SARAH: This is At the Core of Care. A podcast where people share their stories about nurses and their creative efforts to better meet the health and healthcare needs of patients, families, and communities.
I’m Sarah Hexem Hubbard, executive director of the Pennsylvania Action Coalition and the National Nurse-Led Care Consortium.
The National Nurse-Led Care Consortium works to strengthen communities through nurse-led models of care and one of the ways we do that is through nurse-led home visiting programs for families with young children here in Philadelphia.
Every year, we reach between 600 and 800 families, all of whom face economic and other social barriers and most of whom are first-time mothers. The evidence-based models we implement—include Nurse-Family Partnership and Parents-as-Teacher—emphasize the importance of social determinants of health. We know from decades of research—and what we hear from our clients and nurses on a daily basis---that health CARE needs to include strategies to address our clients’ social needs.
One way that we work to address social needs is through our Nursing-Legal Partnership—a prevention-focused variation to the now well-recognized medical-legal partnership approach to healthcare. Civil legal aid attorneys are embedded in our services as part of an interdisciplinary care team. They help both clients and nurses navigate a complex system that sometimes doesn’t seem to have any way forward.
Both legal and nurse home visiting services shifted exclusively to telehealth through most of the COVID-19 pandemic, but the work definitely did not slow down.
The many hardships of the pandemic and the complex web of resources designed to address them---like Pandemic Unemployment Assistance or PUA…and the various rounds of stimulus funding and now proposals like the Biden Administration’s American Families Plan—all offered much needed relief to many but a lot of confusion and challenge as well.
On this episode, we’ll hear from our two staff attorneys and one of our public health nurses about this complicated mix of challenges and benefits for the pre-natal and post-partum women who they directly serve.
They are also going to highlight a critical gap in relief for some of our clients that went largely unnoticed: women who were pregnant but unemployed before the pandemic who were then not eligible for any of the pandemic unemployment assistance. At the same time, they’ll highlight many other families who were able to receive assistance that ultimately helped them save money and take paid time off from work.
We’re going to hear about a range of related issues on this episode, including pregnancy work discrimination, the significance of paid leave, maternal and child health, navigating the public benefits system, accessing pandemic unemployment assistance, and the potential impact of the American Families Plan on the community of women and families who we serve.
First, we’re going to hear from Rachel Mark who’s one of our staff attorneys…then Erin Blair who is the nurse liaison for the Nursing-Legal Partnership…and finally Susanna Greenberg, the managing attorney for the NLP.
Before we hear those perspectives, just a quick bit about how NNCC is structured to help you follow along. Our organization consists of various nursing initiatives, including the Philadelphia Nurse-Family Partnership program that links first-time low-income mothers with a nurse home visitor during pregnancy and until the baby turns two. We also run the Mabel Morris Family Home Visit program—which uses the Parents-as-Teachers curriculum--- and serves families with children until they enter kindergarten. The staff attorneys for the Nursing Legal Partnership are with an organization called HELP: MLP, which is the legal partner in our Nursing Legal Partnership. They are fully integrated into our programs and services. Our staff attorney Rachel Mark will tell us more about how this all works.
RACHEL: The way that our program actually works on the ground is that nurse home visitors will screen clients in the field. So pre COVID, that meant that within the first few home visits while they're working basically doing intake paperwork, they would also do a screening to determine whether or not the family had any legal needs. and it's about 30 questions of information that might be very personal information that might be hard for a client to share in the beginning. And so, the screenings will be done at scheduled intervals. So, with Nurse-Family Partnership, it's based on the stage of pregnancy, and then at like the child when the child knew that when the child was born, six months, 12 months, at like regular intervals. And with Mabel Morris, it'll be done just on a more of a scheduled basis. And then there also will be screenings kind of when a need comes up for the family, that nurse will make a referral. And the nurse will then make a referral directly to the lawyer. So, when there's an acute legal need, they'll send us a referral, they'll also send us a form that will and they'll describe the legal issue that the family is facing. And so, at that point, myself or Susanna will either consult directly with a nurse and give them information to have of how best to support the family if there's not yet a real acute legal need. Or if there is a legal need, we will go directly and reach out to the client. Sometimes we'll end up doing some sort of like hybrid, or we'll do a case conference. Well, we'll work with the nurse and with the client together, all of us will sit down and talk. Right now, that's something that often happens over Zoom. And it really depends on what the client's individual needs are and what the legal issue is to determine what steps what will be our next steps that we take.
