# medicaid 

# kaiser commission
o n



# uninsured and the

# medicaid uninsured and the 

# kaiser commission

The Kaiser Commission on Medicaid and the
Uninsured provides information and analysis
on health care coverage and access for the
low-income population, with a special focus
on Medicaid’s role and coverage of the
uninsured. Begun in 1991 and based in the
Kaiser Family Foundation’s Washington, DC
office, the Commission is the largest
operating program of the Foundation. The
Commission’s work is conducted by
Foundation staff under the guidance of a bipartisan group of national leaders and
experts in health care and public policy.

James R. Tallon

Chairman

Diane Rowland, Sc.D.

Executive Director

### EXE CUTI V E SUMM ARY

Migrant and seasonal farmworkers are an integral support to the nation’s agricultural industry. Nearly th ree m illion workers earn their living th ro ugh m i grant or seasonal farm labor. Migran t and seasona l f arm workers and the i r f a m ilies conf ront hea lth c h alleng es stemm i ng f r om the nature of their work, their extrem e poverty a nd m obility, and living and w o rking arrangem ents that impede access to health cov e rag e and care. This brief provides an ov erview of mi grant and seasonal farmworkers and the health challenges they face an d considers options for improving their health coverage an d access to care.

Overview of Farmworkers and th eir Health Coverage and Care

Al m o st all m i grant and seasonal farmworkers ar e foreign-born with only 6% reporting being born in the United States. The m a jority (70%) p e rm anently r e side in the United Stat e s

. Although concentrated in certain areas of the co untry, mi grant and seasonal farm workers reside in all states. They travel frequently between states for their employm e nt. As a group, m i grant and seasonal far m workers face significant languag e barriers— about 9 in 1 0 say they read and speak little or no English. They are predominan tly m a le (88%), over half are m arried (52%), and over four in ten have children (44%). Even though m i grant and seasonal f arm workers report working five to six days a week, they are extrem ely poor. In 2000, the median income for

m i grant and seasonal farmworkers was $6,250, co mp ared to $42,000 for U.S. workers overall (Figure 1).

K A I S E R C O M M I S S I O N O N M e d i c a i d an d t h e U n i n s u r e d Fi g u r e 1 

## M i grant Farm w o rkers: Medi an A nnual I n come

$ 6 , 250 $ 42, 000

M i gra n t a n d S e a s ona l Fa rm w o rke r s U

. S. W o r ker s

S ourc e : N a t i on al A g ri c u l t ur al W o rk ers Sur v ey , 2000



### Migrant and seasonal farmworkers and their fa milies are overwhelmingly uninsured. In 2000, 85% of m i grant and seasonal farm workers were uninsured, compared to 37% of low-incom e adults nationally (Figure 2). Fu rther, nine in ten children in m i grant and seasonal farmworker f

a m ilies wer e uninsured comp ared to less th an a quarte r(22 %) of low-in com e children nationally.K A I S E R C O M M I S S I O N O N M e d i c a i d an d t h e U n i n s u r e d Fi g u r e 2 

## Migr ant Far m w o rkers: Health Cov e rage f o r A dult s

5% 18 % 10 % 33 % 85 % 37 %

12 %

M i gr a n t a nd S e a s ona l F a rm w o rk ers Low- I n c ome A dul ts Na ti ona l l y ( < 20 0%F P L ) Unins u r e d Ot h e r Pri v a t e P u b lic

N o t e : Low

- i nc ome i s l e s s t h an 20 0% of t he f e d e r a l po v e rt y l e v e l $2, 6 8 2 per mont h f o r a f a m i ly of t h r e e. Sour c e : Nat i on al dat a f r om K a i s er C o m m i s s i on on M e di c a i d and t h e U ni ns ur ed, ”Heal t h I n s u ranc e C o v e r a g e i n A m er i c a: 2000 D a t a Upd a t e , ” Febr uary 200 2; Far m w o r k ers e s t i m at es f r om 2000 N A W S

.



### Ref l ecting their low lev e ls of covera ge, m i grant and seasona l f arm workers and the i r f a milies use very little health care compar ed to other low-incom e people. In 2000, only 20% of mi grant and seasonal farmworkers reported using any healthcare se rvic es in the preceding two years. Further, one study found that on ly 42 % of wom e n in farmworker families reported seeking early prenatal care comp ared to over three

- quarters (7 6%) nationa lly (Fig u r e 3 ) . Data sho w a nearly one in four incidence of undesirable birth outcom es and elevatedrates of low birthweights and pre-term births am ong the farmworker population.

K A I S E R C O M M I S S I O N O N M e d i c a i d an d t h e U n i n s u r e d Fi g u r e 3 

## Migrant Farm w o r ker Families : Utiliza t ion ofH e alth Ca re

42 % 76 %

M i gr a n t Fa r m wo r ke r s U ni t e d S t a t e s

SO U RCE: M a t e r n al Care C o ordi n a t i on f o r M i grantF a rm w o rk er W o m e n: P r ogr a m St ruc t ur e and E v al u a t i on of Ef f e c t s on Us e ofP r enat a l Car e an d B i rt h O u t c ome (Res o u r c e I D # 298 8 ) Perc ent of pr egna nt w o men t h at sought car e during the fi r s t trimes ter of their pregnanc y :



### The low utilization patterns am ong farm workers are not a reflection of limited health care needs. Migran t andseasonal farmworkers ar e often in po or health an d they are at elevated ris k for an

enorm ous range of injuries and i llnes ses due to th e natur e of thei r jobs. T h e two m o stsignificant reported barriers to care am ong m i gr ant and seasonal farm workers are cost and language.

### Health Centers Serving Farmworkers

Federally funded health centers are a key source of care for migrant and seasonal farmworkers. In 2002, 125 of the nation’s 843 federally funded h ealth centers received funds specifically targeted to meet migrant health needs. These centers serviced some 670,000 migrant and seasonal farmworkers and their families. An ad ditional 247 health centers, which did not receive a specific migrant subsidy, served another 39,000 migrant and seasonal farmworkers and their families.

The vast majority of health cen ters that receive migrant fundi ng also rely on general health center grants and serve the overall low-inco me population. Because they serve both farmworkers and other community residents, they ar e similar to health centers that do not receive special migrant funding in terms of the insuran ce distribution of both th eir patients and their revenues—Medicaid covers about 35% of patients and accounts for over a third of revenues, and about a quarter of revenues comes from federal grants. Centers that receive migrant funding do differ from other centers in that they often o ffer services tailored to migrant and seasonal farmworkers families’ needs, such as outstationed services.

In 2002, some 15 health centers we re funded exclusively with migr ant grant funding and did not receive general health ce nter grants. These centers tend to be far smaller than other health centers, and, because the overwhelming majority of their patients are un insured (92%), their revenues primarily come through their federal grants (80%).
Medicaid Coverage Barriers
Migrant and seasonal farmworkers face a number of barriers to obtaining Medicaid coverage. Some of these problems affect the low-income population generally, but many of them are exacerbated by the characteristics of migrant and seasonal farmworkers, such as their immigrant status, their fluctuating incomes, and their migratory patterns.

• Many migrant and seasonal farmworkers are not eligible for Medicaid. One significant barrier is that, under current law, states cannotprovide Medicaid coverage to non-disabled low-income adults without dependent childr en. Further, since 1996, recent immigrants, including legal immigrants, have been excluded from Medicaid for the first five years they reside in the United States. From a financial e ligibility perspective, so me states use monthly budgeting rules and have restric tive asset tests, which make it difficult for low-income workers with fluctuating incomes and assets need ed for employment (e.g., a truck) to qualify.

• Eligible migrant and seasonal farmworkers ca n have difficulty enrolling in Medicaid. Migrant and seasonal farmworkers who are eligible for Medicaid may have difficulty completing the application and enrollment proce ss. Given their limited English skills, it can be very difficult for them to complete long ap plication forms or meet extensive verification requirements, particularly if there is limited av ailability of language assistance. Inaccessible site locations can also impede enrollment.

