^ff7^%:L

United States >4^^ 5^

Department of »w 5L>

Agriculture

Economic

Research

Service

Rural Development

Research Report

Number 39

CP- Farm People's Health

Insurance Coverage

Helen H. Jensen
FARM PEOPLE'S HEALTH INSURANCE GOVERAGE, by Helen H. Jensen.

Economic Development Division, Economic Research Service, U.S.

Department of Agriculture, Rural Development Research

Repi^rt No. 39.

ABSTRACT Families with farm income are less likely to have insurance

coverage than are nonfarin families^—-86 percent of the farm

population compared with over 90 percent in the total population. Only 82 percent of farmers are covered and they are

less likely to be covered by workers' cott^ Farm

families are more likely to be coyered by individual than

group plans. Families most dependent on farm income are least

likely to have health insurance. This report analyzes factors

associated with the lower coverage including coverage from

group and individual plans.

Keywords: Costs of farming, farm income, health insurance,

rural health

ACKNOWLEDGMENTS

SALES INFORMATION

The author thanks John Baumgartner for programming assistance

and Tom Carlin, Bernai Green, Bob Hoppe, Bill Saupe, and Leslie

Whltener for íy^minénlrs attd Süg§és1:;ions on the coi^^^ and organization of this report.

This report may be ordered from:

National Technical Information Service

Identification Section

5285 Port Royal Road

Springfield, VA 2^161

Ask for Farm People's Health Insurance Coverage and indicate

whether you want paper copies or microfiche. Cost per paper

copy is $8.50; cost par microfiche copy is $4.50 (prices subject to change). Enclose check or money order, payable to NTIS,

Or call (703) 487-47ßä.

Washington, D.C. 20250 December 1983

XI
CONTENTS

Page

SUMMARY .^ iv

INTRODUCTION 1

DATA 2

TYPES OF HEALTH INSURANCE COVERAGE 4

Private Insurance 4

Alternatives to Private Insurance 5

FACTORS AFFECTING DEMAND FOR HEALTH INSURANCE 7

Farmers' View of Risk 7

Household Characteristics 7

Health Insurance Provided as Compensation for Work.... 7

ANALYSIS 8

Farm People 10

Insurance Through the Work Place. 13

IMPLICATIONS FOR SELECTED POLICY ISSUES 19

REFERENCES 20

iii
SUMMARY Farmers and farm families are less likely to have health insurance coverage, or to participate in group insurance plans.

At the same time, farmers have higher accident rates than

workers in other occupations and are less likely to be covered

by workers' compensation* This study looks at health insurance

coverage of the farming population and the sources of coverage

obtained. Findings include:

—^Only 86 percent of the farm population have health

insurance^ compared with 90 percent in the total

population.

—^Only 82 percent of farmers and farm managers are covered,

with coverage more likely if the spouse is employed,

especially off the farm.

—^^Farm people are more frequently covered by individual

policies and their level of coverage is more likely to be

less than in the total population.

--Families most dependent on farm income (that is, with

farm income a higher portion of total income) are the

least likely to have health insurance.

—-Young farmers, farmers in the South and West, those with

low incomes, and those with chronic health problems are

less well covered than other farmers.

—Farm people least likely to have health insurance coverage include relatives not members of the immediate family

of the household head, the unemployed, and unpaid farm

family labor.

Faced with this situation, farmers and other members of farm

households might explore various alternatives, including obtaining lower cost group insurance or the tax advantages others

have in gaining access to insurance through employers. Incorporation of the farm business, greater use of farmer groups to

provide fraternal benefits, and operator and family employment

off the farm are other alternatives.

IV
INTRODUCTION

Farm People's Health

Insurance Coverage

Helen H. Jensen

Those living on farms are less likely to have health insurance

coverage than others, despite the fact that farming has a high

risk of accident and injury. For self-employed farmers and

their hired and unpaid help, the lower coverage is particularly

significant in light of their lack of coverage under workers'

compensation. Without health insurance, many farmers and other

workers on the farm may not have access to necessary health care

for injuries sustained at work or at home. Limited access to

group insurance is a significant deterrent to farmers' coverage.

Although most surveys report that those in farm families are

less well covered than others, farm people are more likely to be

covered by more costly individual policies rather than group

policies. The prominence of private health insurance among the

farm population, in view of its limited access to group policies, indicates a willingness and interest in obtaining insurance.

This study addresses the factors affecting insurance coverage

of farmers and farm people, the role of health insurance in the

farm business, and effects of changes in legislation affecting

farmers' coverage.

Farmwork is dangerous; agricultural work has a higher accident

rate than other occupations (10). 1/ Long hours operating

machinery under varying conditions and diverse tasks all contribute to the greater likelihood of accidents. In addition,

difficulty finding suitable substitutes for operator labor increases the costs of ill health for the self-employed farmer.

Those in agriculture may experience higher accident rates due to

the age and sex composition of the work force. Young males have

the highest nonfatal accident rates and older males, the highest

^Assistant Professor, Department of Textiles and Consumer

Economics, University of Maryland, College Park, Md., formerly

economist, Economic Development Division, Economic Research

Service, U.S. Department of Agriculture.

1/ Underscored numbers in the parentheses refer to items in

the references.
fatal accident rates among; workers in general (10)> Both

groups are important in agricultiaral employment. The relative

isolation of nonmetropolitan areas makes immediate care for

accidental injuries difficult and may increase the severity of

the effects of any given accident. 2_/

A recent study at the University of Iowa indicates that health

hazards may be a greater problem for farmers than has been

traditionally perceived. After eliminating smoking-related

cancers, the death rate from cancer was much higher among farmers than nonfarmers. Of major forms of cancer, the rates were

78 percent higher for prostatic cancer, 77 percent higher for

leukemia, 60 percent higher for stomach cancer, and 39 percent

higher for cancer of the large intestine (5). These results

suggest that farmers may have underestimated their expected

level of health, perhaps due to the lag times for higher cancer

rates to become apparent.

Farmers also live in areas where health status is lower. The

same factors that affect the health status of other rural residents affect the farm population as well. Popular assumptions

about the health of rural and farm residents are that they are

healthier, self-reliant, and can take care of themselves at

home. Health Indicators show this may not be true. Both the

infant mortality rate and a composite health status index (using

infant mortality rate, an age-standardized mortality rate, and

an age-standardized mortality rate of deaths due to influenza or

pneumonia) indicate that nonmetropolitan residents were less

healthy during 1969-73 than others (1, p. 23). More recent

figures support this. These health conditions reflect the joint

effects of the availability and utilization of medical services,

income levels, underlying environmental factors, added cost of

greater travel distance, lack of compensated time off from work

for illness, and lack of health insurance coverage, all of which

deter use of medical services.