We’re able to connect with clients before there's an acute legal need. So sometimes, oftentimes, when especially serving clients with criminal needs, and also with other civil legal needs, they'll come in when they're kind of, they're essentially going to the emergency room, right. Someone's coming in, they've already received an eviction notice someone's coming in, and they've already had their utilities shut off. And when you're in a position where someone is already about to be evicted or has already lost their food stamps, you're in a much weaker position in terms of your ability to help them and support them. And they also themselves are in a much more acute position. And so, working with another social services provider, in this case, with nurse home visitors, we are able to reach clients before an issue becomes acute. So, we're able to start working with a client before when maybe they're just behind on their rent, and to work with a landlord and negotiate with them and figure out what resources are available to the client in order to help them and prevent them hopefully, from getting an eviction notice at all.
And the same thing goes for public benefits, we're able to help them when maybe they've gotten a notice that their food stamps have been reduced, or they've gotten a notice that they haven't, there's paperwork that they have to submit and they haven't for some reason it hasn't been done yet. And so, when we get to them at that point, we're able to prevent a crisis from happening, as opposed to supporting a client when they're already in a crisis.
And so being able to support families and helping them live in healthier homes, helping them making sure that they have access to utilities when they need something like medication or medical device to that requires access to refrigeration or electricity. So being able to support families, in those ways through legal assistance to improve their health is something that I find really meaningful and really important.
Before COVID, we were doing mostly housing, so housing was utilities, housing conditions, issues, and eviction kind of cases. And we were doing benefits work. So, we were doing a lot of SNAP, TANF cash assistance. And I had a handful of Medicaid cases. And that was really the majority of the work that we were doing, we did not I, before COVID hit, I think I handled maybe one unemployment case. And then COVID hit and we really had to pivot the work that we were doing, because we kept on getting unemployment referrals. And we did, and we had to really work to educate ourselves so that we could learn how to best support our clients and really teach ourselves a whole new area of the law, right, because there are attorneys whose entire specialty is unemployment work. And that was not something that we were used to taking.
So, we had to learn how to do that. And we really shifted our practice to figure out the best way to support our families. And we did see a hole though in that the there was definitely expanded relief, which a lot of our families benefited from in the expanded unemployment increased weekly payments for unemployment, pandemic unemployment assistance. All of these things definitely helped a lot of our families but there were still a core number of our families that were not afforded protection through these expanded benefits.
And this mostly came about with people who were pregnant and not working when the pandemic hit. And oftentimes, the reasons why they weren't working were related to Pregnancy Discrimination, right. So oftentimes, we'll have cases might consider like soft Pregnancy Discrimination where, for example, you have a client who is working in a grocery store or liquor store, and part of their regular job requires them to do heavy lifting. And they're not able to do that during their pregnancy, either because of normal pregnancy, because just a typical pregnancy or in theirs will have a pregnancy complication that restricts them from lifting or requires them to be sitting for longer periods of time. Or maybe they need more breaks. And once they, if they ask their employer for that sort of accommodation, they're often told no, or that, that there's no such position at that place of employment or at that store. Or there's a lack of communication, sometimes between the healthcare provider and the employer, that makes it unclear exactly what it is that the client is able to do.
And that means that pregnant people who were jobless when COVID hit, were often not included in the expanded COVID protections and in the expanded COVID benefits around unemployment. And at the same time that they're not eligible for UC, the benefit that they are eligible for was cash assistance, Temporary Assistance for Needy Families, which has not gotten a raise in over 20 years now, I think, almost 25 years. Currently, a pregnant person who receives cash assistance gets $205 a month, which pales in comparison to the benefits that they would be entitled to if they were receiving unemployment compensation, an extra $600 a week.