• Because of their frequent movement amon g states for work, migrant and seasonal farmworkers also face state residenc y barriers to Medicaid coverage. Medicaid is a state-based program. It rec ognizes state residency among pe ople who live in a state for work-related purposes and states also are require d to provide out-of-state coverage for their

### residents to permit travel, but this coverage can be very limited. Accordingly, migrant and seasonal farmworkers can seek to apply for Medicaid each time they change their state residence, but they may encounter enrollment barriers such as those mentioned above. On the other hand, farmworkers can travel with a Medicaid card fr om the state in which they permanently reside but may find that they are only covered for emergency situations and/or have difficulty identifying out-of-stat e providers willing to honor the card.
Options to Improve Coverage and Access to Care
Over the years, a few states, including Wisc onsin and Texas, have attempted to improve Medicaid’s ability to serve farmworkers. From these state experiences, we have learned that Medicaid can be made more accessible thr ough rapid enrollment, accessible enrollment locations, acceptance of out-of-stat e enrollment cards, and payment for a broad range of services provided out-of-state. Federal e fforts could be undertaken to improve states’ willingness to pursue these initiatives and to improve their eff ectiveness. The federal government also could pursue broader efforts to address farmworkers’ coverage challenges:

• Improving access to Medicaid. A number of actions could be taken to facilitate farmworkers’ ability to enroll inand utilize Medicaid coverage. Facilitating eligibility reciprocity across states. The model of accepting an out-of-state enrollment card can work well but is hindered by varying eligibility standards across states. It could be facilitated by federal guidelines for implementing a fast track enrollment option, changing existing eligibility criteria, and iden tifying health centers and other programs to serve as enrollment sites. It could be furt her encouraged by allowing states to establish separate eligibility standards for farmworkers and their families that could be consistent
across states. Improving “traveling Medicaid card” models. The model of paying for out-of-state services requires efforts to identify out-of-state provi ders willing to participate and a claims administration intermediary. Federal efforts c ould encourage and improve this model. For example, if a regional intermediary were iden tified, it could enable processing of out-of-state claims, creation of provider networks, and outreach and education for traveling families. Costs for this effort would app ear to be directly related to state Medicaid administration and, thus, eligible for reimbursement.

• Creating a new federal coverage program for farmworkers and their families. While these initiatives may help encourage enrollme nt and access among eligible farmworkers, they will not be able to overcome the barriers stemming from Medicaid’s exclusion of adults without dependent children and recent immigrants. A broader solution for farmworkers and their families might be to couple Medicaid acces s efforts with a federal coverage program that could enroll farmworkers and their families on a nationwide basis, thereby permitting interstate movement and portable benefits.

The health needs of farmworkers are considerable, but their number s are relatively modest. The evidence reviewed in this analysis suggests the importance of addressing their needs and presents a range of viable options, including efforts thr ough Medicaid and other programs to complement Medicaid’s reach. Such efforts might help surmount the major challenges farmworkers and their families face in terms of securing health coverage and accessing needed care.

### I. INTRODUCTION

An estimated three million workers earn their living through migrant and seasonal farm labor, traveling the nation to support an agricultural i ndustry which yielded $28 billion in fruit and vegetable business in 2001 alone. 1 

### Forty-five years ago, farmlabor was the subject of Harvest of Shame, 2 

### a classic documentary which chronicled th e devastating condition s under which migrant laborers worked. Much has changed over the pa st four and a half decades where workplace safety and healthcare access are concerned; at the same time, migrant and seasonal farmworkers continue to confront unique heal th and healthcare challenges aris ing from the hazardous nature of their work, their extreme poverty and mobility, and living and working arrangements which serve to make access to health insurance a nd health care especially difficult.

As part of the 2002 reauthorization of the health centers prog ram, Congress mandated a study to examine “the problems experienced by migran t and seasonal farmworkers (including their families) under Medicaid and SCHIP.” 3 

### Congress sought an analysis of Medicaid enrollment and portability barriers as well as options for possi ble solutions, both within the current limits of Medicaid and SCHIP and through use of Sec tion 1115 demonstration au thority and publicprivate partnerships to devel op coverage alternatives.

This policy brief begins with a review of the health and healthcare environment in which migrant and seasonal farmworkers and their families live and work, as well as the challenges faced by the nation’s federally funded health centers serving the farmworker population. It then reviews the literature on farmworker healthcare coverage a nd considers policy options for improving health insurance coverage and healthcare access for farmworkers.

II. STUDY APPROACH

A. Data Sources

The information used to develop this analysis co mes from a review of the literature as well as two data sources: the 2000 National Agricultural Worker Survey (NAWS), a periodic national survey of farmworkers conducted by the United States Department of Labor; and the Uniform Data System (UDS) maintained on federally funded health centers by the United States Department of Health and Human Services, He alth Resources and Serv ices Administration. Although other data sources exist fo r describing the migrant labor force, only these two data sets provide information on migrant heal th status and health care access. 4 

### (In January 2005, the Department of Labor announced that it was discontinuing NAWS, thereby ending access to specialized economic, living arrangement, and h ealth insurance coverage information about farmworkers.)

1 National Center for Farmworker Health, Facts About Farmworkers (Accessed September 6, 2004) www.ncfh.org

. 2 Walter Goodman, “New Harvest, Ol d Shame” NY Times (1990) Accessed at http://www.galaninc.com/press/prharvest.phtml (September 6, 2004)
3 §404, Pub. L. 107-251 (107 thCong., 2d Sess.)
4 Although the monthly Current Population Survey provides detailed information on the labor force, it does not specifically target migrant workers. The Department of Agriculture conducts two surveys, the Farm Labor Survey (FLS) every 4 months and Census of Agriculture every five years, for the purpose of tracking wage rates and production.

### Several years of NAWS data we re examined in this study. The 2000 NAWS data are based on interviews with more than 3,500 randomly sele cted workers who perform various agricultural services. The survey exclude s secretaries and mechanics, as well as workers who are nonimmigrants working in the U.S. under a temporary visa issued pursuant to the Immigration and Nationality Act. 5 

### The NAWS analysis is based on a sub-sample of approximately 1,400 workers who identified themselves as migrant farmworkers.

The UDS includes tabulated patientdata and select encounter information from all federallyfunded health centers. The UDS identifies migrant and seasonal farmworkers, including their dependents. In 2002, 372 out of 843 federally funded health centers (44%) served 708,611 persons identified as migrant and season al worker s and family members. Among this broader group of grantees receiving both general and migr ant health center funding, 15 health centers received migrant and seasonal farmworker gr ants exclusively and served a total of 58,350 patients. The UDS analysis provides informati on on this small grantee subset as well as the broader universe of migr ant health centers.

B. Defining the population

As with any analysis of populat ion characteristics, an examin ation of farmworkers and their families begins with a discussion of definitions. Two separate sets of policies – those which are a part of labor law, and those which govern the provision of migrant health care – are relevant.

Department of Labor definitions : The Migrant and Seasonal Agri cultural Worker Protection Act 6 

### (MSAWPA) extends protections to individu als currently employed as farmworkers and reaches two distinct classes of farmworkers: migrant agricultural workers and seasonal agricultural workers.