DATA The best data on health insurance coverage come from national

surveys of households. These surveys avoid double-counting of

coverage from more than one source of insurance. Two surveys

on health insurance coverage are worth noting: the 1977 Health

Care Expenditures Survey (NHCES) and the 1976 Survey of Income

and Education (SIE). Overall, health insurance coverage has

remained relatively constant over the last 10 years, with some

II Reports of farm accidents are somewhat distorted by the

difficulty in differentiating work-related and home-related

accidents, both of which occur on the farmstead. The number of

reported farm accidents is inflated to include some accidents

occurring during recreation or other home aetivities. Fritsch

and Zimmer cite a study which indicates that 36 percent of

fatalities involving a farm tractor occurred while the tractor

was being used for nonwork purposes (10, p. 1). The National

Safety Council estimated for 1970 that work time occupies 36

percent of an individual's total exposure time to accidents»

On the average, work accounted for 41 percent of all injuries,

but only 25 percent of all accidental deaths.
overall decrease during periods of high unemployment. Both

these surveys provide the most recent national data on health

insurance coverage, with the SIE providing broader representation of the farm population.

NHCES was a Purvey conducted by the National Center for Health

Services Research in 1979. It includes data about individual

expenditures and health insurance coverage, as well as information from employees and insurance companies. Preliminary

results of the survey have been reported in data previews.

Although these releases do not distinguish between the farm

and nonfarm population, they do allow locational comparisons.

The primary data source used in this analysis was the SIE, a

survey reporting on amounts and sources of income, education,

health status, and health insurance coverage (see 22). Most of

the analysis of the farm population comes from a sample of all

persons who lived in families reporting any farm income. The

survey included 24,052 such persons. Those whose primary occupation was farmer or farm manager were distinguished from those

who lived in families or as primary individuals who received

farm income. Estimates of coverage are based on weighting the

sample to reflect the national population.

Data on health insurance coverage of the total U.S. population

come primarily from a study by the Congressional Budget Office

(GBO) based also on the SIE, The CBO estimates are adjusted

upward to reflect unreported eligibility (though not necessarily participation) in public programs such as Medicare, Medicaid, Veterans Administration, and the Civilian Health and

Medical Program of the United States (CHAMPÚS) programs.

The issue of whether or not to count people as "covered" if

eligible for public programs providing health insurance is not

clearcut. Eligibility for health care insurance through a

public program implies a degree of protection. However, individuals may not realize that coverage is available or may

prefer not to participate in the public program. The rural

population eligible for coverage from public sources, particularly Medicaid and Medicare, uses that coverage less often than

others (T) • Rural residents appear more reluctant than others

to apply for public assistance programs such as Aid to Families

with Dependent Children (AFDC). Because some of Medicaid's

eligibility requirements are tied to participation in other

public programs, the reluctance to participate in public assistance programs means lower effective coverage under Medicaid.

Hence, many members of the farm population, although eligible,

are not covered by Medicaid or other public programs. Inflating

the estimates of coverage to adjust for the underreporting of

program eligibles would increase estimates for those groups.'

A second issue, not analyzed in this study, is /the adequacy of

coverage among people having insurance. Coverage varies considerably depending on policy exclusions, waiting periods,

comprehensive amounts, déductibles, and maximums. When faced

with a high price for the desired level of insurance, an
TYPES OF-HEALTH

INSURANCE COVERAGE

Brivate ïnsürance

individual or family may elect to purchase lower cost, less

comprehensive insurance.

Most health insurance in the United States is purchased privat ely~that is 5 not through a public or government program.

Individuals purchase insurance through individual policies or

through a group with which they are affiliated. Others obtain

insurance through public programs.

Private health insurance, which offers individuals the opportunity to purchase insurance to cover medical or hospital costs,

often carries a deductible coinsurance provision where the

individual pays a portion of the costs, with a maximum amount

of coverage. In other cases, the insurance pays a fixed amount

for each illness or accident, or each day in the hospital (indemnity insurance). More recently, health maintenance organizations (HMO's) provide health insurance on a prepaid expense

basis to their Subscribers.

All those over the age of 65 or disabled qualify for Medicare,

which pays for a portion of medical and hospital expenses, up

to a maximum. Medicaid is available to those qualifying according to federally mandated, categorical programs (such as AFDC)

and to State-specific, medically needy criteria. Those qualifying for Medicare may also qualify for Medicaid. CHAMPÚS is

another public program funded through the Department of Defense,

providing care in the private sector to the dependents and survivors of active duty personnel and military retirees.

Group insurance is the preferred form of health insurance for

most people. Although options available are more limited,

coverage is provided at a lower cost than comparable insurance

purchased individually. Groups provide lower rates due to

better bargaining and lower administrative costs. Employers,

unions, and other associations (such as the Farm Bureau) can

offer group insurance; specific qualifications for offering

group policies are regulated by State insurance commissions.

Employers frequently pay part of the premium as a form of nonwage compensation. Group insurance accounted for an estimated

83 percent of total private insurance in 1975 and of that, 96

percent was through employer or union groups (16) . 3^/

Policies sold directly to .iiidiyiduals tend to^ relatively expensive because of adverse selection (those seeking individual

insurance may anticipate higher than average medical expenses)

or because the policies cover a short period of time and have

higher administrative costs (for instance, during periods of

unemployment). Although individual private policies may be the

only insurance available, they offer the possibility of selecting the type of package (déductibles, coinsurance, and maximum

coverage) which best suits individual preferences.

3/ The data reported later in this study distinguish between

group policies, offered by employees and unions, and individual

policies, purchased directly by individuals.
Federal tax lavs relating to health insurance provide some

incentive to purchase private health insurance for those who

itemize deductions. Until 1983, individuals could deduct half

of their health insurance premium, up to $150. In addition,

that portion of the total medical expenses (including half of

the premium up to $150) greater than 3 percent of adjusted gross

income was deductible. For the 1983 tax year, that portion of

expenses greater than 5 percent of adjusted gross income is

deductible, somewhat reducing the tax incentive to health expenditures.