ERIN: My name is Erin Blair. I am a 13-year experienced nurse home visitor with the Philadelphia Nurse-Family Partnership. And currently I am the acting nurse liaison for policy and advocacy and complex case navigation with the HELP MLP Nursing Legal Partnership and I am also the emergency fund manager for the Mabel Morris and Nurse-Family Partnership home visiting programs.
When we brought in a legal partnership, we wanted to kind of set it apart from a medical-legal partnership and follow in the role of having nurse-led care. We wanted it to be a nurse-led legal partnership.
We as home visitors were informing our leadership that what we were seeing changes in the field that we're not good. And we were having to spend more and more of our time crisis managing complex issues that we really weren't trained to manage or navigate. So, when we have clients that are facing eviction, right, so and then and then housing insecurity, trying to become an expert in preventing eviction. And like nurses were regularly looking up laws and trying to act in this capacity to prevent families from losing benefits and housing and all of these different needs. And we were aware legal systems and protections existed. But we really didn't have the skill and were with all to implement those and put them into action. Prior to having our policy and advocacy team and the nursing legal partnership, we had a resources team that would often talk about these kind of complex issues that families were having, and draw on one another's expertise and resource navigation. So, we weren't trying to recreate the wheel each time a nurse had a new family crisis that arose and to share that information in real time on what supports were out there and how to navigate them.
It's an ineffective use of nurses time to continually crisis manage things that are outside of their wheelhouse, right? So, we when you can't focus on teaching health and nutrition and early childhood literacy, and all of these other things, because your crisis managing or figuring out even where to go meet a client, because they're homeless, or figuring out you know, they can't tune in and really, truly give their focus to any of the stuff you might be working towards teaching them, when you're continually trying to prevent them from losing the very base. You think about Maslow's hierarchy of needs. The nursing legal partnership and the social determinants of health really are that base on the Maslow's hierarchy. And without that base, you can't build on top of it, which is how you get up to that kind of higher-level thinking that gives you the time and energy and emotional resources to be able to develop other skills and time with your child and just emotional energy to parent well.
So, for pregnant clients, during the pandemic, the issue was that kind of coming out of the pandemic, because they didn't lose employment associated with the pandemic, they may have gone on maternity leave, or unpaid time off or whatever prior to then, and couldn't prove that their economic losses were associated with COVID, they didn't become eligible during that period, or it was a real uphill battle for people who left work due to pregnancy. We don't have any real protections very often, for a lot of low wage workers. I believed that we had actual protections, right, so you've got like 12 weeks of FMLA, or whatever associated with a position. But that's only if you work a certain number of hours. And if you've worked in a position for more than a certain number of weeks or months, and if you're somebody that's piecemealing, two or three jobs together, the likelihood that you have any protection from losing employment for calling out sick or anything else is very, very small, and the likelihood that when you leave that job to deliver a baby, they'll hold that position for you doesn't exist at all.
But during the pandemic, I saw a couple of different things. For many of the families that I work with, they had the first paid time off in their entire lives. They had enough money to live off of for the first time in their lives, if they were employed prior to COVID and were getting pandemic unemployment compensation. This sort of false narrative that the reason people are poor is because they lack the ability to manage their money well, was very much tested because many people that had been low-wage and low-income prior to COVID, who received unemployment compensation and PUA, saved money, purchased homes, were able to save enough to get cars and like all of these things and they came out on the other side of the pandemic healthier than they were going into the pandemic or with more of their social determinants of health needs in place.
We also came out on the other side of the pandemic, after very many moratoriums on eviction. Our families weren't being evicted during the pandemic. Our families weren't becoming unhoused at alarming rates as normally, because pregnancy and pregnant and parenting people with children less than school age are some of the highest risk people in the country, particularly black women, with young children to become evicted or homeless during pregnancy and shortly after pregnancy.
But these groups are traditionally very much left out of that conversation, in terms of how we design meaningful program to support people to prevent them from loss of their housing and loss of their jobs, loss of like those workers protections and stuff like that. But that sort of tale of two families of seeing like these benefits that were so meaningful to my low-wage families, and how much they did with meaningful amounts of support in such an overwhelming and tumultuous time, was really amazing.
And then to see the families that lacked support, and how challenging it was for them, and how, you know, as, as our emergency fund manager, another of my hats, I was fielding all of the application requests for emergency money for families that didn't qualify for the other emergency and economic income supports.
