But the most unusual doctor’s referral of her life came last year: Go see an attorney.

Enriquez De Santiago sought help at a Colorado health clinic that takes a novel approach to improving the health of its patients: It incorporates legal assistance into its medical practice for patients facing eviction or deportation proceedings, among other legal woes. And the state’s Medicaid program helps fund the initiative.

Although Medicaid traditionally doesn’t fund clinics to supply legal assistance, Colorado is one of several states that have been given permission to use some of their Medicaid money to help pay for such programs. Every day in Commerce City, four lawyers join the physicians, psychiatrists and social workers at Salud Family Health Centers’ clinic in this suburb north of Denver, as part of Salud’s philosophy that mending legal ills is as important for health as diet and exercise.

The goal: Reduce toxic stress and keep families intact, on the premise that it will serve their health for years to come, said Marc Scanlon, the attorney who directs the program.

Mostly, that has meant helping people with unemployment benefit claims and Social Security Disability Insurance denials. But it also regularly entails helping patients — many of whom speak only Spanish after having arrived here from Mexico or Central America — with immigration hearings.

The program is among at least 450 existing medical-legal partnerships across the nation that typically serve impoverished people and migrants. The vast majority don’t rely on Medicaid dollars, which are used only in fewer than 10 states, according to the National Center for Medical-Legal Partnership.

The role of these sorts of medical-legal partnerships has grown over the past year as millions of people in the U.S. have faced lost income and the threat of losing their homes during the covid-19 pandemic. Some partnerships have helped patients secure unemployment checks, while others have fought some of the evictions that weren’t already barred by state or federal moratoriums.

“All the issues that people are struggling with in the pandemic are all the same issues that medical-legal partnerships have been trying to work with forever,” said , a law professor and co-director of the Georgetown University Health Justice Alliance in Washington, D.C.

In Montana, Kallie Dale-Ramos helped persuade a primary care association, the state’s legal aid organization and six community health centers operating in cities across Montana to pool $20,000 to help hire an attorney, who can split time among the clinics to help patients affected by the pandemic.

Since the start of 2020, that investment has helped more than 130 patients seek unemployment claims — and potentially stave off financial ruin.

One woman had been waiting for unemployment assistance since applying in March 2020, and only recently received her first check, said Dale-Ramos. Without legal help along the way, the woman “would have just been like, ‘I can’t do this anymore,’” Dale-Ramos said.

This sort of legal-medical partnership is centered on the notion that doctors can do only so much to keep their patients healthy.

Proponents See Lasting Impact

Advocates for such programs cite the example of a child suffering from asthma caused by mold in a dilapidated apartment. While a doctor couldn’t force a landlord to clean up the property or break the lease, a letter from a lawyer might be persuasive, said Dr. Tillman Farley, Salud’s chief medical officer.

“Some of these impacts carry out for decades,” Farley said. “And once you get into effects like that, then you’re really talking generational changes in health outcomes.”

Beyond common sense, evidence from emerging research suggests the approach can work. Patients at Veterans Affairs clinics in Connecticut and New York, for example, saw their mental health improve significantly within three months of consulting a clinic attorney, according to a .

And at Colorado’s partnership, a survey of patients from 2015 to 2020 found statistically significant drops in stress and poor physical health, as well as fewer missed medical appointments among its 69 respondents, said , a professor at the Colorado School of Public Health who led the research.

The possible reasons for missing fewer doctor appointments after getting the legal help, Sauaia said, included patients having more income, being less depressed and having an improved immigration status that made them less fearful to venture into public.

Medical-legal partnerships should be considered part of health care, Sauaia believes. “You should be referring to them the same way a provider would be referring a patient to a specialty, such as endocrinology or surgery.”

The biggest challenge for these programs is securing stable funding. Many are funded with a small amount of seed money, or by grants that run only a year or two.

Medicaid, established in 1965, is a nationwide health care program for people who have low incomes or are disabled. It’s jointly funded by the federal government and each state, and traditionally has covered medical costs such as physician visits and hospital stays.

In recent years, though, some states have increasingly sought to use Medicaid dollars to fund initiatives such as using social workers or offering legal assistance to address the . That includes North Carolina, which is using a federal waiver and hundreds of millions of dollars in a highly scrutinized effort to transform its Medicaid program. Among its strategies is more legal aid for patients.