A “ migrant agricultural worker” is an individual who is
employed in agricultural employment of a seasonal or other temporary nature, and...is required to be absent overnight from his permanent place of residence. 7



### The term “seasonal agricultural worker” means an individual who is employed in agricu ltural employment of a seasonal or other temporary nature and is not required to be absent overnight from his permanent place of residence: (1) When employed on a farm or ranch performing field work 8 

### related to planting, cultivating, or harvesting operations; or (2) When employed in canning, packing, ginning, seed conditioning or related research, or

5 For more details on the survey methodology, see the Department of Labor's The National Survey of Agricultural Workers at http://www.dol.gov/asp/pr ograms/agworker/naws.htm.
6 29 U.S.C. §1801 et., seq.
7 29 C.F.R. §500.20. The NAWS survey notes that a 75 mile travel distance is used to measure “required”.
8 The concept of field work as it relates to seasonal and migratory farmwork encompasses planting, cultivating or harvesting operations and “includes all farming operations on a farm or ranch which are normally required to plant, harvest or produce agricultural or horticultural comm odities, including the production of a commodity which normally occurs in the fields of a farm or ranch as oppo sed to those activities which generally occur in a processing plant or packing shed. A worker engaged in the placing of commodities in a container in the field and on-field loading of trucks and similar transports is included.”

### processing operations, and transported, or cau sed to be transported, to or from the place of employment by means of a day-haul operation. 9



### The term “agricultural employment” means agricultural work within the scope of the Fair Labor Standards Act and the Internal Revenue Code. It incl udes service activities involving
the handling, planting, drying, packing, packaging, processing, freezing, or grading prior to delivery for storage of any agricultural or horticultural commodity in its unmanufactured state. 10



### “Agricultural commodities” encompass products “of the soil that are planted and harvested by man.” 11



### The definition of migratory and seasonal farmworkers under the MSAWPA does not include individuals who are temporary non-immigrants authorized to wo rk in agricultural employment under the Immigration and Nationality Act. 12 

### NAWS provides data on both farmworkers employed in their communities as well as those w ho travel for work as defined under the law.

Health centers program definitions : The definition of “migrant and seasonal farmworker” which is used in the health centers program actually is somewhat broader than that found in U.S. labor law.

Under the Public Health Service Act, a “migratory agricultural worker” means An individual whose principal employment is in agriculture on a seasonal basis, who has been so employed within the l ast 24 months, and who establishes for the purposes of such employment a temporary abode. 13



### A “seasonal agricultural worker” means an individual “ whose principal employment is in agriculture on a seasonal basis and who is not a migratory agricultural worker.” 14



### Unlike the more narrowly circumscribed Depart ment of Labor (DOL) definition, the Public Health Service definition recognizes individuals and families for whom migrant labor is their principal, although potentially not their only, fo rm of labor, as well as persons who were farmworkers in the recent past (presumably and sens ibly in order to allow for transitional health care within a health center). In addition, the Public Health Service Act does not contain distinctions based on lega l or immigrant status.

As with the DOL definition, the term “agricultu re” under the health cent ers program focuses on farming the land, as well as preparation and proce ssing performed either by a farmer or on a farm

9 29 C.F.R. §500.20
10 Id.
11 29 C.F.R. §780.12
12 29 C.F.R. §500.20
13 42 U.S.C. 254(g)
14 Id.

### for the purpose of market and delivery to storage. 15 

### The Public Health Service Act does not distinguish between immigrants and non-im migrants who perform farm labor duties. 16



### These definitional differences mean that the pot ential eligible migrant and seasonal farmworker population at migrant health centers may be larg er than the population counted as farmworkers by the DOL. This population would include tem porary non-immigrants, as well as citizens and legal residents for whom migrant farm labor is a principal (but non-excl usive) occupation. The eligible population also could include families with a member who worked as a migrant or seasonal farmworker within the preceding 24 mo nths but does not do so at the present time. Despite these distinctions, expe rts in migrant health care view NAWS as providing an accurate portrait of migrant and seasonal farmworkers fo r purposes of designing health care services. 17



### C. Counting Farmworkers

Simply calculating the size of the migrant a nd seasonal farmworker population presents a challenge. Because NAWS is a sample-basedstudy, it does not offer a population census. According to the Bureau of Primary Health Care within HRSA, which administers the health centers program, the most re cent national population estimates of migrant and seasonal agricultural workers are found in the 1993 “Atlas of State Prof iles which Estimate [the] Number of Migrant and Seasonal Farmworker s and Members of their Families.” 18 

### The Bureau initiated an update of this census in the late 1990s, but th e latest estimates are available only for a 10-state subset; 19 

### as a result, the most recent national census data are over ten year s old. The 1993 Atlas enumeration reports slightly over three million migrant and seasonal farmworkers. This figure is below the four million worker census from 1990; however, the estimation methods changed between the two time periods, making accu rate trend examination impossible. 20



### III. A PROFILE OF FARMWORK ERS AND THEIR FAMILIES

A. Residential Patterns and Demographics

Residential Patterns. Although concentrated in certain ar eas of the country, migrant and seasonal farmworkers are found in all states. Fi gure 4, drawn from the 1993 enumeration shows, that 68 % of all migrant and seasonal farmworker s were concentrated in 8 states that year: California, Florida, Georgia, Michigan, North Carolina, Oregon, Washington State, and Texas. 21

15 Id.
16 Programs of the Public Health Servi ce Act, and specifically health centers, are not consideredpublic benefits whose use is restricted under the Immigration and Nationality Act.
17 For an excellent source of information on farmworkers ina health and healthcare context, see the National Center for Farmworker Health, www.ncfh.org

. 18 National Center for Farmworker Health, Migrant an d Seasonal Farmworkers Demographics Fact Sheet http://www.ncfh.org/docs/fs-Migrant%20Demographics.pdf (Accessed September 6, 2004).
19 State level analyses were completed in 2000 for Arkans as, California, Florida, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, Texas and California. They can be viewed at http://bphc.hrsa.gov/migrant/Enumeration/EnumerationStudy.htm (Accessed September 6, 2004)
20 National Center for Farmworker Health, Migrant and Seasonal Farmworkers Demographics Fact Sheet http://www.ncfh.org/docs/fs-Migrant%20Demographics.pdf (Accessed September 6, 2004)
21 Id. Table, p. 3.K A I S E R C O M M I S S I O N O N Medi c a i d a nd t h e Uni n sur e d Fi gu r e 4 

## Distribution of Mi grant and Seasonal F a rm w o rkers

< 1 0 , 00 0 (15 stat es)

10 , 000 -49 , 00 0 (23 stat es)

5 0 , 0 00- 100 , 0 0 0 (4 sta t es )

>10 0 , 00 0 (8 sta t es )

In c l ud e s all 1 2 5 h ealt h c e nt er s t h a t r e c e iv e mig r ant h e alt h f u nd i n g. Sou r c e : 1 9 93 e num er a t io n o f mi g r an t and s e as on a l f a r m w o r k er s

. N a tio nal C e n t er f o r F a r m w o r k e r H e a l t h

, Migr an t a nd S e as o nal F a r m w o r k er s D e m ogr aphic s F a c t S h eet
, t abl e 3. ( n o e s t i mat e s f o rN o r t h D a k o t a , S o ut h D a k o ta , a n d Di s t r i c t o f Co l u mbi a )

.


### Approxim a tely 70% of mi grant and seasonal farmwo rkers perm anently reside in the US. Figure 5, drawn from the 2000 NAWS, shows the states in which m i grant and seasonal farm workers tend to be domi ciled (i.e., reside perm anently). As Figure 5 indicates, C a lif ornia is the larg est domi cile state, representing 30% of all farm worker s. Twenty two percent of respondents report a domicile in a southeastern state, 17% report a southwestern stat e domi c ile, 12% report a Midwestern state domicile, 12% report an ea ste r nstate dom icile, a nd 5% a northwestern dom i cile. 22 

### These residential patterns underscore that dom iciles differ m arkedly from t h e states in which workers resid e f o r rela tive l y brief pe riods of tim e as they travel f o r employment

reasons.