And I have to say that our families that are undocumented and our families that did not have legally mandated access to unemployment compensation and PUA were the ones that were most likely to seek out supports for rental assistance, or utility assistance, or even just paying for childcare assistance paying for all of these different things that were really challenging to access just so people could maintain that very base level.
It's always highest in my pregnant and newly postpartum moms. For 13 years, I've been trying to set people up economically for this like dry spell that I know is coming up, because they're not going to have paid maternity leave or, unemployment and TANF, it's just not enough to really meaningfully survive off of and a lot of people that don't have those supports are the same people that really can't put away a lot of savings because every single dollar they have goes towards just meeting the most base level of needs.
SUSANNA: My name is Susanna Greenberg, and I'm the managing attorney of the HELP MLP site in Philadelphia. When I learned about HELP MLP and their model of working with pregnant and parenting families at the sort of the critical moment of children being born in their first few years of life, and really trying to holistically target all of the unmet legal needs that emerged in that period, both to improve maternal-child health outcomes, but really just the long term ability of the family to thrive, that felt to me like the kind of intervention that might really make a difference in the long term beyond the one issue representation. And that was incredibly compelling to me as the way to direct the skills that I have as a legal aid attorney.
So, there's, you know, a broad number of public agencies that our clients sort of day in day out need to navigate in order to take advantage of benefits that they are entitled to by law. And unfortunately, while on paper, a lot of these benefits are great supports, it's actually just the the navigation and the accessibility of the systems that can be the biggest hurdles.
You know, it was so funny during the pandemic to see as a lot of people who don't ordinarily intersect with that many government programs or aid programs were on unemployment. You know, there were these newspaper articles about how many times people had to call the helpline to get help from unemployment. And, like, yes, it was maddening. But, you know, my clients regular lives is, you know, intersections with six different agencies on which they're dependent for food and housing and childcare and formula for their baby. And, like, that's how most of those systems are working most of the time. I mean, it is a full-time job. That doesn't leave much room for, you know, working on your educational goals or focusing on, you know, what your goals for your baby. These systems aid people, but they are also an enormous source of distraction. And it's easy to feel, I think, very disregarded by them.
I think so many of the right intentions went into COVID relief. And, you know, the devil is always in the details with how these things end up applying. But you know, for instance, while the stimulus payments were such a saving grace for many people, they were based on prior year's tax filings. And so, if you had a baby in 2020, there was no way to access the stimulus funds for the baby until you file taxes, you know, in mid-2021, and have, you know, refunds come subsequent to that. So, some people might say, you know, well, it came at the end of the day, right, it was just a year later. But, you know, when you have a brand-new baby, and you're at that moment of maximum vulnerability, both financial and physical and emotional, you know, there is a window in which the stresses have demonstrated impacts on maternal-child health and your ability to focus on bonding with your baby. And if you're worrying about the fact that there's not money to pay rent that month. You know, getting money a year later, doesn't change the impact that stress had on your body and your relationship with your baby.
You know I think a lot of government agencies were sort of creating new programs wholesale and trying to implement them really quickly. And understandably, there's glitches when you try to do that, and then all of the Legal Aid universe and social service universe, we're trying to rapidly understand the new programs coming into effect and apply them to clients as broadly as possible. And I think like, on the whole right out, you know, it works for some percentage, and then you find some more that you can like, squeeze through the cracks, and then you have some that are less, you know, just left out at the end of the day. And so we certainly, you know, we saw some improvements along the way. Initially, there was a real challenge with people who hadn't filed taxes in previous years because they didn't need to because they didn't earn income. Whether they receive Social Security or just were young and hadn't had enough income in a prior year, eventually the IRS set up what we call the nonfiler portal that'll enable those people to say, Hey, I'm out here, this is how many dependents I have, and then get their stimulus. And those, you know, all of these sorts of things emerged, because advocates identified and pointed these needs out to the agencies.