Some Critics See Overreach by Medicaid Plans

The nationwide shift has prompted some health policy experts to question whether Medicaid is beginning to run too far afield of its purpose.

“Everybody agrees that social factors play a very large role in health outcomes; the question is what to do about it,” said James Capretta, a resident fellow of the American Enterprise Institute who was an associate director of the Office of Management and Budget during the George W. Bush administration.

“Medicaid is already an immense program with lots of financial challenges,” Capretta noted. “The program was not built for Medicaid to pay for too many services beyond the more direct services that are related to a medical condition or a disability.”

The small-scale use of waivers and supplemental Medicaid dollars to fund programs aimed at the social factors of poor health — such as housing for people with severe mental illness — works in some places, said Matt Salo, executive director of the National Association of Medicaid Directors. But for Medicaid to provide widespread funding for such social service programs would be unsustainable, and shouldn’t happen, he said.

“It is not — and should not be — Medicaid’s responsibility to figure out how to pay for it,” he said.

Some advocates for legal assistance programs and health policy experts worry about a potential public backlash based on misperceptions about how the little-known medical-legal partnerships use Medicaid. For one, the programs generally aren’t reimbursed for services in the same way traditional Medicaid programs are, said Sara Rosenbaum, a health law and policy professor at George Washington University. Medicaid is more of “an indirect funder,” she said.

A 2019 Manatt Health Strategies report on funding for medical-legal partnerships said “the time is ripe” for these partnerships to explore the little-used avenues available in Medicaid.

The states that administer the Medicaid programs and the managed care organizations that contract with them have some discretion to fund non-clinical services that improve access or outcomes for social determinants of health, according to the report.

States also can write the medical-leaderships programs into a larger federal waiver application for experimental, pilot or demonstration projects that promote Medicaid’s objectives.

“The dollars are minimal,” said Ellen Lawton, former director of the National Center for Medical-Legal Partnership, and a senior fellow at HealthBegins, a consulting firm. “And I think what we’re seeing is that — appropriately — the Medicaid programs are pacing themselves. They’re looking to see what works — what works in our state, what works in our region, what works with the populations that we’re focused on.”

States have been creative in funding these sorts of legal assistance programs. Colorado officials said they amended their Medicaid spending plan to provide grants to two such partnerships. Other states have sought federal waivers allowing them to support those programs. The Department of Veterans Affairs also offers the services of medical-legal partnerships funded by outside organizations.

Scanlon, the attorney at the Salud clinic, is part of a nonprofit organization called Medical Legal Partnership Colorado that operates under a joint agreement with the clinic. Colorado’s Medicaid program approved a $300,000 grant to the partnership that was renewed this year to pay for three attorneys’ salaries.

Authorizing the funding took little convincing, said Michelle Miller, chief nursing officer for the state’s Medicaid program. “When we were asked to approve funding for this, I jumped at it,” Miller said.

One Woman’s Story

For Cynthia Enriquez De Santiago, the 19-year-old patient from Salud’s Commerce City clinic, legal advice made all the difference in her medical care.

In addition to her cerebral palsy, the teen is blind and has difficulty speaking; she needs round-the-clock care, including help eating and using the bathroom. Her doctor at the clinic put Rafaela De Santiago, Cynthia’s mother, in touch with an attorney who could help her continue to be her daughter’s legal guardian after the teen turned 18 last year.

The timing of that legal help proved critical: Several months after seeing the attorney, Enriquez De Santiago was rushed to a hospital. For no obvious reason, she had become hypothermic; her blood pressure dropped and her blood-oxygen levels cratered.

“The doctors were telling me I had to be ready for the worst,” the teen’s mother said through a Spanish-to-English interpreter.

Because she was Enriquez De Santiago’s legal guardian, her mother was able to sign off on follow-up tests after that emergency to quickly get to the root of the medical problem and help prevent it from happening again.

Without guardianship, “it would have been really, really hard, because I wouldn’t know where to begin the process,” Rafaela De Santiago said.

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Any such shout could release the coronavirus to congregants. With some 500 people singing along, though, any concern about a deadly virus circulating was hard to find other than the spaced-out chairs in the 6,000-person hall. Although Colorado’s governor had issued a statewide order days earlier mandating masks, hardly anyone at this service at New Life Church obeyed.