K A I S E R C O M M I S S I O N O N M e d i c a i d an d t h e U n i n s u r e d Fi g u r e 5 

## Migrant Farm w o r ker s b y Pr incipal Pl ace of Resi den c e

5% 12% 12% 17 % 22% 30%

C a l i f or n i a S out hea s t S out hw e s t M i dw e s t E a st N o r t h w e s t

S ourc e : N a t i on al A g ri c u l t ur al W o rk ers Sur v ey , 2000

22 East includes DE, K Y , M A

, ME, NC, N J

, NY , P A

, TN

, a n d WV; S o utheast includes A L

, AR, F L

, GA , L A , a n d MS; Midwest i n cludes IA

, KS , IL

, IN , MI , M N , M O

, NE

, O H

, SD , a n d WI ; Southwest includes AZ

, OK , and TX;

an d Northwest in clu d e s CO, ID, OR, WA. Califo rn i a is the on ly state th at is reported sep arately.

### Work Patterns. The NAWS data indicate that among mi grant and seasonal far m workers, 24% indicate they had at least two farm j obs m o re th an 75 m iles apart. The rem a ining 76% report that they shuttle to two or more crop locations at least 75 miles from their residence.

Demographic Characteristics . Figure 6 shows that mi grant and seasonal far m workers are overwhelmingly foreign-born and as a group tend to speak and read little or no English. Six percent of NAW S respondents identify them se lves as U.S. born, while 67 percent identify them selves as first gen e ration farmworkers. 23

K A I S E R C O M M I S S I O N O N M e d i c a i d an d t h e U n i n s u r e d Fi g u r e 6 

## Migr ant Far m w o rkers: English Skills an d Count r y of Origin

87 % 90 % 92%

67 %

S p eak lit t l e t o n o En g l i s h Re ad lit t l e o r n o En g l i s h B o r n in Mexic o F i rstg e n e r a t i o n

m i g r a n tw o rker

S ourc e : N a t i on al A g ri c u l t ur al W o rk ers Sur v ey , 2000



### Most m i grant and seaso n al farm wor k ers are m a le , and 52% are m arried (F igure 7). Som e what fewer than half of all mi grant and seasonal farmworkers have children, while about half live in households with parents and other fam ily m e mb ers. Am ong mi grant and seasonal farmworkers with children, 66% mi grate with their childr en and an estim a ted 250,000 children mi grate with their paren t s each year. 24

23 Fi rst gene rat i o n mi grant s rep o rt pare nt s di dno farm work

. 24 Nation a l Cen t er for Farm wo rk er Health, Matern a l an d Ch ild Hea lth Fa ct S h eet (B uda T e xas) ( A ccesse d Sep t em b e r6, 20 04 at h ttp ://.www.n c fh.org )K A I S E R C O M M I S S I O N O N M e d i c a i d an d t h e U n i n s u r e d Fi g u r e 7 

## Migr ant Far m w o rkers: G e nder and Family Composit ion

88%

52% 44 % 46 %

Male Ma r r i ed P aren tw i t h Ch ild r e n L i v e wi th P a r e nts

or Othe r Re l a ti v e s

S ourc e : N a t i on al A g ri c u l t ur al W o rk ers Sur v ey , 2000



### Poverty am ong m i grant and seasonal far m worker fa m ilies is v e ry deep. In 2000, U.S. workers earned a m e dian annual incom e in excess of $42,000. 25 

### Figure 8 shows that the 2000 m e dian incom e of migrant and seasonal farm workers sto od at $6,250, even as they reported working 5 to 6 days a week. Further analysis of incom e data show that 91% of m i grant and season al far m workers reported annual incom e below $15,000 in 2000, while 56% reported earnings lower than $5,000. Incom e trends drawn from NAWS data show the proportion of mi grant and seasonal farmworkers with annual family inco m e s below the federal poverty level increased from 51% in 1993 to 76% in 1998, falling back to 59 % in 2000.

K A I S E R C O M M I S S I O N O N

M e d i c a i d an d t h e U n i n s u r e d Fi g u r e 8 

## M i grant Farm w o rkers: Median A nnual Income

$ 6 , 250 $ 42, 000

M i gra n t a n d S e a s ona l Fa rm w o rke r s U

. S. W o r ker s

S ourc e : N a t i on al A g ri c u l t ur al W o rk ers Sur v ey , 2000

25 U.S. Census B u reau. http://www .census.gov/hhes/incom e /i nc om e00/inctab1.html (Accessed Septem ber 2004)

### B . Health Coverage, Utilization, and Status

Health Coverage. Compared to workers generally, mi grant and seasonal far m workers and their f

a m ilies ar e overwhelm ingly uninsur ed. Figures 9 and 10 illu stra te th e extent to which far m workers and their fam ilies lack covera ge. In 2000, 85% of m i grant an d seasonal f

arm workers were comp letely un insu red, comp ared to 37% o f all low-in c o m e adults n a tiona lly (i.e., adu lts with f a m ily incom e s at or below 200% of the federal poverty level). 26 

### Ten percent of

m i grant and seasonal farmworkers reported priv ate coverage, while 5% reported coverage through Medicaid. Children of mi grant and se as onal farm worker families sim ilarly w e re pervasively uninsured comp ared to low incom e c h ildr e n natio n ally ; near ly 90% were c o mp letely uninsured in 2000, comp ared to 22% of all low-inco m e children that year. 27 

### Trends over tim e, as shown in the NAWS data, suggest that despit e the advent of major Medicaid reform s for children, Medicaid coverage am ong c h ildren in migrant and seasonal farm worker fam i lies

rem a ins very low, although Medicaid represents the dominant form of he alth insurance for

m i grant and seasonal farmworker children.

K A I S E R C O M M I S S I O N O N M e d i c a i d an d t h e U n i n s u r e d Fi g u r e 9 

## Migr ant Far m w o rkers: Health Cov e rage f o r A dult s

5% 18 % 10 % 33 % 85 % 37 %

12 %

M i gr a n t a nd S e a s ona l F a rm w o rk ers Low- I n c ome A dul ts Na ti ona l l y ( < 20 0%F P L ) Unins u r e d Ot h e r Pri v a t e P u b lic

N o t e : L o w
- in c o m e is le s s t h a n 2 0 0 % o f t h e f e de ra l p o v e rt y le v e l $ 2

, 6 82 p e r
m o n t h fo ra fa m i l y o f th r e e

. Sour c e : Nat i on al dat a f r om K a i s er C o m m i s s i on on M e di c a i d and t h e U ni ns ur ed, ”Heal t h I n s u ranc e C o v e r a g e i n A m er i c a: 2000 D a t a Upd a t e , ” Febr uary 200 2; Far m w o r k ers e s t i m at es f r om 2000 N A W S

.

26 U. S. De part m e nt o f La b o r , “ N at i onal A g ric u ltural Workers Survey”(Release 3.0) a n d Kaiser Co mmiss i o n on M e di cai d a n dth e Uni n s u re d, “Heal th Ins u ra nce C ove rage i n Am eri ca: 20 00 Dat a U pdat e ,” Fe bruary 2 0 0 2

. 27 U.S. Dep artmen t of Labo r, “Natio n a l Ag ricu ltu ral Wo rkers Survey”(Release 3.0) an d Kaiser Co mmiss i o n on M e di cai d a n dth e Uni n s u re d, “Heal th Ins u ra nce C ove rage i n Am eri ca: 20 00 Dat a U pdat e ,” Fe bruary 2 0 0 2

.K A I S E R C O M M I S S I O N O N M e d i c a i d an d t h e U n i n s u r e d Fi g u r e 1 0 

## Migr ant Far m w o rkers: He al t h Co v e ra ge for Chil dr en

10 % 78 % 90 % 22 %

Ch il d r e n i n F a r m w o r k e rF a m ili es L o w - In c o m e Ch il d r e n Nat i o n a lly ( < 20 0%F P L ) Uni n sur e d In s u r e d

N o t e : Low

- i nc ome i s l e s s t h an 20 0% of t he f e d e r a l po v e rt y l e v e l $2, 6 8 2 per mont h f o r a f a m i ly of t h r e e. Sour c e : Nat i on al dat a f r om K a i s er C o m m i s s i on on M e di c a i d and t h e U ni ns ur ed, ”Heal t h I n s u ranc e C o v e r a g e i n A m er i c a: 2000 D a t a Upd a t e , ” Febr uary 200 2; Far m w o r k ers e s t i m at es f r om 2000 N A W S

.



