Thanks to your generous support, HLA has represented clients in 1,346 cases so far this year. With many cases involving multiple family members, we have served thousands of individuals this year.

Photo by Kenny Eliason on Unsplash

Amy is the mother of Khalil, 18, a senior in high school. Khalil is goofy, enjoys playing basketball and football, is a good big brother, and loves his family and friends. In middle school, he began to struggle: he was quiet and reserved in class and had to develop his own coping mechanisms for untreated ADHD. He was also diagnosed by a mental health professional with PTSD and anxiety. Amy advocated for him to get a special education plan, but his school refused to provide any services to help him succeed. 

Amy was aware that in their school district, kids with ADHD were treated as problem students. Additionally, her son is one of only a few dozen Black students in his predominantly White school district. In early 2021, Khalil was also arrested off campus. He was not convicted of anything but was put on probation for six months. Amy had seen that the school disciplined the students of color more often and more harshly than their white peers. The school continued this pattern and chose to suspend Khalil during his probation, even though suspension was entirely at their discretion. Instead of providing needed support, they penalized him. In total, Khalil was excluded from school for 13 months. 

Khalil’s probation officer referred Amy to HLA’s Mental Health Advocacy Program (MHAP) for Kids. A constant advocate for her children, Amy decided that she needed legal counsel in this fight to secure school-based services for Khalil. She teamed up with MHAP for Kids Western Mass. Staff Attorneys Caitlin Reed and Jessie Fried and with the family’s Court Appointed Special Advocate (CASA). In September 2022, Caitlin helped the family secure an independent mental health evaluation which led to Khalil receiving his first ever individualized education plan (IEP). The plan contained essential support services during his suspension, including school counseling and tutoring. Later, Jessie won updated services in Khalil’s IEP to set him up for success when he returned to school. 

Khalil finally rejoined his class earlier this year with the new IEP services and is passing all of his classes. He and his mother are thrilled to have him back in school and out of probation. Khalil is motivated to complete his high school diploma in 2024. 

“[The] law being used to keep kids out of school is being used inappropriately. For children that struggle academically this is a way to get them out of school [and] this is a school-to-prison pipeline … a lot of people don’t know where to turn to and (MHAP for Kids is) something I feel is more necessary for parents to have in their tool belt”

– Amy

Photo by Christian Langballe on Unsplash

“Alice” is a social worker and wellness coach. She also takes care of her mother, “Miriam,” who is 85 years old.

In March, Miriam went to the emergency department with an infection and several days later had to have her leg amputated. Following the amputation, in early summer, she had multiple strokes. While her mother was in rehab, Alice worried about how to care for her when she came home. Alice had already taken leave from work and Miriam requires care 24 hours a day.

Miriam was covered by MassHealth Limited at the time of her surgery, but this plan does not include comprehensive benefits and does not cover any of the long-term services Alice knew her mother would need. The family did not have precise information about Miriam’s immigration status and Alice hesitated to seek a higher level of coverage through MassHealth. A doctor at Miriam's rehab center referred Alice to HLA, and her case was assigned to Supervising Staff Attorney Jennifer Cedor.

Jennifer confirmed Miriam’s immigration status and, with Alice, gathered the required documents needed to prove her eligibility for better MassHealth coverage. Jennifer immediately wrote to MassHealth explaining Miriam’s health issues and immigration status and got her coverage upgraded to MassHealth's Family Assistance plan, allowing Miriam to access many more services like physical and occupational therapy.

Later, as Miriam's recovery continued, Alice determined that Miriam needed more care, including a day center placement and personal care attendant (PCA) services. To help Miriam access these services, Jennifer navigated a special process that MassHealth created for non-U.S. citizens with special health care needs in the Family Assistance plan to receive expanded services. Jennifer helped Alice complete the required forms and Miriam was upgraded again, this time to MassHealth's highest level of coverage, the Standard plan.

Now, Alice can put in place PCA and other services to support her mother’s care. At the end of August, Miriam received her first MassHealth-covered transportation service to a doctor’s appointment and began adult daycare, which she loves. Alice is finally able to go back to work and is immensely relieved that her mother is safe, cared for, and happy.