With a lot of it, we just ended up having to be far more hands on, then we're usually comfortable being so sort of, I mean, it's funny with having figured out zoom and sharing screens, you know, we were able to sort of get online with a client and figure out how to log in to the non-filer portal or the unemployment compensation portal and really sort of try to weed through these new online systems with them in order to enter the information needed. And, you know, for many clients, it just felt like that wasn't going to happen without that level of support. And, you know, again, remember that, you know, the vast majority of the people that needed to do something like the non-filer portal don't have a nurse and a lawyer on speed dial the way our clients do, you know, our program is a wonderful one that I'm very proud of, but it's not it's not a, it's not a solution to poverty, because of the limited scale of clients that we can reach. And ultimately, these these systems have to be accessible enough that you don't need a lawyer to, you know, let the IRS know that you exist.
For instance, there's a new non-filer portal to help people access the child tax credit, which, you know, is the biggest sort of strike against child poverty in a very long time, very exciting. The non-filer portal is not accessible by mobile phones. Well, for most of our clients, that's their only internet access. And so, you know, it's, it's, it's those small things that are not at all small, the person who is or isn't going to reach this money as a result of it. So, we're, you know, we're hoping we see that and other changes made as it evolves.
I think COVID shined a spotlight on what we're already like glaring inequities and shortfalls in our safety net, particularly for people during pregnancy and early childhood. And, you know in some ways, the gap that Rachel and I have pointed to of like, well, what if you were pregnant before COVID and then you couldn't get paid anyway. And then you know, whatever. It may sound to people like a sort of niche situation. But it's really just a way of shining light on the fact that like in the absence of paid leave, there are so many ways to like not quite fit into the other systems that exist.
I think the the proposed American families plan really rises to meet a number of what I see is the the biggest hurdles for our families, I mean in the first place the expansion of the child tax credit and making its existence as a refundable credit, permanent meaning you get it regardless of how much you owe in taxes, really meaningfully puts, you know, 250 to $300 per child into the pockets of people raising children. And the difference I think that that makes in a city where there's, you know, such exorbitant increase in housing costs increase in utility costs, you know, to the point that for, you know, if there's a single parent with one child to meet housing and energy costs, you know, puts you in a position that sort of usually the third need mentioned by our clients is just paying for diapers. And you can imagine if that's a stretch, then sort of everything on the list you would want for a child after that is, you know, going to be a real deprivation.
And so just money in the pocket to support the costs of having a child is, is, you know, I think it's been sort of widely reported as potentially the biggest reduction in child poverty in in many years. And hopefully, as long as sort of the basic tax filings are made, it's not a whole another benefit system that one has to constantly report every change in one's life to and keep up with its, you know, hopefully, will be pretty self-executing. I think that, you know, that's the biggest thing, but then beyond that, you know, the biggest challenges we see, for clients who do have employment, are really, first of all, the lack of paid family leave, so you have employment, but you know, you have to figure out how to get through the period after delivery, with no income without losing your housing, and there's just a financial spiral that can happen there, if you don't have family or partner support at that time. So, you know, just nationally, you know, compared to other countries, you know, I think the lack of paid family leave makes us such an outlier, and just no matter where you are in the economic spectrum, but certainly, you know, if you are lower-income, it's, it just sort of guarantees that a child's birth is a destabilizing financial experience. And so, you know, for me, is one of the things I'm most excited to see happen that hopefully, it also, you know, maybe means that employers are, work with pregnant people a bit more and sort of know that they're going to have some coverage and come back and and then that, you know, as soon as you get back from sort of the time you take off after delivery, then childcare is the dilemma. And so the investment in childcare, you know, to have more and higher quality and subsidized childcare is really sort of the third pillar that I see making a huge difference.
CREDITS
SARAH: Special thanks to Erin Blair, Susanna Greenberg, and Rachel Mark for taking time to talk with us.
Funding for this episode of At the Core of Care comes from The Valentine Foundation.
For more about us and our programs, log onto paactioncoalition.org and nurseledcare.org. And you can connect with us on social media @PaAction and @NurseLedCare.
At the Core of Care is produced by Stephanie Marudas and Emily Previti of Kouvenda Media and mixed by Brad Linder.
I'm Sarah Hexem Hubbard of the Pennsylvania Action Coalition. Thanks for joining us.