### Utiliza tion o f

Hea lth Care. Migr ant and seasona l f arm workers and the i r f a m ilies use very little health care comp ared to other low-incom e peopl e. The 2000 NAWS data indicate that only 20% of mi grant and seasonal far m workers reported the use of any health care services in the preced i ng 2 years. Although the NAW S does not inquire about related reasons for use or nonuse of services, it does ask about barriers. Survey re spondents identified cost and language as the two most significant barriers to care, as b o rne out by sm aller studies of farmworkers in selected
states. 28 

### Additionally, one study found that only 42% of far m worker wom e n reported early prenatal care (i.e., within the first 3 months of pregnancy) co mpared to 76% nationally (Figure 11). Resear chers hav e n o ted tha teve n where serv ices ar e ava i lable, extr e m e mobility m eans that f

a m ilies m a y leave an ar ea bef o re tre a tm ent is f u rnished. 29 

### Extr em e mobility leaves f a milies at particular ly great risk f o r limited andinterrupted health care.

28 M

. Pe rez, G. R e ube n, H

. Pi n z on , " N o r th e r n C a l i f orni a Hi sp anic mi grant farm workers h ealth status: a c a se study," Mi grat i o n Wor l d M a g a zi ne , 26 (1 -2)

, 19 98

. 29 Gin a R. Lo m b ard i , “Den tal/Oral Health Serv ices” Mi gr an t Heal t h Is sues (Natio n a l Center fo r Farm work er Health (Acces sed Se pte m ber 6, 2004 at h ttp ://www.n cfh

. o r g ) 2 001.K A I S E R C O M M I S S I O N O N M e d i c a i d an d t h e U n i n s u r e d Fi g u r e 1 1 

## Migrant Farm w o r ker Families : Utiliza t ion ofH e alth Ca re

42 % 76 %

M i gr a n t Fa r m wo r ke r s U ni t e d S t a t e s

SO U RCE: M a t e r n al Care C o ordi n a t i on f o r M i grantF a rm w o rk er W o m e n: P r ogr a m St ruc t ur e and E v al u a t i on of Ef f e c t s on Us e ofP r enat a l Car e an d B i rt h O u t c ome (Res o u r c e I D # 298 8 ) Perc ent of pr egna nt w o men t h at sought car e during the fi r s t trimes ter of their pregnanc y :



### Health Status. The limited use of health services by m i grant and seasonal far m workers cannot be attributed to a low need for health care. Indeed, by virtue of th eir extrem e poverty, their mobility in s earch of work, and hazardous livin g and housing conditions u nder which they work,

m i grant and seasonal farmworkers have an extraord inary n e ed for health care. Farmworkers are at elevated risk for an en orm ous range of injuries and illnesses. According to a review of data from the Bureau of Labor data, while agricultu re-related employm e nt comprised only 2% of overall employm e nt, agricultura l and livestock-related produ ction, along w ith agricultural services, comprised 13% of all occupational deaths over a 1994-1999 tim e period. 30 

### Risks arise as a result of work-related conditions, the use of equipm ent, and exposure to chem icals, with resulting elevated rates of chronic conditions, mu sculoske leta l inju rie s , se rious disabilities, and f

a talities.

More than 40% of all workers reported leaving or changing jobs as a result of chronic pain. 31 

### Respirat ory illn esses su c h as asthm aand bronchiti s are re lativ e ly comm on, as are skin problem s, exposure to infectious diseases such as tuberculosis and paras ites, and diseases related to unsanitary and close living condi tions in substandard housing. 32 

### Higher rates of cancer are suspected, as are elevated ra tes of eye and vision problem s. 33 

### Pesticide exposure and its consequences represent one of the best docum ente d risks, although experts believe that there are insufficient studies examining the eff ects of mu l tiple pesticide exposure. 34



### The fa m ilies of far m workers also ap pear to h a ve poor health status and to be at high risk for illn ess. Exp o sure to ch emicals can result in c ontam ination, which, in tu rn, is brought hom e to

30 Alice Larson

, Env i ro n m en tal/Occu p a ti o n a l Safety and Health , “ Mi gra n t Heal t h Is sues Mo no gr ap h Se ri es (N ation a l Cen t er for Farm w o rk er H ealth, Bud aTex a s, 200 1) (A ccessed Sep t em b e r 6
, 2004 at h ttp ://w ww .n cfh

. o r g)
31 I d

. 32 Id. See als o C h ristopher Hol d en, “ H ousi ng,” Mi gr ant He a l t h Iss u es (National Ce nter for Farm worker Health, B uda Texa s, 2 0 0 1 ) ( A ccesse d Se pt em ber 6

, 2 0 0 4 at h ttp ://www.n cfh

. org )
33 I d

. 34 I d

.

### the children of migrant and seasonal farmworkers. 35 

### Research has documented a rate of selfreported fair-to-poor health status among farmworker mothers that st ands at more than triple the rate for the general population. 36 

### Data from a special CDC data system which measures pregnancy nutrition among the population found dimi nished weight gain, a nearly one-in-four incidence of undesirable birth outc omes, elevated rates of low bi rthweights and preterm births among farmworkers. 37



### Health problems among farmworker children ar e extensive, with studies showing a high incidence of intestinal parasites, severe as thma, chronic diarrhea, Vitamin A deficiency, chemical poisoning, and continuous ear infections. 38 

### Despite their greater health risks, depressed access to care means that farmworker children are delayed in their immunization schedules. 39 

### Migrant children also have been found to exhibit “striking” levels of mental illness such as anxiety, depression, and disruptive behaviors. Researchers have attributed these risks to the psychological impact of the extreme poverty, separation, and dislocation experienced by children in farmworker families. 40 

### Dental problems among migrant and seasonal farmworkers and their families rank among the top five health problems for individuals ages 5 through 29; children of farmworkers experience a rate of decay twi ce that for children in the general population. 41



### IV. A PROFILE OF HEALTH CENTERS SERVING FARMWORKERS

In 2002, 125 of the nation’s 843 federally funded h ealth centers received funds specifically targeted to meet migrant health needs; th ese centers served 6 70,000 migrant and seasonal farmworkers and their families. Another 247 h ealth centers, which do not receive a specific migrant subsidy, served an additional 39,000 farmwo rkers and family members. That year, 44% of all health centers se rved migrant and seasonal farmworkers and some 25% of all migrant and seasonal farmworkers reported in the 1993 Enumeration received health care at a health center. These statistics capture the central importance of health centers to farmworker healthcare access. Figure 12 shows the relative distribution of health centers receivi ng migrant grants.

35 Id.
36 National Center for Farmworker Health, Maternal and Child Health Fact Sheet (Buda Texas) (Accessed September 6, 2004 at http://www.ncfh.org )
37 National Center for Farmworker Health, Maternal and Child Health Fact Sheet op. cit.
38 Id.
39 Id.
40 Joseph D. Hovey, “Mental Health and Substance Abuse” Migrant Health Issues (NCFH, Buda Texas, 2001) Accessed September 6, 2004 at http://www.ncfh.org

. 41 Gina R. Lombardi, “Dental/Oral Health Services” Migrant Health Issues (National Center for Farmworker Health (Accessed September 6, 2004 at http://www.ncfh.org ) 2001.K A I S E R C O M M I S S I O N O N M e d i c a i d an d t h e U n i n s u r e d Fi g u r e 1 2 

## G e ographic Dis t ribut ion of M i grant Heal t h Cent ers

None ( 10 st at es & D C )

1- 2 C e n t er s ( 28 st at es)

3- 5 C e n t ers ( 7 st at es)

6- 10 C e n t er s ( 2 st at es) N a tion al To tal of 843 H e alth C e n t ers

Sour c e : He al t h R e s o urc e s a n d Ser v i c es A d mi ni s t rat i on, U n i f orm Dat a S y s t em , 2002 > 10 C e n t er s ( 3 st at es)



### The vast m a jority of health cen ters receiv i ng m i grant fundin g (110 out o f 125 in 2002) are “m ixed grant” cen ters ; th at is, they also receive general health center grants. This dual status
perm its health centers to serv e the general populati on, as well as furnis h continuing care to f

a m ilies af te r they leave f arm labor. Approxim a te ly 27% of patien t s se rv ed at “m ixed grant” centers nationally are mi grant and seasonal farm wo rkers andtheir family m e m b ers. In term s of both insurance distribution of patients and reve nue distribution, these “mixed grant” h e alth centers resemble those that do not receive mi grant grants. At th e s a m e tim e, m i xed grant he alth
cente rs also of f

e r service s which are tailo red to m i grant and seasonal farm worker fami lies, in particular, outstationed services in accessib l e lo cations, Med i caid enro llm ent assistan ce, and services which are geared to addressing the uniqu e health conditions and n eeds of mi grants (see text box on next page).