“[Jennifer] did amazing work. She acted quickly – she just told me, send this and I’ll do what I need to do…I think she’s pretty amazing…I’m just grateful that I met her and she was the one assigned to this case”

– Alice

Zooming in on Medical Debt in Massachusetts

Medical debt is a persistent problem for people in Massachusetts and throughout the United States. In recent years, though our state's health insurance coverage rates have remained high, medical debt remains a major problem for many people both with and without health insurance.

A 2022 report by the Kaiser Family Foundation (KFF) revealed just how pervasive and harmful medical debt is nationally. The report found that “about a quarter of adults (24%) say they currently have medical or dental bills that are past due or that they are unable to pay.” KFF’s research also revealed that medical debt disproportionately burdens Black and Hispanic people and women, forces millions to miss housing payments and cut back on spending on food and clothing, and acts as a major barrier to future health care. Learn more here from Naga Vivekanandan, HLA’s summer Medical Debt clerk. 

According to the United States Consumer Financial Protection Bureau, medical debt can also have serious health impacts; people may feel forced to avoid seeking medical care or to make difficult cuts to essential expenses. Some health care providers sue patients over bills that should have been covered by health insurance and report medical debt to credit rating agencies, which can impact housing. The stress of medical debt can also create new physical and mental health problems.

Here, we are taking a closer look at medical debt in Massachusetts to understand where we are and how to approach the goal of medical debt elimination statewide. 

Despite Massachusetts’ success in expanding health insurance coverage, medical debt inflicts extreme difficulties in residents' lives:

HLA collects data as a component of our Medical Debt Initiative. The data collected from our cases helps us understand why our clients incur medical debt and how to fight debt on a systemic level.

Insurance Cost Sharing, such as deductibles and copays, makes up 21.6% of unaffordable medical debt bills in HLA cases, making it the most common reason for medical debt we see. Interestingly, these bills represent a much smaller portion (9.7%) of the total amount billed across all HLA medical debt cases. This illustrates the prevalence of cost-sharing as a source of medical debt and highlights that even small bills can be a heavy enough burden on consumers that they might need legal help.

We have also found that although insurance coverage denials are a less common cause of medical debt among our clients (7.3%), they make up 26.1% of the total amount owed. At HLA we regularly fight for insurers to cover medically necessary services. Getting necessary health care should never result in unaffordable medical debt.

Health care provider billing practices generally are also a common cause of medical debt for HLA's clients, with a variety of provider billing issues constituting 18.5% of the number of medical bills causing debt and 11.9% of the amount of debt our clients report. A specific billing practice, balance billing (wrongfully billing MassHealth or private insurance members for the remainder of a bill after insurance payment) makes up 3.5% of bills and 7% of debt in HLA cases.

Regardless of the cause of medical debt, wrongfully issued health care bills make individual and families suffer substantial hardships.

HLA also uses our data to enhance the services we provide and seek systemic solutions. Our current data tell us the Medical Debt Initiative reaches people of color, in particular black people, at a lower rate than it should when compared to 2021 state data from the Center for Health Information and Analysis. We are addressing this by focusing outreach efforts on underrepresented groups, making connections with community organizations, and translating promotional materials. The data are vital to ensuring that our work is advancing health and economic equity in Massachusetts. 

If you know of any organization or group that would like to connect and learn more about our Medical Debt Initiative, contact HLA’s Communications and Administrative Associate Abby Craig at acraig@hla-inc.org.

Sources and Further Reading:



• Medical Debt May Be Declining in the U.S., but Disparities Persist, U.S. News & World Report
• Medical Debt Burden in the United States, Consumer Financial Protection Bureau
• Findings from the 2021 Massachusetts Health Insurance Survey, Center for Health Information and Analysis
• The burden of medical debt in the United States, Peterson-KFF Health System Tracker
• 1 in 10 Adults Owe Medical Debt, With Millions Owing More Than $10,000, Kaiser Family Foundation

HLA’s Immigrant Health Initiative celebrated a recent victory when MassHealth reformed its policy for providing enhanced access to health care services for non-U.S. citizens with high health care needs. For years, many non-citizens, because of their immigration status, qualified for relatively comprehensive MassHealth benefits, but not for the highest level of insurance. As a result, many immigrants lacked coverage for long-term stays in nursing homes and rehab facilities, which are often needed by older individuals recovering from issues like strokes, people with multiple health conditions, and people unable to live on their own due to disability. In November of 2021, MassHealth created a process for immigrants in need of these longer-term services to request a coverage upgrade to permit access.