Alternatives to Purchasing insurance through health insurance carriers is only

Private Insurance one way of handling expenses associated with ill health. Selfinsurance, self-protection, and workers' compensation are all

available to the individual outside the private insurance

market (8, 15).

In self-insuring, an individual or group maintains sufficient

financial resources to compensate for losses due to poor health.

Farmers traditionally delay personal consumption in their

efforts to build up farm equity. Though this process serves to

develop the farm, it also provides a reserve in the event of a

major accident or illness (19). A farmer with capital assets to

draw on or borrow against may be able to self-insure against

health loss and reduce or eliminate purchased insurance.

Self-protection efforts can minimize an individual's expected

loss by reducing the probability of the loss occurring. By

operating machinery with caution, an operator is less likely to

be injured; by wearing protective hard hats, an individual reduces the probability of serious head injury; by immunizing

against diseases (measles, mumps, polio), the probability of

experiencing these health problems is reduced. Since selfemployed workers control their own work environment to a greater

extent than nonowner employees, they may have greater incentive

(and opportunity) to substitute self-protection for insurance.

However, they likely are less informed about risks involved in

equipment and chemical use than specialists in a larger firm

and may be more inclined to assume more risk in their farm

operation. If they underestimate risks or assume more risk

(operating long hours, taking chances in the use of equipment),

they may use less self-protection than would others.

In general, though, self-insurance and self-protection are both

substitutes for private insurance. If the farm population has

greater ability to substitute for private; insurance (that is,

has larger amounts of capital to draw on or more individual

control of the work environment), it is less likely to have

purchased insurance coverage.

Workers' compensation insurance refers to State programs to

compensate workers for work-related accident and injury losses.

For many workers, mandated coverage under workers' compensation

substitutes for health insurance coverage at work.
In most industries, employers assume responsibility for workrelated accidents through workersV compensation, financed either

through insurers (private or the Staate) or by self-insurance.

Employees are reimbursed for losses occurring in work-related

activities, including income maintenance, medical costs, payments for rehabilita:tion when necessary, an<i some payments to

survivors in case of deaths To the extent that employers oan

shift part of this expense to emplaoyees, workers receive lower

wages. The remainder may be passed on to consumers.

Agricultural workers, including owner/operators, however, are

among the least likely to be covered by workers' compensation.

This is due to the small size of the establishments, to historical reluctance to include agricultural workers in labor

legislation, and to the high cost of coverage for farm employees

due to the risks associated with their work. In most other

industries, employers assume responsibility for work-related

accidents through mandated workers' compensation. Self-employed

farmers and workers not covered by workers' compensation bear

the risk of work-related injury themselves unless suitable private coverage is purchased.

States have increasingly included agricultural workers in the

mandatory compensation programs and a few require participation

for operators who have only a few employees. _4/ As of March

1983, 13 States, the Virgin Islands, and Puerto Rico required

equal coverage for agricultural workers. Another 20 States

required conditional coverage of agricultural workers. The

remaining 18 jurisdictions, including the District of Columbia,

did not require coverage of agricultural workers, though employers could voluntarily participate in the States' programs

(25). The requirements for coverage are wide-ranging. Sellers

estimates that there were 1.3 million hired farmworkers in 1979

employed on 40 percent of the farms and representing 34 percent

(1.3 million) of the total farm workforce of 3.8 million workers

(as cited in 15). In addition to these hired farmworkers,

330,000 members of farm operator families (excluding farm operators themselves) were paid in 1979 (15) . Only paid eiícilíoyees

are eligible for workers' compensation in most States, although

many members of farm families, including those paid, are automatically excluded.

In some States, farm operators who are sole proprietors may be

required to participate in workers' compensation programs if

they hire .any farmworkers. Enterprises such as general partnerships or corporations may hire a larger number of employees,

which affects the required participation in State workers' compensation programs.

The degree of workers' compensation coverage affects farmers'

need and use of health insurance. The amount of compensation

4/ The following section draws heavily on (1¿). The later

version of that paper contains some errors in the reporting of

coverage of workers' compensation and should be used carefully.

The data reported here come from the earlier version.
for a given injury varies greatly among States. Rates charged

for coverage under workers' compensation to small firms can be

quite high; in some cases there is a fixed minimum charge. Many

farm operators prefer to cover employees through health insurance if offeted the choice. Because of varying rates, relative

costs of workers' compensation and private coverage also differ

among States.

FACTORS AFFECTING

DEMAND FOR HEALTH

INSURANCE

Demand for health insurance is affected by the price of insurance, likelihood of others bearing some of the cost, tax incentives, household characteristics, and willingness to bear

risk.

Farmers' View

of Risk

Farmers face a great deal of risk: risks of operating a farm,

debt financing, price uncertainty, greater likelihood of accidents, and hazards of outdoor activities. Their willingness to

assume these risks indicates that farmers may be less averse to

risk than other types of workers. However, studies of farmers'

attitudes toward technological change indicate that most farmers

are risk averse (4).

Household

Characteristics

An individual's attitude toward risk is an important determinant

of willingness to purchase insurance coverage. The less one is

willing to assume risk, the more willing one is to purchase insurance that reduces the individual's payment for medical expenses. An insurance company expects to be able to cover these

expenses because it can pool expected losses and charge a fee

("loading factor") to cover administrative expenses.

Besides the unique risk factors associated with farming, farmers' demand for private health insurance is also influenced by

the same factors that affect the general population. Income is

positively correlated with health insurance coverage; households

with higher income are most likely to have health insurance.

Family composition and age affect the level of expected medical

expenses and, in turn, the willingness to assume risks. Young

single adults, for example, are more willing to assume health

risks than older individuals or families with children. Large

families might expect to have more total health expenses than

small families and hence would be more inclined to buy insurance.

Health Insurance

Provided as Compensation for Work

Other studies show blacks have fewer medical expenses than

others, though they are not necessarily healthier O)• With

lower expected medical expenses, blacks would less likely have

coverage. Lower income among black farm families, however,

also likely contributes to their lower coverage.

Firms are increasingly expanding to nonwage types of compensation, due both to tax advantages of nonwage income to employees

and, in the case of insurance, to lower prices for group plans.

The tax advantage comes from an employee's not having to report

as income the employer payment of insurance premiums and the

employee's ability to deduct at least part of the payments for

group health insurance in calculating Federal taxable income.