Som e 15 m i grant health centers were funded exclusively as migr ant health centers, that is, without m i xed grants. T h ese 15 health centers w e re located in Alabam a, Georgia, Iowa, Illinois, Kansas, Kentucky, Massachusetts, Maine, Mich igan, Minnesota, Montan a, New York, North Carolina, South Carolina, and W y oming. Although these centers ar e as likely as their “m ixed grant” colleagues to be located in rural areas and provide similar services, the 15 migrant health

cen ters tend to be far smaller. Approximately two-thirds reported fewer than 5,000 patients an d only one exclusively migrant health center reported serving more than 10,000 patients.Farmworker Services in a Michigan Community Health Network

The Intercare Community Health Network has served farmworkers and community residents throughout western and southwestern Michigan for more than 30 years. From its beginnings as a modest community clinic for farmworkers and local area residents, Intercar e has grown into a six-site health network serving more than 40,000 patients. More than one in four Inte rcare patients is a member of a migrant or seasonal farmworker family. Intercare’s services parallel those found at many health centers: comprehensive primary medical care; dental care; prenatal and obstet rical care; maternal and infant support services; breast and cervical cancer screening and testi ng; health education and outreach; and behavioral health care. More than 80% of Intercare’s patients have family incomes below 100% of the federal poverty level, 45% are uninsured, and 38% are insured through Me dicaid. Although 11% of Intercare’s patients have private health insurance, among Intercare’s pregnant patients, the figure is far lower; of 300 pregnant women who received care in 2004 at one site , only 10 (3%) had private health insurance.

For more than a decade, Medicaid application assistanc e has been a central feature of Intercare’s patient support services. Farmworker familie s are included in this su pport effort, with particular emphasis placed on pregnant women and children. Medicaid coverage is enormously important to the success of Intercare’s obstetrical program: 98% of all pregnant applicants qualify for help (either full coverage or emergency Medicaid and state-funded medical assi stance for expectant mothers who cannot satisfy Medicaid’s legal status test).

Intercare acts as a “bridge” into Medicaid for its patients, assisting with completion of the applications, assembly of necessary do cuments related to eligibility determinat ions, and ensuring t hat applicants are able to get to local welfare offices to complete t he enrollment process. The state requires in-person appearances by all applicants and does not outstation e ligibility workers at health centers. Intercare’s services also include assistance with the enrollment of newborns and children. The state’s financial aid to support Intercare’s outreach efforts ceased in 2004, and Intercare now provides these services with its own health care revenues.

Another one of the clinic’s most important types of Medicaid support is advocating with local agencies on behalf of migrating farmworker families who are inadv ertently enrolled in managed care. Because of confusion that surrounds Medicaid enrollment, farmworker families inco rrectly assume that they must enroll in managed care plans, even though the plan ne tworks are not accessib le as they follow the harvest. Thus, as they migrate north to follow the harvest and leave their plans’ service areas, families can encounter significant health care access barriers , even for serious health care needs. Intercare provides key assistance by helping families dise nroll from managed care and reenroll in the basic Medicaid fee-for-service sy stem before leaving the area



### .

Figure 13 shows the age distributi on of farmworkers and their fam ily members served at health centers. Because adults are more likely to travel and work, a la rge proportion of migrant health center patients are working-age adults. Howe ver, the proportion of migrant and seasonal farmworkers served by migrant health centers who are working age adults is only slightly higher than the proportion of patients in health centers that do not receive migrant grants (61% versus 57%).K A I S E R C O M M I S S I O N O N M e d i c a i d an d t h e U n i n s u r e d Fi g u r e 1 3 

## M i grant and Sea s onal Far m w o r ker Heal t h Cent er Pat i ent s by A g e

El d e r l y

1%

C h ildr e n <1 9 38% A dult s 1 9

- 64 61%

Sour c e : He al t h R e s o urc e s a nd Ser v i c es A d mi ni s t rat i on, U n i f orm Dat a S y s t em , 200 2. E s ti mat e s f r om 13 heal t h c ent ers t hat s e rv e o n l y m i grant us ers

.



### Health cen te rs tha tdo no t re ly sole ly on m i grant h ealth g r ants report tha t approxim a tely 35% of their total patien t s re ceiv e Medic a id. The picture is mu ch diff erent at health centers funded solely by mi grant health center grants. As Fi gures 14 and 15 show, health centers receiving

m i grant-only grants are far m o re lik ely than h ealth centers genera lly to report uninsured patients, and experience vastly reduced levels of Medicaid revenues. In health centers that receive both general and m i grant grants, m i grant and seas onal far m workers comp rise 27% of the total registered patient population; this relatively low presence helps explain why “mixed grant” health centers continue to regi ster relatively high propor tions of Medicaid patie nts. Other factors

m a y be the greater likelihood of “ m ixed grant” h ealth centers to see Medi caid-eligible m i grants and the resulting greater level of assist ance furnis hed in Med i caid en rollm ent.

K A I S E R C O M M I S S I O N O N

M e d i c a i d an d t h e U n i n s u r e d Fi g u r e 1 4 

## Healt h Center Pa t i ent s by Pa y o r S ource and Healt h Center T y pe

36 % 36%

7% 39 % 39% 25 % 25% 1%

92 %

A l l 8 43 He al th C e n t ers 110 Heal t h C e n t e rs Wi t h M i g r an t an d Oth e r F u n d i n g 15 He al t h Cen t e r s Wi th M i grant F u ndi ng O n l y Oth e r Un i n su re d M e d i cai d

Sour c e : He al t h R e s o urc e s a n d Ser v i c es A d mi ni s t rat i on, U n i f orm Dat a S y s t em , 2002.K A I S E R C O M M I S S I O N O N M e d i c a i d an d t h e U n i n s u r e d Fi g u r e 1 5 

## Health Cent er R e v e nue by Healt h Center Ty pe

35% 38% 25% 25% 20% 11% 11% 30% 26% 7%

2% 80%

A ll 84 3 He al t h Cen t e r s 1 1 0 He al t h Cen t e r s W i t h M i gr a n t a nd O t h e rFundi ng 15 Hea l t h Ce n t er s W i t h O n l y M i gr a n t Fundi ng Ot h e r St at e an d L o c al G r an t s Fe de r a l Gr a n ts Me d i c a i d

Sour c e : He al t h R e s o urc e s a n d Ser v i c es A d mi ni s t rat i on, U n i f orm Dat a S y s t em , 2002.



### Reflecting their patient distribution, health centers receiv ing only m i grant grants are more dependent on federal funding to care for a larg ely uninsured m i grant and seasonal farmworker population. Figure 14 shows that, in 2002, health centers operating ex clusively as mi grant health centers reported that only 2% of their operating revenues cam e fr om Me dicaid. In contrast, other health centers reported Medicaid accounted for more than one-thir d of their operating revenues. Unlike health centers generally, for whom Medicai d is the largest source of financing, mi grantonly health centers exist virtu a lly ex clusiv ely on grants; their modest size offers a further suggestion of the role played by Medicaid in perm itting health centers to grow and expand their services.