While the establishment of this process was a big win for those who advocated for it, including HLA, a roadblock to implementing the policy quickly became apparent. In order to receive an insurance upgrade, an individual had to already be accepted by a nursing home or rehab facility. However, these providers were rejecting patients because they did not yet have the right level of insurance.

HLA Attorneys Kate Purrington, Jennifer Cedor, and Andrew Cohen identified this problem and submitted a legal memo to MassHealth officials explaining this Catch-22 and the problems it created: patients were stuck in the hospital, not receiving the services they need, and in an unnecessarily restrictive environment. Meanwhile, hospitals were losing bed capacity because patients could not safely be discharged to the right long-term placement or home.

MassHealth responded to our advocacy, changing the policy so patients’ MassHealth coverage could be upgraded before being discharged to nursing homes or rehab. This change is improving immigrant patients’ ability to get out of hospital beds, improve their quality of life, and regain health faster. 

Language Access in Schools

Attorneys from HLA’s Mental Health Advocacy Program (MHAP) for Kids recently testified in support of legislation that will have a strong impact on kids’ mental health and educational success across the state.

MHAP for Kids Hyannis-based staff attorney Brian Bermudez joined numerous others testifying in front of the Massachusetts Legislature's Joint Committee on Education in support of a bill to improve language access in schools. Massachusetts Advocates for Children is leading the campaign to pass this bill.

Brian spoke about the experience of his client, who immigrated to Massachusetts at age 14 and has PTSD and anxiety. At school she had very little language support and struggled to follow classes taught completely in English while she was still an English language learner. Without interpreters, she was unable to communicate with the school about her mental health and the bullying she experienced. These issues worsened and she was removed from school for most of the year.

Some Massachusetts schools aim to be “fully immersive environments,” where all communication is in English, except in English Language Learner classes. Other districts may rely on bilingual staff or volunteer interpreters who are not qualified and risk miscommunicating at important moments in a student’s education. This bill would help schools put proper language access services in place by creating a system that trains and evaluates interpreter qualifications.

In his testimony, Brian shared that his client’s problems in school could have been resolved with access to language services, but instead she was left out for nearly a year. He stated that for this student and others, a lack of communication in one’s preferred language equated to a lack of access to education.

Enhancing Data Transparency to Identify Discrimination

Also testifying in front of the Joint Committee on Education was MHAP for Kids Quincy-based Supervising Attorney David Satin. David spoke in support of the Equitable Data Access Bill, led by Citizens for Juvenile Justice, with the support of Massachusetts Advocates for Children and The EdLaw Project, among others.

This bill would require the Department of Elementary and Secondary Education (DESE) to change the way it publishes data for the public. Data is currently publicly available and can be sorted by factors like race, sex, economic status, and disability. The new legislation would enhance the way this data could be categorized, so parents and advocates can find specific data based on the intersection of multiple categories. For example, rather than simply seeing data for disciplinary action taken on all students with disabilities, it would be possible to search for data specific to female students of color with disabilities.

David testified to the impact having this data would have for families and kids considering current school discipline practices systematically exclude children unequally. Children with disabilities are often disciplined for behaviors directly related to their disabilities, including mental health disabilities, and this affects children of color more than their white peers. David stated that the ability to get more specific data that includes multiple aspects of students’ identity will help parents, advocates, and policy reformers to better understand who is being excluded from school and fight those inequities at both the individual and systemic levels.

HLA is proud of our attorneys for using their expertise and experience to support our partners’ legislative advocacy efforts to improve kids’ lives at the state level. 