A recent CBO study terms the exclusion of employer contributions

as the largest tax expenditure for medical care (21). The
employer's payment is deductible as a cost to the firm but is

untaxed income to the employee.

Sole proprietors and those who work for firms which do not offer

group insurance cannot take advantage of this tax incentive.

Without the tax incentive, they will either choose less insurance or pay higher prices for the insurance. However, if farm

firms can organize the farm into a partnership or corporation,

paymetits for group health insurance may qualify as a business

cost, reducing taxes to the business as well as providing untaxed compensation to employees. Some farm firms have bought

private group policies to provide insurance to all their employees; other farmers have purchased private insurance individually or through farm or religious organizations. As farm

firms hire more labor or change the organization of their business, there is greater pressure and incentive to offer coverage

through the business.

Policies offered as compensation for off-farm work to farmers

and members of the household are another source of health insurance coverage and an enhancement for off-farm employment.

Nonfarm income has become increasingly important to farm people,

providing greater income with which to purchase insurance (12).

Hence, we can expect that self-employment would be negatively

correlated and off-farm work positively correlated with the

likelihood of the farm population being covered by health insurance.

To the extent that a self-employed person views health insurance

as insurance for expected work-related injury or sickness, such

insurance is a cost of doing business. However, only when the

farm firm is incorporated and meets specific conditions with respect to group policies can it count insurance premiums as a

business cost. Hence, many self-employed people do not qualify

for the same tax-related subsidies to insurance payments as do

wage earners, nor are they required to be covered under workers*

compensation.

ANALYSIS According to the SIE, 85.7 percent of persons in families with

farm income had health insurance coverage in 1976, compared with

over 90 percent of the total population (table 1). Before adjustments for public programs, 87.9 percent of the total population was covered (20, p. 13). The differences in coverage,

while not large, are statistically significant. 5/

5^/ The significance of the differences was tested for the

differences of two means in a sample with binomial distribution

(see ^, p. 70-78, 136-139), using

/ Ti-^(l-TT^) - ÏÏ2(i-ÏÏ2)

^1 ^2

where Tr-|_, i = 1, 2, is the proportion of successes in the population and TT^ the proportion of successes in the sample, n^ and

n2 are the size of the two unweighted samples.
Table l--4feálth insuranœ œverage of the total poptûaticm and In familles reœlvlng fam income, 1976

arsons with health ;: Itersons with some private health

insurance : insurance 1/

Item : I^rcentage : Itereentage of : Bercentage of : Perœnt^i^ of

of total : farm population total popilation : farm population

2/ : 3/ 2/ 3/

Bercent

Tbtal family Income: :

Less than $5,000 : 82.6 73.6 73.1 63.0

$5,000*-$9,999 : 83.4 81.5 63.3 72.9

$10,000 - $14,999 . 90.8 88.6 83.4 85.2

$15,000 and above ! 94.3 90.8 90.8 87.9

Aße: i

Less than 6 jears : 86.1 79.7 71.6 79.1

6 to 18 jears : 88.8 84.7 77.0 82.4

19 to 24 îears : 79.5 79.1 71.0 75.9

25 to 44 years : 90.7 85.0 82.3 83.0

45 to 64 jears : 92.4 86.6 83.5 83.3

65 years and ovier : 99.0 95.4 61.3 63.3

Bnploynent status:

Hnplojed : 91.8 85.9 87.2 82.3

Uiemployed : 73.2 60.8 55.1 55.5

Retired : 98.0 96.5 64.0 65.3

Other : 88.6 86.3 71.0 78.8

Tbtal population : 92-95 85.7 77.0

NuTÉjer

80.1

Size of total population : 211,000,000 8,389,000 211,000,000 8,389,000

1/ Includes all those reporting CDV^^ from SCHTE private source.

2/ Mjuöted for urrierreportlng o^

3/ Data reported on all persons In families or as primary individuals receiving farm incoiTE.

Sources: (20); SIE.
Patl^fns of coverage for farm people and the total population

were similar, based on the SIE. Coverage was least coimnon among

low-income people, young children and young adults, and the

unemployed. Private health insurance provided the bulk of

coverage for both the total population and farm people under 65

and a majority of the population over 65 had private insurance

as a supplement to their Medicare coverage. People with hiigher

incomes and the employed were generally most likely to have

insurance.

The most recent national data confirm that while health insurance coverage is quite broad, certain groups, including rural

residents, consistently have the least coverage. The NHCES

estimates indicate that while 87.4 percent of the total population had health insoiranee coverage, only 82.4 percent of those

living in predominantly rural areas had coverage in 1977. These

estimates do not include estimates of public coverage. Earlier

studies also found lower overall coverage for those in the farm

and rural nonfarm population (2_, 11) .

Farm People Age, family status, region, employment status, occupation, and

income all have a statistically significant effect on the likelihood of health insurance coverage (tables 2 and 3). Families

with both husband and wife present were most likely to have

coverage, particularly if the wife was employed outside the

home. People least likely to have coverage included relatives

not members of the immediate family of the household head, unemployed, and unpaid farm family labor.

A particular problem for farm families is the inability to

insure unpaid family labor. Less than 80 percent of unpaid

family labor was covered, compared with 82 percent of farmers

and 85 percent of paid farm labor (table 2) . 6^/

Regional differences also existed, with the South and West having less health insurance coverage than other areas (table 2).

These regional variations are attributable to differences in

income, types of farm organization, education, and access to

group coverage through off-farm employment.

Higher income increases the likelihood of health insurance

(table 3). About 70 percent of the farm population below the

poverty line had insurance, far below the 90 percent with income

more than 50 percent above the poverty line.

The level of farm income does not significantly influence coverage, but the level of total income, both farm and nonfarm, is

more likely to influence health insurance coverage. Low farm

income is often coupled with sizeable income from other sources.

6^/ Data based on the 1976 Health Interview Survey indicate

that almost 81 percent of farmers and farm managers were covered

compared with 93 percent of other managers (nonfarm); 59 percent

of farm laborers were covered compared with 88 percent of operatives and 78 percent of nonfarm labor (24). Estimated coverage

for farm labor was much lower in this survey than in the 1976 SIE

10
Ikble 2—Selected characteristics of farm people, farmers, and farm man¿^rs with health insurance

coverage, 1976

: Farm people 1/

• 4

Kaimers and farm manager 2/

Item : Iteroentage : itercentage with • Rsrcentage : Percental with

: covered : private Insurance covered : private Insurance

Bercent

^e:

Ihder 6 years : 79.7 79.1 —. .