V. BARRI ERS TO M E DICAID COVERAGE

Refor m ing Medicaid to improve its perform a nce for mi grant and seasonal far m workers and their f

a m ilies has been a prog r a m f

o cus f o r som e 30 years. The lite ratur e on f arm workers and Medicaid 42 

### points to a set of problem s which are related, specific, longstanding, and well-

42 See, e

. g., Mary Kenness o n, I m

pr

ovi n g He al t h Se rvi ce Acc e ss f o r Med icaid

- Elig ib le Migra n t Farmw o rkers (Cen ter fo r Health Care St rateg i es, Prin cet on N.J., 2 000 ); Natio n a l Healt h Po licy Forum

, Po licy Op tio n s fo r S e rving Mig r an t C h ild ren a n d Families Un de r Med i ca id an d S C HIP (T he Ge or ge Was h i n gt o n U n i v e r si ty , W a s h i n gt o n D

. C., 2000 ) ; Sar aRosenb aum , Opt i ons f o r Exp a n d i n g P u bl i c l y Fi na nce d Heal t h Co ve rag e of Mi gr a n t Far m w o rke r s

an d t h ei r F a mi l i e s , (Nation a l Asso ciatio n of Co mmu n ity Health Cen t er s, W a sh ing t on D

. C. 200 0) ; Elizab eth Kap e ller, F a r

m worker Acces s to Safety Net Ins u r anc e Pr ograms : Harves ting Sol utions to a Thirty-Seve n Ye ar Old Issue

, (Natio na l Center fo r Farm worke rHeal th, B u d a TX, 20 03) ; E. G a llard o and V

. Hu an g, Expa nd ing Access to Hea lth C a re Services: A Po li cy Brief (Califo rn i a Prim ary Care Asso ciatio n, Sacram en to , C A 2 002 ); Natio n a l Im m i grat i on L a w C e nt er, Gu ide to Immig r an t Elig ib ility for Fede ra l Progra m s, 4 th ed. ( L os A ngel e s , C A , 20 0 2 ); Judi t h M o o r e, Po licy Op tion s fo r S e rving Mig r an t C h ild ren an d Fa milies Unde r Med ica i d a n d S C HIP (Natio n a l Health Po licy Fo ru m , W a sh in g t o n D.C. 200 0). In add itio n, th e Cong ressio n a lly m a n d a ted Nation a l Adv i sory Co un cil on Mi g r an t Health , t h e Migran t Cli n ician s Netwo rk (a sp ecial n e t w ork of h ealth cen ter clin icians wh o sp ecialize in farm wo rk er h ealth care), and o thers h a v e reco mmen d e d ch anges. In ad d ition

, t h e Health C are Fi nanci n g A d m i ni strat i on ( n ow th e C e nt ers f o r M e di care a n dM e di cai dS e rvi ces (C M S ) com m i ssi oned a stu d y i n th e early 1 990 s to ex amin e th e feasib ility o f Med i caid refo rm s. Th e resu lts were p u b lish e d in 199 3. Georg e E. Wri g h t , Nan c y Fasciano and Hilary Frazer (Math e m a tica Health Po licy), Ian Hill an d Beth Zimmer m a n (Health Syste m s Research), and Nan c y Pin d u s (Urb an In stitu te), Fe asibility Study to Devel op a Medicai d reci procity

### recognized. Although there are few systematic studi es of farmworker Medicaid eligibility and enrollment barriers, information gathered by rese archers, as well as repeated and widespread anecdotal evidence supplied over nearly four d ecades by a legion of health care providers and analysts, point to a series of problems which combine to cause exclusion. Some of these problems are present among many low-income populations excluded from Medicaid, but what is striking is how migratory farmwo rk serves to elevate and inte nsify their effect, while adding others attributable to barriers cr eated by legal status and frequent changes in state residence. In short, classic Medicaid eligibility and enrollment barriers appear to combine with particular force in the case of migrant and seasonal farmworkers.

General problems that are particularly problema tic for migrant and seasonal farmworkers. One problem is the lack of cate gorical eligibility fo r certain groups of low-income people, in particular, childless working-age adults without disabilities. A second problem is financial eligibility barriers. States have considerable di scretion in how they define and count income and resources. Use of monthly budgeting rules and restrictive asset test s are financial eligibility rules that tend to penalize itinerant and fluctuating work income (relatively high in relation to Medicaid eligibility rules one month, and then extr emely low in the next month) and that fail to recognize work implements (e.g., tools, a truck) as a permissible asset. A third major barrier is legal status requirements that pr ohibit all but emergency Medicaid c overage of otherwise eligible legal U.S. residents who recently immigrated into the U.S. This barrier is the result of 1996 welfare reform legislation that eliminated Medica id eligibility for otherwise-eligible recent legal immigrants. 43 

### A final barrier arises from application and enrollment barriers such as inaccessible site locations, long application forms, extens ive verification requirements, and limited to no language assistance.

Barriers related to the lack of state residency. Medicaid is a stat e-based program; state residency requirements, coupled with the problems described above, can lead to nearly insurmountable Medicaid access problems for farmwo rkers. State residency problems arise in one of two ways. Medicaid recognizes state re sidency among persons who live in a state for work-related purposes. However, anecdotal eviden ce from advocates and health centers suggests that the work-related test may be honored only in the breach and that many state and local welfare agencies continue to deny enrollment to individuals and families who enter communities to work but do not intend to reside indefinitely. Medicaid also requires states to provide out-ofstate coverage for their residents to permit travel . However, state policies may limit out-of-state coverage to persons whose out-of- state travel is related to institutional placement, the use of services located in nearby regiona l facilities (e.g., a regional ch ildren’s hospital), or to persons who travel for brief periods of time a nd face emergency health care needs.

Federal regulations appear to requi re states to pay for medical car e furnished out of state where it is a general practice for residents of certain state localities to us e services furnished in another

Program for Migrant and Seasonal Farmworkers (Cont. No. 500-92-0037, Task 2). The National Association of Community Health Centers has been extensively involved in this issue over the years and from time to time has compiled information on the problem and options for reform. See, e.g., Migrant and Seasonal Farmworker Access to Health Care Services and Insura nce Coverage: Summary Report on Issues, Resources and Potential Solutions (NACHC Washington D.C., 2003).
43 §401, Personal Responsibility and Work Opportunity Act of 1996 (P. L. 104-193)

### state. 44 

### These rules seemingly could apply to farmwork ers who live in certain localities of a state and who customarily travel to certain other stat es for work purposes. In the absence of this “portability” provision, farmworker families appe ar to be caught between two diametrically opposed problems. On the one hand, farmworkers s eeking to apply for Medicaid as they change their state of residence for work related reas ons may encounter numerous barriers including the absence of a rapid enrollment system, inaccessible points of entry, extensive verification requirements, and inadequate application support. On the other, farmwo rkers traveling with a valid Medicaid card issued by the state in which they permanently reside may find that coverage is denied for all but dire emerge ncies. Compounding this restricti on is the fact that few if any out-of-state providers, other than programs such as migrant health centers that are accustomed to traveling patients, will honor the card.

Migrant health concerns have been a feature of public policy for more than four decades, beginning with the 1962 passage of the Migrant Health Act45 

### and continuing with the legislative establishment of the Health Centers Program in 1975, which c ontained specific authority for grants to serve migrant and seasonal farmworkers. 46 

### In 1979, the Carter Administration promulgated regulations which re vised the definition of state re sidence for Medicaid and cash welfare assistance purposes to require states to recognize as residents workers and their families who were present in a state for employment relate d reasons (either with a job or seeking one). No interpretive guidelines applyi ng out-of-state coverage and paymen t rules to travel related to coverage for farmworkers ever have been issued.

