Nerlinger, Abby.; Dale, Karen.; Teach, Stephen. (manuscript in preparation). Building the Business Case for MLP Investment: Cost Avoidance Associated with MLP Intervention for Children with Asthma.


About BUILD’s Opportunity Fund:

In 2018, BUILD’s funder collaborative allocated $250,000 (total) to be made available for past BUILD awardees in an effort to support BUILD projects and improve community health. The goal of this fund is to provide monetary support to awardees when a unique opportunity to catalyze efforts in a targeted manner presented itself. From these projects, BUILD sought to gain insights into the BUILD model, systems change, and better understand the role of targeted interventions that have the potential to be replicated or scaled.