In March 2015, the US Department of Justice’s Civil Rights Division released a scathing report on police practices in Ferguson, Missouri, where 18-year-old black Michael Brown was shot by police last year. former. It described a police department that regularly issued citations to generate revenue for the city budget and a city court that authorized arrest warrants for non-criminal matters as a means of collecting payments.
For those living in or near poverty in Ferguson, the fines were exorbitant. Failing to obey an officer would result in a $792 fine, having tall grass and weeds on your property would result in a $531 bill, and “walking on the pavement” would cost up to $302. Those who could not pay or who misunderstood expectations for court appearances faced additional fines or even arrest. A woman who had two unpaid parking tickets, initially totaling $151, spent six days in jail. When her fines and costs were tallied, the woman, who had experienced periods of homelessness, owed $1,091.
Over the past several decades, states and localities across the country have increased the number and amount of fines imposed for low-level civil and criminal offenses, such as parking and traffic violations, as well as fees. used to pay for court-related activities. . In 2017, the US Civil Rights Commission found that municipalities routinely target the poor and people of color for fines and fees. In the same year, a study of more than 9,000 cities found that municipalities with the largest share of black residents collect more than five times more fines and fees per capita than cities with the smallest share of residents. black.
Court-imposed fines and fees have been a long-standing concern in New Jersey, where the Camden Coalition, which I lead, provides managed care services to people with complex health and social needs. Many of our clients struggle with debt incurred due to fines and fees, which often stem from petty infractions such as citations for vagrancy or jaywalking. It is with these challenges in mind that we have published a briefing note entitled “Why unfair and heavy court-imposed fines and fees are a health issue – and what health and policies can do about it”. He describes how these debts exacerbate the situations of individuals already experiencing health problems due to social determinants of health. Financial penalties imposed by the courts are another obstacle to managing and maintaining their health and the stability of their lives.
A medico-legal partnership
In late 2017, based on our own direct service work and an assessment that revealed a substantial need for legal services of all kinds in the Camden, New Jersey area, the Camden Coalition formed a Medico-Legal Partnership ( MLP) with Rutgers Law School. in Camden. At the time, we were in the final year of a randomized controlled trial in Camden and knew, even without counting the results, that our clients needed other supports to improve their well-being. Like other healthcare organizations that use MLPs, ours often helps people pay off debt, fight evictions, or take other steps to shore up their finances. Lawyers participating in the Rutgers Law School/Camden Coalition medical-legal partnership join care teams made up of nurses, social workers, community health workers and housing coordinators to discuss ways to resolve the legal issues that interfere with a client’s ability to maintain their health.
Over the past four years, our MLP has assisted nearly 50 clients with municipal offenses and related issues. This includes helping restore suspended driver’s licenses, recalling outstanding warrants, and eliminating thousands of dollars in accumulated debt from fines and fees. The total amount of fines and fees our patients faced was over $40,000. We were able to help get over $15,000 in fines and fees waived or transferred to payment alternatives. This amount does not include fines and fees avoided by helping customers resolve open cases, many of which would have resulted in additional fines and fees on top of those already imposed.
Even a relatively small fine or fee can cause extreme hardship for our customers. Patients with complex health and social needs face many competing priorities, such as getting food on the table, buying medicine or finding stable housing. In many cases, a simple letter, call, or email from a clinician or case manager describing how monetary penalties and the threat of incarceration affect a client’s treatment plan and recovery can persuade judges to reduce or cancel the sanction. When the stakes are high, nurses and lawyers have accompanied clients to court to advocate for alternatives to fines and fees or incarceration and have been successful.
In the case of one MLP client, a woman in her twenties with a newborn, had progressed through treatment for opioid addiction and was eager to return to school and find employment. Yet she was facing more than $5,000 in fines and court costs that had accrued during her active addiction. With her driver’s license suspended for non-payment of fines, she was forced to transport her baby and bus gear by bus.
After requesting a municipal court hearing in the client’s hometown in New Jersey, our MLP showed up with our client and her baby and persuaded the judge to waive all fines and fees by awarding credit for his brief past prison sentences. She walked out of court elated, knowing she could get her license, continue her progress through her treatment, and move on.
Although some hospitals support MLPs and most have some case management and social work services, civil fines and costs generally fall outside the traditional categories of civil legal issues that MLPs deal with, even when they are essential to help clients change their lives. Hospital risk managers and attorneys can actively discourage staff from asking patients for fines and fees, believing that they are outside the scope of healthcare.
But those who are unable to pay court-ordered fines and costs face a range of collateral consequences that can lead to further harm, including job loss, homelessness and family separation, not to mention health issues. A systematic review of 33 peer-reviewed studies found that debt was associated with suicidal ideation, depression and poor self-esteem.
In particular, the stress of attending a hearing, often without legal representation, can exacerbate mental and physical health issues. An MLP client who had serious mental health issues became extremely agitated in court – he broke up and left before his case was called, leading to further penalties. With this in mind, MLP lawyers have implemented trainings to help members of the care team, including nurses and community health workers, defend their clients in court and push judges to reduce or eliminate fines and fees. Eventually, MLP and Camden Coalition staff were able to help this individual through many hearings, reducing his stress and improving his health and social outcomes.
Our brief outlines relatively simple steps that providers and others in the complex care community can take to deal with the impact of fines and fees on the people in their care. These recommendations include:
- Integrate fines and fees into care planning by inquiring about unpaid fines and fees once trust has been established with the patient;
- Support patients with commitments in court by testifying on their behalf or writing a letter of support in court detailing a patient’s progress and the impact that additional monetary penalties – and possible incarceration – could have on their progress ; and
- Connect with local organizations engaged in fines and fees reform to improve their understanding of the issue.
By acknowledging the issue, starting a conversation, or creating a template letter to the court, providers and health systems can take key steps to address a key issue that impacts the health of the people they care for. . As calls for equity in health care grow louder, we as health care leaders must recognize that the systems that perpetuate structural racism and fuel health disparities can only be dismantled if we are willing to step out of our comfort zones. Investments in training clinicians and case managers to provide this kind of support – with or without the help of an MLP – are critical to promoting health and well-being and will also help restore strength. ethics of compassion in health care.