6 to 18 years : 8A.7 82.4 83.1 78.1

19 to 24 >ears : 79.1 75.9 71.3 69.6

25 to AA ypars : 85.0 83.0 77.4 75.6

45 to 64 yf*ars : 86.6 83.3 81.3 78.6

65 yaars and over ; 95.4 63.3 94.5 64.7

Fieglon: :

NDrtheast ! 87.5 83.8 84,6 80.5

îtorth Central : 88.3 83.7 87.3 80,6

South 82,6 74.7 75.2 66»8

Ifest : 83.7 80.1 75.5 68.4

Family status: ;

Husband 88.8 81.3 — - —

Primary individual : 86.9 65,5 — —

Wife : 87.7 83.0 — —

Child : 82.9 80.5 — -.

Other relative : 76.6 51.1 — —

Bnplojment status: :

Hnployad : 85.9 82.3 — —

Ihemplojed : 60.8 55.5 — —

Retired : %.5 65.3 .— —-

Other, not In labor :

force : 86.3 78.8 —

Occupation: :

Farmer, farm manager: 82.0 74.9 — —

fôid farm labor : 85.0 81.5 — —

Ihpald family labor : 79.7 76.2 — —

All other ocaipa- :

tions : 87.2 85.1 — —

Never worked : 86.8 74.2 — ' —

Tbtal population : 85.7 80.1 82.0 74.9

— ' Nbt applicable.

1/ teta reported for all perscxis in families or as primary individuals receiving farm income.

2/ D&ta reported for all those reporting occupation as farmer or farm manager, living in faidlies or

as primary individuals i^ receive farm income.

Source: SIE.

11
Tsú>le ^HBriopme d»racteit^ic^ of faim pople, farnecsy aid fstK^ßm^agexB ^títh<h Insurmœ

: Fain people ä î faemxsa^^

Item : lëroentage : Ifercentage with percentage : Itercentage with

: coveted : lávate insurarase : (bvered : peivate insurance

Bercent

"Sïtal family Inoone:

0 or less ! 79.2 77.3 76.4 72.5

$l-$4,999 : 72.4 58.7 73.5 61.3

$5,000-$9,999 : 81.5 72.9 80.8 70.1

$10,000-$14,999 ! 88.6 85.2 84.6 79.1

$15,000-$24,999 ! 89.2 86.4 84.7 82.1

$25,000 and above ! 93.0 90.1 89.8 86.9

Faim Inoorae V:

0 or less :: 89.5 86.8 79.8 73.6

$1-$2,A99 : 84.0 73.7 78.9 65.3

$2,50(H4,999 : 81.9 75.4 76.6 66.5

$5,000-$9,999 82.2 78.4 82.2 76.8

$10,000-$14,999 : 87.4 85.5 86.6 84.9

$15,0ÖO-$19,999 ! 86.a 83.5 86.4 82.4

$20,000 and ábow ! 89.5 87.9 88.6 87.2

I^rœncage of fapdly '

Inooae from fanning: ;

Tf>ss than 25 percent : 88.9 82.6 83.1 72.1

25-49 percent ! 84.0 74.5 81.4 69.8

50-74 percent : 84.7 79.8 84.6 77.9

75 percent or more : 79.4 77.7 80.1 77.6

%rcent^^ above/below:

poverty line: !

Below : 70.8 63.6 70.3 63.2

100-124 percent : 72.5 57.8 75.2 61.5

125-149 percent : 75.1 66.9 74.3 67.1

150 and above ; 89.9 85.4 86.0 79.5

Tbtal population ; 85.7 80.1 82.0 74.9

1/ Data reix>tted for all persons in families or as prlinary individuals receiving farm inooms.

2/ Data reported for all those reporting occupation as farmer or farm manager, Hving in fandlies

or as primary Individuals who receive farm income.

3/ Farm income reported for farm people applies to data reported for family; farm income earned by

the individual applies to data reported for farmers aid farm manager.

Source: SIE.

12
Dependence on off-farm income affects coverage. Families with

more than 75 percent of their income from off-farm sources had

almost 89 percent coverage, compared with 79.4 percent coverage

for those with 75 percent or more of their family income from

farm sources (table 3). Families with a larger share of income

from farm sources tended to have lower total income and less

wage and salary employment (employment where group policies are

more readily available).

Reduced access to group insurance most distinguishes the farm

population from others in their insurance coverage. In the

total population, almost 62 percent had some form of group

coverage, but only 43 percent of farm people obtained group

coverage (table 4) (20). Alternatively, insurance through individual plans costs more or covers less and was more common

among farm people (26.2 percent) than among the total population

(7.5 percent).

Higher income farm people were more likely to have group policies, since they more often^had off-farm employment offering

group insurance (table 5). Again, the type of income is important. Only 18 percent of people in families with 75 percent or

more of their income from farming had group insurance, well below the 59 percent of those with more than 75 percent of their

income from off-farm employment. Farm people in the Northeast

were more likely to have group coverage and less likely to rely

solely on individual coverage than the rest of the country,

reflecting the greater importance of off-farm income.

While most farm family members employed off the farm work for

establishments in nonmetropolitan areas, the effect of off-farm

income on total family income is significantly greater for those

living near urban areas (19). In either case, farm families can

obtain health insurance through group plans offered to family

members working off-farm, although those working for nonmetropolitan employers are less likely to be offered insurance by the

employer, and receive less in coverage than others. A survey of

private, nonfarm establishments in 1974 indicated that fewer

nonmetropolitan firms offered insurance than did metropolitan

ones. The average employer payment for health related insurance

by metropolitan establishments was $334.23, while that by nonmetropolitan ones was only $258.17 (13).