No systematic evaluation of the impact of the 1979 rule ever has been conducted, but its limited effect appears to be evident in the statistics on Medicaid enrollment and revenues from the UDS, as well as the results of our NAWS analysis. Anecdotal evidence from the literature and from persons familiar with farmworker issues suggests widespread failure on the part of local welfare agency staff to consistently recognize this ex panded definition of residency. Furthermore, community health providers frequently report th at even where employme nt-related residence is recognized, the application process poses such serious problems that the residency change alone has little impact.

Moreover, there is evidence thatresidency-related problems are intrastate as well as interstate, with documented barriers in states such as California, 47 

### where migration is significantly in-state, and where county government agencies appeared to require reapplication and submission of new proof of eligibility with eachmove. Following the 2000 issuance of a State Medicaid Directors

44 Federal rules require payment for residents, including residents who are absent from a State. 42 C.F.R. §435.403(a). States must pay for covered services furnished out-of-state services to residents in medical emergencies, where services are needed and travel would e ndanger the patient’s health or where the state determines on the basis of medical advice that necessary health care is more readily available in another state. In addition, states must pay for services furnished in another state if “it is general practice for recipients in a particular locality to use medical resources in another st ate.” 42 C.F.R. §431.52 (b)(4)
45 P. L. 85-61 (85 thCong., 2d Sess.)
46 P.L.
47 California Primary Care Association, Policy Options Related to the Medicaid Portability for Migrant Farmworkers Project (Sacramento, CA, 2002)

### letter clarifying that such procedures vi olate Medicaid statewideness requirements, 48 

### along with sustained advocacy, California officials issued a directive to county offi cials clarifying their obligations to allow county-to-county move ment by Medicaid-enrolled farmworkers. 49



### VI. OPTIONS FOR IMPROVING COVERAGE

Over the years, a few states have attempted to improve Medicaid program performance for farmworkers. Wisconsin is particularly not able for having develope d a reciprocal rapid enrollment system, which automatically extends c overage to any family w ith a valid out-of-state enrollment card, using a shortened application pr ocess. Enrollment lasts until the date on which the out-of-state enrollment expires, at which ti me families who continue in-state reapply for benefits using normal in-state procedures. Wisc onsin also has adopted an income eligibility calculation methodology that permits families to annua lize their income in order to avoid months of ineligibility as a result of fluctuating earnings. 50



### While Wisconsin has pursued a reciprocal rapid in-state enrollment approach, Texas attempted an initiative that mirrors the Wisconsin method and applies the out-of-state coverage option to promote continuous access to coverage even during periods of work. In 2001, the Texas legislature enacted legislation to study an out-of-state portab ility demonstration project for migrant farmworker children. Under the demonstr ation, the state assured coverage on an out-ofstate basis when migrant farmworker children traveled, signing up out-o f-state providers and compensating them for customary, not merely emergency services. 51



### The pilot project achieved signi ficant “upstream” participati on by out-of-state physicians and hospitals in several dozen states and involved on ly a small, manageable number of children. State efforts to take the model “to scale” for all migrant farmwo rker children failed when no satisfactory full-risk contra ctor could be identified. 52 

### The effort also revealed small but important state-to-state variations in childre n’s eligibility and bene fit packages, program management problems created by the lack of a uni que farmworker identifier, and challenges in making out-of-state provider payment systems work smoothly. During the pilot phase, Texas and Michigan (more than three-quarters of whose migrant farmworkers come from Texas) prepared for an expanded collaboration; however, the failure of the Texas program to achieve full implementation has set back a collaborative effort.

From these state experiences, cert ain lessons can be gleaned. The first is that there are indeed handles for making Medicaid work better for eligib le farmworkers and their families. Whether a

48 State Medicaid Director from Timothy Westmoreland, http://www.cms.hhs.gov/states/letters/smd12400.asp (Dec 4, 2000)
49 Harvesting Solutions, op. cit.
50 Id.
51 Federal rules on payment for out of state care allow states to honor such out of state claims for covered services in numerous circumstances beyond documented medical emergencies. Out of state payments may be made when “it is the general practice for recipients in a particular locality to use medical resources in another state” or when “medical services are needed and the recipient’s health would be endangered if he were required to travel to his State of residence,” or when “the state determines on the basis of medical advice that the needed medical services or necessary supplementary resources are more readily av ailable in another state.” 42 C.F.R. §431.52(b).
52 Id.

### state uses the Wisconsin appr oach or the Texas strategy, th ere are ways to facilitate farmworkers’ access to Medicaid coverage. Wisconsin relies on fast-track access to enrollment in strategic locations (e.g., migrant health clin ics, programs serving farmworkers), coupled with the adoption of a “card swap” rule. Texas has attempted, at least in the case of children, to operationalize a “traveling Medicaid card” through broader standards for out-of-state coverage and active efforts to identify and enroll participating providers.

At the same time, the limits are clear. The Wisc onsin model of simply exchanging an in-state card for an out of state card fo r the duration of eligibility is hindered by varying eligibility and asset rules across the states. The Texas model re quires an active effort to identify out-of-state providers and a claims administration intermediary.

Were HHS to spearhead an active collaboration between the Centers for Medicare and Medicaid Services (CMS) and the Health Resources and Services Administration (HRSA), both approaches would be more feas ible. CMS and HRSA could embark on a “Wisconsin” strategy for states that opt to fast-track enrollment a nd adopt eligibility standards suitable to families whose incomes are derived through seasonal agricultural work. Guidelines explaining a fast track enrollment option, options fo r altering existi ng eligibility criteria, and identifying health centers and other farmworker prog rams to serve as enrollment sites, all might provide a useful stimulus.

In order to facilitate the Texa s model, CMS and HRSA could identify a regional intermediary capable of processing out-of state claims for participating states, arranging networks of participating migrant health cente rs and other providers; arrange for the provision of information for traveling families; and issue guidelines explaining the expanded use of the out-of-state coverage option. Costs associated with such an expanded effort would appear to be directly related to state Medicaid administration and thus eligible for reimbursement.

Were CMS and HRSA to engage in such a coordi nated strategy, states would have two feasible approaches to easing entry into Medicaid and be tter coverage during periods of enrollment. Well thought out strategies, coupled with greater attention to the problem of coverage, could be expected to have some impact over time.

In the long run, however, it is ev ident that problems of legal status, categorical Medicaid barriers, and frequent movement combine to make the potential for improved Medicaid coverage for this especially vulnerable slice of the low-income populati on limited at best. A more long term solution might be to couple Medicaid acces s and enrollment improvement efforts with a federal insurance program, administered by a national intermediary, that would enroll and cover families on a nationwide basis, thereby permitting interstate movement, portable benefits and strategically accessible m eans of enrollment.

### VII. CONCLUSION

For over 40 years, the health of migrant and seasonal farmwo rkers has received national attention. The latest effort to address the needs of migrant and seasonal farmworkers can be found in the Congressional study mandate enacted in 2002. The health needs of farmworkers

are considerable, but their numbers are relatively modest. The evidence reviewed in th e analysis presented here suggests the importance of an intervention a nd a range of viable options, including

more energetic Medicaid interventions and other programs to compleme nt Medicaid’s reach. More active attention to overcoming Medicaid barriers, coupled with a national program that uses a nationwide intermediary to bring benefits to families, would help surmount the inherent difficulties for this population created by state border s and state-based healthcare programs. It is also evident that additional datawould greatly inform any effort to expand insurance coverage for migrant and seasonal farmworkers.The Kaiser Family Foundation is a non-profit, private operating foundation dedicated to providing information and analysis on health care issues to policymakers, the media, the health care community,

a nd the general public. The Foundation is not associated with Kaiser Permanente or Kaiser Industries.1330 G S TREET NW, W ASHINGTON , DC 20005
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Additional copies of this report (# 731 4 ) are available on the Kaiser Family Foundation’s website at www.kff.org.