“I’m finding this to be true at churches all over America: If they’re told they have to wear a mask, they’ll stay home,” said Brady Boyd, senior pastor of the 15,000-member New Life Church, a nondenominational megachurch that meets in five locations across the Pikes Peak region.

Long considered one of the country’s evangelical strongholds, Colorado Springs returned to church in ways both guarded and full of gusto after the state lifted lockdowns June 4 with limitations on how many people could gather. But as the county’s coronavirus cases and hospitalizations climb to their , many of the city’s largest and most well-known congregations remain undeterred — openly flouting the new statewide mask order and, in at least one instance, threatening not to stop holding in-person services again if ordered.

It all comes as church leaders across the nation navigate a growing set of political pressures: For months, President Donald Trump urged them to resume services despite pleadings from public health officials for caution and orders by some governors to stay home.

That pressure is particularly acute here at the base of Pikes Peak. Long the conservative bastion of Colorado, this city and surrounding El Paso County, home to about 720,000 people, overwhelmingly voted for Trump in 2016. (The county last voted for a Democratic candidate for president in 1964.)

The Republican sheriff has vowed not to enforce the that Democratic Gov. Jared Polis issued July 16. And several churches are as openly defiant.

But any indoor activities, such as worship services, pose a particularly high risk for coronavirus transmission even with masks, especially when they include singing, said Dr. Jonathan Samet, the Colorado School of Public Health’s dean. While coughing or sneezing can spread larger respiratory droplets, singing and talking release smaller infectious particles that can hang in the air and circulate in enclosed spaces.

“The circumstances of having large groups of people together without masks and doing things like singing is a setup that people talk about for superspreading events,” Samet said.

In Arkansas, for example, at least after two people showed up at a church function with COVID symptoms. And , dozens of choral group members were infected after a single symptomatic person attended a 2½-hour practice. Two people died.

The New Life Church, where at least 9 in 10 parishioners went without masks on the first Sunday after Colorado’s order began, was certainly not unique. Nearly all of the roughly 100 people gathered at Church for All Nations also skipped masks.

Pastor Mark Cowart kicked off his sermon there by questioning statements about masks from Dr. Anthony Fauci, the nation’s top infectious disease expert with the National Institutes of Health.

“We are not the mask police,” Cowart said, before warning state officials against trying to restrict their gatherings.

“If they come trying to tell us we can’t meet anymore, or we can’t sing, or we can’t have a Bible study anymore, that’s not going to go,” Cowart said to applause at the nondenominational church. “God does not want us to allow that to happen.”

Colorado health officials recently warned several counties that large worship services could be restricted if the rise in infections doesn’t ease. Average daily confirmed cases across the state more than doubled in July, rising from 215 a day in June to 451 as of last week, according to a state database.

The rise in COVID cases comes as residents disregard social-distancing guidelines. A recent report by the Colorado COVID-19 Modeling Group found that the share of Coloradans complying plummeted from .

Across the Pikes Peak region, dozens of pastors and parishioners described an intense and deeply spiritual desire to return to worship with their fellow believers. Meeting in person provides a unique opportunity to hug, to know they are not alone during such trying times.

“The church isn’t really a place — it’s a gathering of people,” said Brian Bone, while meeting with a dozen others at Woodmen Valley Chapel, where masks were common on a recent visit. “We get comfortable coming to a place we call church, but really it’s being with other people physically that’s important.”

And some ministers fear that not meeting regularly in person could lead to apathy among parishioners, causing them to drift away.

Not all congregations in Colorado Springs have been averse to the state’s new mask order. And the myriad approaches to reopening highlight the difficulty of placing a single label on churchgoers during the pandemic.

For the Rev. Jeremiah Williamson, masking up is the Christian thing to do.

“A lot of this stuff has been caught up in partisan politics, and I’m not interested in that,” Williamson said. “I’m interested in keeping our people safe. We’re one of those churches that believes science.”

At Grace and St. Stephen’s Episcopal Church, Williamson has forsaken his pulpit for the front lawn. There, on a recent Sunday, dozens of church members sat in folding chairs spaced 6 feet apart, inside white circles painted on the grass. No congregants sang. Everyone wore masks.

