Farmworkers and ObamaCare

There are an estimated 600,000 crop workers, and an additional 20,000 livestock workers, in California at any given time. Theirs are physically demanding jobs that carry a high risk of occupational injury – yet the vast majority of these workers lack health insurance. That could change in 2014 when the Affordable Care Act is fully implemented, although significant barriers will need to be overcome between now and then, if most farmworkers are to benefit. 

Don Villarejo has worked for more than three decades as a researcher and advocate on behalf of California farmworkers, and has authored major studies on farmworker health in the state. He recently spoke to New America Media editor Jacob Simas.

New America Media: What can you say, generally, about the health status of farmworkers in California today?

Don Villarejo: In general, the health status of California farm workers is poor -- that is, less healthy than the population in general in the state, even compared to unemployed persons. The measures that we use for making that statement have to do with physical health -- the normal things that you think about -- as well as dental health, mental health and access to care. In regards to the latter, the most reliable data we have indicates that only about one-quarter of all hired farm workers in California have any form of medical insurance, whether it's government provided or private insurance. 

With respect to dental care, about a quarter of farm workers have not been to a dentist since coming to the United States, and most do not go to a dentist for regular care.

So you have all of these conditions combined, as well as an increasing problem of obesity in this population, which was kind of a surprise. We did not expect to see a lot of obesity because for many workers this is heavy manual labor; it's outdoors and is active work. This is something that has now been picked up in the public health arena with an increased focus.

NAM: What do you attribute the rise in obesity to?

DV: We don't have a good answer to that, yet, but we can say the following -- that the evidence does indicate there is a deterioration of diet when folks come to work in the U.S. from Mexico and Central America. And remember, over 95 percent of California crop farmworkers were born in Mexico or Central America -- only five percent were born in the U.S. My colleagues in Mexico have also reported to me that the penetration of junk food and other unfortunate diet choices in Mexico has been increasing, and so there's been a deterioration of diet there as well.

On the other hand, because of the lack of access to care, there is no good monitoring of health status or information flow to workers about things they need to do [to improve their health]. If you go regularly to a physician, as is recommended by the public health service, at least once every two years, then some of those conditions can be caught. 

NAM: What does the farmworker population in California look like today? And how has it changed over, say, the last decade?

DV: What we know at present, given the best estimates, is that 99 percent of all the crop farmworkers in California are Hispanic. More than 91 percent are from Mexico, about 4 percent are from Central America and the remaining 5 percent are from the U.S. But the most recent information we have, based on the last couple of years, indicates that there's been an increase in the U.S.-born workforce as people from certain industries -- for example, construction -- have tried to get jobs in other industries, including agriculture, due to the recession. 

However, within that framework, what we've also seen in the past 10 years is a major increase in the population of indigenous migrants from southern Mexico and Central America. That is, persons who identify as indigenous themselves, or who were born in villages where indigenous languages are spoken -- Mixteco, Zapoteco, Purépecha and other indigenous populations. That was probably about 15 to 20 percent of the California crop workforce 10 years ago. Now, it's over 35 percent. 

This is significant because many of these folks are bringing to their work in the U.S. a very different view of health as well as very different dietary behaviors, as well as in some cases, a lack of Spanish. They still speak their indigenous language and if they have any facility in Spanish, it's limited. Those are all concerns in terms of public health.

NAM: So there are the cultural factors that can affect one’s access to care. There’s also the question of legal status. 

DV: Yes, as well as linguistic and financial barriers. There are barriers to care on both sides -- in the population and their views, and the system itself. For example, if you're undocumented, there are fears on the part of workers about going to the government, or going to agencies that deal with the government, due to the risk of being deported. 

On the other hand, from the point of view of the agencies that are providing services, they're under very strict regimens from the federal authorities that provide their funding that they cannot serve a population that is undocumented.  A clinic is faced with -- well, if an individual is poor, does not have medical insurance, such as more than three-quarters of farmworkers in California, who's going to pay for their services?  Medicare and Medicaid [the federal-state program called MediCal in California], all prohibit services to undocumented workers. So from the point of view of providers that depend on public funding to serve a population that is uninsured, where do they go? That's a tough question. 

What we actually find that's quite interesting is, of workers who said in the past two years they've sought health care in the United States, a majority of that population have said that they paid for it out of pocket. And that's relatively rare, you know? Most people who get health care in the United States are covered by insurance, and they don't pay out of pocket. So here is the poorest population that is, in a way, carrying the burden of paying out of pocket for something that everybody else gets through insurance.

NAM: What responsibility will the employers, the growers, have to provide health insurance to their workforce under the Affordable Care Act?

DV: Starting in 2014, all employers that have at least 150 workers, including agricultural industry workers, will have to provide medical insurance for their employees, and that will have to be provided at the point of hire for new employees and retrospectively for all existing employees when the annual renewal of policy occurs. That's a brand new requirement. 

Now, unfortunately, if you are working for an employer for less than 120 days in a given year, then that requirement does not apply. So that's a really critical thing for agriculture employees, because many workers do not work 120 days for a single employer and therefore that employer would not be obligated to provide medical insurance for them. And I've heard, although it's strictly anecdotal -- there's no clear evidence to support it -- that some employers are contemplating how they might calculate that determination of 120 days and possibly lay off people and hire other workers, in order to avoid having to pay medical insurance for them. 

In addition, under the law, if you are required to provide medical insurance and do not provide it, there's a system of financial penalties. Roughly speaking, you could think of it as $2,000 per year, per employee. If you compare that to the cost of providing medical insurance for that employee, which would very likely be several thousand dollars greater than the $2,000 fine, there are employers who could be thinking about paying the fine instead of providing the insurance. That hasn't happened yet -- it's strictly speculative -- but it's worth monitoring.

Then there are other things that will happen under the ACA. People not currently covered will be compelled to purchase insurance privately. Undocumented workers, however, are excluded from that. They can if they want to, but will not be required to do so. So educating this particular workforce will be key.

NAM: And whose job is it to do that educating?

DV: By March 1, employers need to educate their workforce, explain their rights under the law. That’s something that employers are still trying to figure out how to do. What if your workforce doesn’t speak English or Spanish? Or can’t read? How do you reach them?

NAM: Are they prepared to meet that deadline?

DV: In agriculture, we can’t say whether employers are ready. We do know there are some efforts being made to educate. The Western Growers Association and other employers have begun disseminating information, but many others are not yet involved and are probably scrambling to figure it out. 

Then there are several large employers who have taken a different approach. In one case, they’re providing clinics at their own expense for their workers, which is neat. 

NAM: Given the high number of farmworkers who are undocumented, there seems to be a contradiction here between federal immigration policy and what the ACA will be requiring agriculture employers to do. It seems like something’s got to give.

DV: The only solution is comprehensive immigration reform. There's no other way. The reason I say that is that if you try to fiddle with, for example, the Affordable Care Act, then you face the danger of undermining the whole system of affordable care, and we don't want to do that. We have to face it squarely and fairly, and this is what the [young, undocumented] "Dreamers" are saying; this is what most workers say.

And this fortunately is what the Obama Administration is now saying: In order to fix the problem, we have to fix it at its root, and its root is addressing the fact that 11 million people in the United States are here without proper authorization to work. And that has to be fixed. So, there's the core of the matter, and I'm optimistic. I do think we have in the next six months a chance to fix it. That doesn't mean that we are going to fix it or fix it right, but I think we have a much better chance than we had before the November 6 election.