Insurance Through An issue separate from the coverage of families with farm income

the Work Place is the question of specific coverage of farmers and farm managers. Eighty-two percent of farmers had health insurance

coverage, with 74.9 percent of those covered by private sources

(see table 2). Only 17.3 percent of farmers with income only

from farming had solely group insurance, compared with nearly

50 percent of those with income from other occupations, including hired farm labor. For most sole proprietors, individual

13
'Mue 4—Seleeted charactertÄlcs of farm people, farmers, atí farm fflßagprs láth imuranœ

oDvergge, by type of coverage, 1976

Private Insurance otil y Private and public

Item : Gtoup : Individual : Gtoup : Otter : Gtoup \! iRlivldual

: plan ': plan : and : private : anl ard

: «ûy . only ! individual : sources : public ;: piljlic

Sferoent

Earn people-^/

^:

liràer 6 : 37.5 31.8 3.9 4.4 1.2 0.4

6 to 18 years ! 44.A 26.5 5.2 5.4 .5 .2

19 to 24 ypATS : 39.9 26.3 4.4 4.7 .4 .2

25 to 44 jeaiB ! 43.1 27.2 7.4 4.1 .7 .3

45 to 64 5iears 34.5 33.0 7.4 5.7 .9 1.4

65 years and over • 1.4 1.8 .2 0 9.1 46.6

Family status:

mad : 31.6 24.9 6.9 4.3 2.8 9.3

Primary Individual :: 13.7 20.3 5.2 U6 1.9 19.3

Wife : 36.1 27.8 6.2 4.5 1.6 5.9

Qdld ; 42.2 27.4 4.7 5.1 0.6 0.2

Other relative : 15.6 15.5 1.2 2.4 1.6 14.1

Secondary mpirher : 2/ 2/ 11 2/ 2/ 2/

SeoOTidary Individual •• 43.3 6.7 0 21.4 0 0

RegiOT:

Northeast : 40.8 19.0 5.1 10.9 2.3 4.5

îtorth Oentral : 35.1 31.8 5.5 4.0 1.4 5.3

South : 35.4 22.0 5.9 3.3 1.4 5.7

West : 39.0 22.5 5.5 6.5 2.4 3.3

Bnplo5«nent status:

Bnplo}iBd : 38.9 25.9 1,1^ 4.8 1.4 3.6

Ihemplpjed : 26.5 21.7 2.9 3.4 0 1.0

fetlred : 5.9 5.5 U5 .7 10.0 37.0

Other, not In labor í

force ; 32.4 28.1 4.3 4.5 1.6 7.2

See footnotes at end of table. Gbntlnued—

14
Table 4—^Selected eharacterlsties of farm people, fanners, and fatm managers with health Insuranœ

œverage, by type of coverage, 1976--cDntlnued

Private insurance only Private and ptblic

Item : Gtotp Individual : Gtoup : Other :: Qcoxsp : Individual

: {dan : plan ; and : prívate : and and

only ; only : individual : sources :• public public

Itercent

Occupation:

Famer, farm manager' 17.3 36.2 3.6 6.2 1.9 9.3

föid farm labor : 32.9 34.2 4.1 7.7 .7 1.0

Ihpald family labor • 26.2 35.3 3.3 7.8 .6 2.8

All other occupations : 49.6 21.5 7.8 3.7 1.1 1.1

Never worked : 25.5 24.8 3.5 3.8 2.7 12.5

Tbtal population

Farmers and farm managers—3/

Agß:

Less than 19 years

19 to 24 jears

25 to 44 years

45 to 64 3^ars

65 years and over

Region:

Northeast

Iferth Gentral

South

fest

36.1 26.2

36.0 33.7

15.6 44.2

19.8 44.2

20.6 43.3

1.3 2.0

20.4 27.5

18.9 41.4

12.5 33.7

20.9 26.8

5.6 4.6 1.6

1.1 7.3 0

4.0 5.5 0

4.2 6.6 .4

4.7 7.8 .6

.1 It 8.4

3.0 17.8 1.9

3.5 5.0 2.0

4.4 3.3 1.8

2.5 10.4 1.1

5.1

0

.1

.4

1.3

50.2

9.0

9.3

10.6

6.1

j_/ Data reported for all persons in families or a primary individual.

2/ Less than 0.1 percent of the population.

3/ Data reported for all those reporting occupation as farmer or farm manager, living in fandlles

or as primary individuals ^dca receive farm Inoooe.

Source: SIE.

15
"Esible 5—^InQome characteristics of farm peoptle, faiineiB, and fatm inanagers with health insurance

coverage by type of coverage, 1976

Private Insurance onl y Private and public

Item : Q»up ! Individual : Gtoup other : Group ! MlvlAwl

plan plan : and fŒivate and and

only : only : Itrilvldual : sources .: piJsllc : public

Iteroent

Eatm people—4/ !

Tbtal £amfly Inoome: :

0 or less : 12.8 51.9 2.5 7.5 0 2.5

$l-$4,999 : 11.8 28.4 2.4 4.2 .9 10.2

$5,00O-$9,999 : 25.1 29.4 4.2 3.5 1.3 8.8

$10,000-$14,999 : 41.2 24.6 8.0 4.5 2.2 4.2

$15,000-$2A,999 :: 49.5 21.0 5.5 4.7 2.1 3.2

$25»0G0 and above : 46.0 26.2 7.7 5.4 1.4 2.7

F!KmlnoonE2/:

0 or less ! 51.5 17.3 7.6 3.8 2.7 3.3

$l-$2,499 !' 35.8 18.4 6.2 3.0 1.7 8.0

$2,500-$4,999 ! 32.9 23.9 6.0 4.4 1.2 6.6

$5,Ö0(>-$9,999 !: 28.0 36.7 3.6 4.9 1.1 3.9

$10,00O-$14,999 : 26.1 41.7 4.6 6.7 .8 4.9

$15,000-$19,999 : 25.4 42.2 3.2 8.3 .2 3.9

$20,000 and above , 23.3 49.0 2.5 9.2 .7 2.9

Berœntage of family

inoome ftom fanning:

Less than 25 pertient : 48.8 14.5 7.9 2.8 2.3 5.4

25-49 percent ! 31.5 24.1 3.9 3*8 1.9 8.4

50-74 percent : 23.1 39.6 3.2 5.3 .6 7.6

75 percent or more : 15.4 48.9 2.4 8.6 .2 2.1

Percentage áboveA>elow

poverty line:

Below : 15.8 35.8 2.5 5.8 .1 3.3

100-125 percent

ahove : 20.8 26.9 1.1 3.0 .3 4.6

125-149 percent

above : 23.1 24.6 3.9 5.1 .9 8.8

150 and above : 41.7 24.5 6.6 4.5 2.0 5.6

Tbtal population : 36.1 26.2 5.6 4.6 1.6 5.4

age footnotes at end of table. Cbntinued^—

16
liable 5—Ihoone characteristics of farm people, fanners, and farm managers with health insurance

coverage by type of coverage, 1976—continuad

Private insurance only Private and public

Item : Gtotp ! Mividiwl ! Qjoup : Otter !: Gcoap : InUvidual

; plan : ^aa : and : private : and : and

only : only !I individual •: sourres : public : piJjlic

Itercent

Fännexs and farm man— !

agers—^/

Ibtal family Inoome: !