Nearby on North Tejon Street, more parishioners sat in parked cars, listening with their radios as the service was broadcast via a shortwave transmitter.

And, before attending, everyone was urged to provide their names and phone numbers, in case someone tests positive and public health contact tracers need to find those who may have been exposed.

“It just seems, as religious people, Christians, we would want to do our best for the common good, for the greater good,” Williamson said.

Across town, Payne Chapel AME Church also has opted not to gather indoors out of concern for its predominantly Black congregation, because Blacks have been experiencing higher rates of hospitalization and death from the coronavirus. Church members recently met in their vehicles in the church’s parking lot, waving to one another through car windows and singing hymns together on a teleconference line.

For that 300-member African Methodist Episcopal church, to have met indoors also would have been “between ridiculous and stupid,” said Pastor Leslie White, who heads the congregation.

However, Calvary Worship Center, which has a racially diverse congregation, is meeting indoors and not enforcing the mask order, even though two staff members were confirmed to have COVID-19. Instead, the church, led by a team of Black and white pastors, only recommends they be worn.

For Joshua Stephens, 29, the key to staying healthy is his faith.

The pandemic hit just as he wrapped up earning a degree from Charis Bible College, headquartered in Woodland Park. The local religious school received in early July from the Colorado Attorney General’s Office for hosting a conference with 300 to 500 people in violation of the state’s lockdown orders that limited gatherings to 175 people. Nevertheless, the college’s pastor had vowed to ignore the order.

Stephens, who attends Church for All Nations, said his belief in God informs his approach to the pandemic, after saying he was miraculously cured of cancer four years ago.

“My personal conviction is, I don’t get sick,” said Stephens, who was not wearing a mask.

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Poking her head out of her green tent on a recent June day, the 57-year-old pointed a few blocks away to the place where city crews picked up her tent from a sidewalk median earlier this spring and replaced it with landscaping rocks, fencing and signs warning trespassers to keep out.

Lewis then moved just a quarter-mile to a new cracked sidewalk, with new neighbors and potentially, homeless advocates fear, new sources of exposure to the coronavirus.

“Where else are we going to go?” Lewis asked. “What else are we going to do?”

Several cities across the U.S. are bucking recommendations from the Centers for Disease Control and Prevention by continuing sweeps of homeless encampments, risking further spread of the virus at a time when health officials seek to gain an upper hand on the pandemic.

Such struggles involving COVID-19 highlight the nation’s ongoing problem with housing. And they showcase the challenge public health officials face: Controlling the spread of the coronavirus also risks increasing the spread of other infectious diseases, such as hepatitis A, that thrive amid the trash-and-feces strewn sidewalks that can be found in some encampments.

In Denver, Lewis and hundreds of others were displaced in late April and early May from sprawling, blocks-long encampments, as part of what city officials say is an ongoing effort to periodically clean city streets and keep infectious diseases down. Most homeless campers moved their belongings just a few blocks, where their tents now line more than a quarter-mile of sidewalks.

An hour south, in Colorado Springs, the police department said that it is continuing to follow CDC guidance to prevent COVID-19 among the city’s homeless population, but also that it has continued enforcing camping bans at certain times on public property, ticketing homeless people who are camping if they refuse to relocate. Those in the camps have said a bulldozer cleared at least one site.

And in St. Louis, the city’s health department ordered the removal of camps near City Hall, prompting an outcry from homeless advocates.

In all, at least a dozen cities in recent months have continued such camp removals — which goes against CDC guidelines amid the pandemic, according to the .

As some communities continue to reopen, and as downtown businesses welcome back employees and customers, some homeless advocates fear such sweeps will only worsen.

“There’s no strategy,” said Jacob Wessley, director of outreach and engagement for the . “That is our concern: When they do sweep this area, where are [those without homes] going to go?”

In Denver, one such cleanup in early May netted 9,500 pounds of trash and more than 50 hypodermic needles, according to Nancy Kuhn, spokesperson for the city’s transportation and infrastructure department.

“Denver has a responsibility to address unsafe, unhealthy, and unsanitary conditions impacting our community,” Kuhn said in an email.

Some cities said the pace of such sweeps has dropped dramatically during the pandemic.