HLA is proud to share that in our most recent fiscal year, our team conducted an amazing 91 training and outreach programs throughout the state. Providing training and outreach programs is an important way to extend our knowledge and expertise to individuals and organizations so they can be better advocates for themselves and their communities.

The audiences for our trainings are most often consumers in low-income situations or staff and clinicians in community organizations and health, social service, and legal service providers. We provide trainings both online and in-person and for audiences of all sizes, from just a few to hundreds.

HLA’s trainings cover a wide variety of topics related to our initiatives. Our Mental Health Advocacy Program for Kids offers sessions on individualized education programs, juvenile court, school discipline, and special education law generally, among many others. Our Access to Care and Coverage Team also conducts trainings on immigrant eligibility for MassHealth, gender-affirming care, medical debt, and other recent developments in health care policy. They have also presented special trainings on the ongoing MassHealth Redetermination process. This work not only provides valuable community education, it strengthens our ties with communities and local organizations, which are vital sources of referrals, knowledge, and partnership. 

Collaboration and Connection at the Children's Mental Health Summit

HLA Deputy Director Marisol Garcia and Yolanda Lewis of the Meadows Mental Health Policy Institute present "Smart Justice" at the Children's Mental Health Summit.

HLA Deputy Director Marisol Garcia recently presented at the Children’s Mental Health Summit, a national conference hosted in Boston by the Massachusetts Association for Mental Health and the Hackett Center for Mental Health. The program included topics on school mental health, community-oriented mental health, and improving access to services. In “Smart Justice,” Marisol presented on the work of the Mental Health Advocacy Program for Kids and with Yolanda Lewis of the Meadows Mental Health Policy Institute facilitated a discussion amongst advocates and policy makers from Texas and Massachusetts. Participating in these events offers an exciting opportunity to learn from and collaborate with people working to make health care more equitable and accessible for kids across the country. 

28th Annual Benefit Breakfast

Two powerful client stories, a beautiful conversation between NBC 10 Boston's Abbey Niezgoda and Min Jin Lee, author of the New York Times bestseller Pachinko, and the good company of friends is the recipe for one of our best Annual Benefit Breakfasts to date!

We are so grateful to everyone who made this event possible! We want to extend special thanks to our featured speaker Min Jin Lee, our emcee/moderator Abbey Niezgoda, our clients Darlene Brown and Josilyn DeMarco, and our amazing Co-Chairs and Event Committee (listed below).

If you would like to learn more, contact Jennifer Javier, Manager of Donor Relations and Events, at jjavier@hla-inc.org. 

28th Annual Breakfast Co-Chairs

Rising Attorneys Event Committee

Jessica Beglin,(Rising Attorneys Events Committee Chair), Novartis

Amara Anosike, Somerville Public Schools

Michelle Choi, Foley Hoag

Carroll Gee, Beth Israel Lahey Health

Anna Gurevich, Hinckley Allen

Marylana Saadeh Helou, Epstein Becker & Green

Sharon Jaquez, Ropes & Gray

Patrick Ouellette, Mintz, Levin, Cohn, Ferris, Glovsky, and Popeo

Allie Shalom, Foley & Lardner

Steve Tringale, Husch Blackwell

As HLA grows, our DEI committee continues working to develop a Diverse, Equitable, and Inclusive environment for clients and staff alike. Here are some of our recent DEI efforts: 

• Building the work of our new School Discipline Advocacy Program within our Mental Health Advocacy Program (MHAP) for Kids to provide immediate representation for kids with mental health diagnoses facing school exclusion. Children of color are much more likely to be unfairly expelled or suspended from school than their white peers. In the past year, four legal interns, with supervision from MHAP for Kids Staff Attorney Kendal Poirier, and MHAP for Kids Staff Attorneys have helped a diverse group of kids stay in school and continue to access school-based treatment.

• Analyzing HLA case and Massachusetts demographic data to identify gaps in our community visibility and highlight areas to improve. The results of this analysis will guide outreach planning for the coming year.

• Hosting a second training led by Tonysha Taylor, director of Diversity, Equity and Inclusion for the Massachusetts Legal Assistance Corporation. This second of three trainings focused on identity and intersectionality.

Thank you to Our 2023 Summer Clerks!