0 or less :• 9.9 49.1 3.6 6.3 0.1 3.2

$l-$4,999 ' 8.6 29.5 2.5 5.5 1.2 13.0

$5,000-$9,999 ; 15.4 33.9 2.5 3.8 2.1 12.1

$I0,000-$14,999 ; 20.1 38.4 4.8 6.0 1.8 7.1

$15,000-$24,999 22.6 36.3 5.4 7.0 2.7 7.9

$25,000 atri above :: 23.6 42.3 3.6 9.3 1.9 5.9

Individual's farm in- ;

come:

0 or less : 18.4 32.6 5.0 5.5 2.1 8.9

$l-$2,499 13.7 28.1 4.1 4.3 2.7 16.4

$2,500-$4,999 : 18.1 28.9 3.8 4.1 2.3 9.2

$5,000-$9,999 • 19.0 43.0 2.7 5.0 2.1 4.8

$10,000-$14,999 : 20.0 45.6 3.5 7.6 .2 8.1

$15,000-$19,999 !: 18.6 45.1 3.4 7.2 .6 7.0

$20,000 arri above : 16.7 49.3 2.9 12.0 1.3 4.8

tercentage of family

income from farming:

Less than 25 percent : 21.0 20.6 5.9 3.8 3.8 15.5

25-49 percent : 21.5 26.1 3.0 3.1 3.2 12.7

50-74 percent : 16.8 40.6 2.9 6.0 1.3 10.0

75 and above : 13.1 48.9 2.7 9.2 .3 3.4

Farcentage above/below

poverty line :

Below : 10.6 37.6 3.0 5.6 .4 4.4

100-124 percent : 12.7 32.6 1.0 5.3 0 8.3

125-149 : 15.0 27.7 1.4 5.7 1.4 15.2

150 and above r 19.5 36.7 4.1 5.9 2.4 10.2

Ibtal population : 17.3 36.2 3.6 6.2 1.9 9.3

1/ Data reported for all persons in families or as primary individuals receiving farm income.

2/ Farm income reported for farm people applies to data reported for family; farm income earned by

the individual applies to data reported for farmers and farm manager.

3/ Data reported for those reporting occupation as farmer or faim manager, living in families or as

primary Individuals \àiD receive farm Inoome.

SDuroe: SIE.

17
health insurance was the only source of protection they have

against health loss since they are not covered by workers*

compensation. !_/

Two-thirds of all farmers and farm managers were covered^by individual plans (table 6). Of those, 90 percent held the policy

themselves. However, of the fanners covered through employer

groups, only half were the policyholders, while 41,3 percent

were covered through their spouse*s policy. Thus, 7 percent of

all farmers (41.3 percent of 17.0) were covered through their

spouse's group plan (table 6). This source of coverage baçomes

increasingly important as labor force participation of women

rises.

Younger farmers, farmers in the South and West, and those with

low incomes were less well covered than other farmers (tables

Table 6—Source of coverage for farmers and farm managers

with health insurance, by type of plan, 1976

Those :

with health :

; insurance :

Policyholder

Coverage j./ Self : Spouse : Child :

• 1

Parent : Other : Don't

: know

Employer group 17.0 49.9 41.3

Percent

0.4 6.1 0.7 1.7

Union group 6.5 87.1 9.1 2.5 .6 .1 .6

Individual plan 51.3 90.0 5.3 2.7 0 .1 1.9

1/ These groups include those reporting coverage by type. They are not exclusive,

nor do they represent all sources of coverage (for example, they omit other private

and public sources).

Source: SIE.

T/ It may be misleading, however, to compare the percentage

values between all persons and those in families receiving farm

income. The distribution for the total population was adjusted

for participation in public programs, while the coverage of the

farm population was not. Differences between the two due to

adjustment for participation in public programs would affect

some population segments more than others. For instance, those

in families with low incomes are often eligible for Medicaid,

hence the coverage for the farm population with low income is

underestimated. Likewise, coverage for the farm unemployed may

be underestimated. Although persons in families with farm income appear to rely on private health insurance more than others

in the total population, some of the difference can be attributed to the effect of adjustment for unreported public coverage

in the total population.

18
IMPLICATIONS FOR

SELECTED POLICY

ISSUES

2 and 3). Almost 65 percent of farmers age 65 and over had some

private health insurance, primarily from individual policies.

Those farmers in families with a higher portion of income from

farming had less insurance from group sources and more from

individual plans (tables 2, 4, and 5).

There was some evidence in the survey data that farm people with

chronic health problems were less well covered than others.

Among the population under age 65, only 80 percent of those with

chronic health problems were covered, compared with 85 percent

of others with no health problems. About 78.9 percent of farmers with health problems affecting their ability to work had

health insurance, compared with 82.6 percent of those with no

health problems.

Many proposals for national health insurance require employerpaid insurance, with allowance for a special fund to provide for

the self-employed (examples are 96th Congress, S. 433, "Health

Incentives Reform Act*'; 96th Congress, S. 139, "Comprehensive

Health Care Reform Plan of 1981"; and 97th Congress, H.R. 850,

"National Health Care Reform Act of 1981"). Since most employers already offer health insurance, using employers as the

mechanism for financing national insurance seems appropriate.

In general, each employer would be required to provide some

minimum level of coverage, while those not already offering that

minimum level would be required to increase coverage.

Farmers and others in agriculture, however, will be more affected than nonfarmers due to the lesser likelihood of already being covered by employer plans. The impact would be felt both in

terms of increased labor costs and some initial reduction in

emplo3^ent as firms cut back on higher cost labor (16), Employers of farmworkers could expect increases in payroll tax to the

extent they offer benefits below the required level. The selfemployed farmer, though, could expect minimum coverage through

the Federal Government. The impact of this provision on uncovered or individually covered farmers must be considered.