Seattle officials conducted four such sweeps from mid-March to early June — each due to “extreme circumstances,” said Kevin Mundt, a spokesperson for Seattle’s human services department. That compares with 303 such camp removals in the final three months of 2019.

Honolulu created a dedicated area for people to camp and “quarantine” for about two weeks before moving into shelters, in case they had COVID-19. But some homeless campers who did not move had their camps dismantled, causing them to disperse through the community.

The goal was to limit the spread of the virus, while encouraging campers to move indoors, said Marc Alexander, executive director of the city’s Office of Housing.

Even so, many homeless advocates say the CDC’s guidance is clear, and such efforts don’t pass muster. If individual housing units aren’t available, the CDC says, homeless campers should be allowed to remain in place during the pandemic. Tents should be at least 12 feet apart, and camps of more than 10 people should be provided hand-washing stations and hand sanitizer.

“Clearing encampments can cause people to disperse throughout the community and break connections with service providers,” the CDC guidance said. “This increases the potential for infectious disease spread.”

Already the disease has infected some people who lack permanent housing. In Colorado, for example, at least 483 homeless people have tested positive for COVID-19, state officials reported June 14. Nearly 80% lived in Denver.

Infection rates in the camps, however, are unclear. None of the 50 homeless campers in downtown Denver who agreed to coronavirus testing in early June were positive, according to the Colorado Coalition for the Homeless. But a different survey a month earlier indicated nearly a quarter of the 52 people tested at a nearby homeless service center were infected with the virus, despite showing no symptoms.

In downtown Denver encampments, dozens of tents stand packed together, often less than a foot apart along sidewalks. Hardly anyone wears masks, and many in the tent community said the virus is low on their list of concerns.

Several hand-washing stations accompany portable toilets in the area, each provided by a local advocacy group. But they don’t always have water.

For some homeless campers, the situation is preferable to staying in a shelter.

Avoiding those cramped confines and the accompanying risk of illness is “common sense,” said Erin Lorraine, 19, who has been homeless off and on for seven years. One sweep led her to move closer to the South Platte River on the west side of downtown.

“These are our homes,” Lorraine said. “We’re not hurting nobody.”

Not all homeless campers see Denver’s cleanups as so nefarious. Many said they were told by Denver officials that they could return after city crews sprayed down the sidewalk.

“As long as they keep it to where we’re getting cleaned, not swept, it’s all right,” said David Scott, 53.

But some of those displaced by previous sweeps say that trust has been broken.

Melody Lewis was away from her tent during a recent cleanup and returned to find that city crews had confiscated many of her belongings, including at least one tent, a bike and some shoes. She refused to go to a shelter, partly because of the threat of illness. As Lewis relates her story, an old sign hanging from a lamppost a few feet away is a reminder of a previous camp cleanup.

“We try to ignore it,” Lewis said of such warnings. “Our stuff and our minds are never secure.”

To limit the spread of the coronavirus, some nonprofits and cities — including St. Louis and other places conducting sweeps — have gotten creative, opening isolation shelters for people experiencing COVID symptoms and helping some particularly at-risk people move into paid motel rooms.

Recent sweeps also have renewed a conversation in Denver about whether to create sanctioned encampment sites — areas where people can pitch tents and live in socially distanced communities with a city’s blessing.

Elsewhere, such regulated camps lend homeless people stability, while increasing the odds that caseworkers can find their clients when housing becomes available, said Tom Luehrs, executive director of the , a homeless services organization in Denver.

Already, San Francisco has temporarily created a few such encampments, with a total capacity of roughly 200 people.

“Some people have been out on the streets for years,” Luehrs said. “And that’s where they feel best about living, because maybe we haven’t given them better options as a community.”

Colleen Echohawk, co-chair of Seattle’s , a coalition of agencies and nonprofits working to address homelessness, said she empathizes with city officials who are having to juggle competing public health threats. Seattle is among the latest areas to face an outbreak of hepatitis A in its homeless community.

But Echohawk questions whether more could be done to limit the impact of sweeps.

“What’s frustrating about this is that you move them, and then they just moved into other encampments, and then took with them their COVID-19, and they took with them their hepatitis A,” Echohawk said. “It’s a real dilemma.”

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