Even without national health insurance, the pattern of less

likely coverage for farmers makes the returns to farming seem

less attractive compared with other occupations. Those choosing

farming are less likely to have health insurance provided by

their place of employment and thus face higher insurance costs.

Since incorporation of a farm allows the payments of health insurance to be included as a cost of the farm operation, it is

also important to consider this factor in comparing incorporated

versus unincorporated farms.

Decisions regarding insurance depend on individual circumstances.

Farmers and their families should explore possible ways of obtaining group insurance and any tax advantages. Incorporation

of the farm business, memberships in organizations that offer

group policies, and off-farm employment are some ways of acquir--

ing health insurance at minimal cost.

19
REFERENGES 1. Ahearn, Mary C. Health Care in Rural America, U.S.

Department of Agriculture, Economics, Statistics, and

Cooperatives Service, AIB-428, July 1979.

2. Andersen, Ronald, Joanne Krauts, and Odin Anderson.

Expenditures for Personal Health Services: National Trends

and Variations 1953-1970, DHEW Pub. No. (HRA) 74-3105.

Chicago: Center for Health Administration Studies,

University of Chicago, 1973.

3. Boehlje, Michael and Kenneth Krause. Economic and Federal

Tax Factors Affecting the Choice of a Legal Farm Business

Organization, U.S. Department of Agriculture, Economics and

Statistics Service, AER-468, June 1981.

4. Binswanger, Hans P. "Attitudes Toward Risk: Experimental

Measurement in Rural India," American Journal of Agricultural Economics, 62:3, August 1980, 395-407.

5. Braun, Dick. "Farming: Hotbed for Some Cancers," Farm

Journal, June/July 1980, 49-53.

6. Daberkow, S. and C. Fritsch. "Agricultural Workplace

Safety: A Perspective on Research Needs," American Journal

of Agricultural Economics, 61:4, November 1979, 824-835.

7. Davis, Karen. "A Decade of Policy Developments in Providing

Health Care for Low-Income Families," A Decade of Federal

Anti-Poverty Programs, edited by Robert Haveman, New Yotk:

Academic Press, 1977.

8. Ehrlich, Isaac and Gary S. Becker. "Market Insurance,

Self-Insurance, and Self-Protection," Journal of Poli^cal

Economics, 80:4, July/August, 1972, 623-648.

9. Fratoe, Frank. Rural Education and Rural Labor Force in the

Seventies, U.S. Department of Agriculture, Economics,

Statistics, and Cooperatives Service, RDRR-5, October 1978.

10. Fritsch, C, and J. Zimmer. U.S. Farm Accident Fatalities

1970-76, U.S. Department of Agriculture, Economics,

Statistics, and Cooperatives Service, AIB-434, Februafy 1980.

11. Hinman, Suki, Jane Fitzgerald, John F. McCoy, and Bernai L.

Green. "Health Insurance Coverage in Arkansas," Arkansas

Farm Research, XXIV, July-August 1975, 15.

12. Hoppe, Robert A. Sharply Fewer Counties Depend on Farming,

U.S. Department of Agriculture, Economics, Statistics, and

Cooperatives Service, ESS-11, July 1981.

13. Jensen, H. H. "Analysis of Fringe Benefit Compensation for

Non-Metropolitan versus Metropolitan Employees," American

Journal of Agricultural Economics, 64:1, February 1982,

124-128.

20
14. Kmenta, Jan. Elements of Econometrics, New York: The

Macmillati Company j 1971.

15. Krause, Kenneth. Indirect Farm Labor and Management Costs,

U.S. Department of Agriculture, Economics, Statistics, and

Cooperatives Service, AER-496, December 1982.

16. Mitchell, Bridger M. and Charles E. Phelps. Employer-Paid

Group Health Insurance and the Costs of Mandated National

Coverage. Rand Reports, R-1509HEW, Santa Monica: Rand

Corporation, September 1975.

17. Oi, Walter Y. "Workmen's Compensation and Industrial

Safety," Supplemental Studies for the National Commission

on State Workmen's Compensation, Vol. I, 1973.

18. Ross, Peggy J., Herman Bluestone, and Fred K. Hines.

Indicators of Social Weil-Being for U.S. Counties, U.S.

Department of Agriculture, Economics, Statistics, and

Cooperatives Service, RDRR-10, June 19 79.

19. Shaw, R. Paul. "Canadian Farm and Nonfarm Family Incomes,"

American Journal of Agricultural Economics, 61:4, November

1979, 676-682.

20. U.S. Congress, Congressional Budget Office. Profile of

Health Care Coverage: The Haves and Have-Nots, March 1979.

21. . Tax Subsidies for Medical Care: Current

Policies and Possible Alternatives, January 1980.

22. U.S. Department of Commerce, Bureau of the Census.

"Consumer Income: Money Income and Poverty Status in

1975 of Families and Persons in the U.S. and the North

East Region, by Divisions and States," Current Population

Reports, Series P-60, No. 110, March 1978.

23. U.S. Department of Health and Human Services, Public Health

Service. NCHSR National Health Care Expenditures Study:

"Who are the Uninsured?" Data Preview 1, 1980.

24. _. "Advance Data: Health Care Coverage: U.S.,

1976." Vital and Health Statistics of the National Center

for Health Statistics, No. 44, September 1979.

25. U.S. Department of Labor, Division of State Workers'

Compensation Programs. Personal correspondence with

Richard Fink, March 1983.

21
Ö^vC

Americans saw their dentists more often and visited

hospital emergency rooms more frequently during the

1970's, according to data in this publication. The report

is a comprehensive study of the volume of outpatient

service from the National Center for Health Statistics.

Dental visits increased 21 percent betv^een 1967 and 1979,

which, after adjusting for the rise in the U.S. population,

meant a net increase of 12 percent.

Hospital emergency room visits increased 97 percent, according to

one data source. Although these visits included only one third of

all outpatient hospital care, they accounted for approximately half

of the outpatient visits increase of 36 percent that appeared during

the 1970's.

The largest portion of outpatient care in the U.S. during the '70's was

provided in physician's office (78 percent) followed by visits to hospital

affiliated clinics (25 percent). There was no significant change in the

rate of office visits during this period.

The report provides data on the volume of services according to the settings in

which they were delivered. Also included are data on geographic region or^titfe,

type of service, demographic characteristics of the patient and the types of health

problems treated.

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