medicaid

kaiser commission o n

uninsured and the

medicaid

kaiser commission o n

uninsured and the

Migrant and Seasonal Farmworkers: 

Health Insurance Coverage and Access to Care

Sara Rosenbaum, J.D. 

Peter Shin, Ph.D, MPH 

Center for Health Services Research and Policy 

The George Washington University 

April 2005 
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
EXECUTIVE SUMMARY 

Migrant and seasonal farmworkers are an integral support to the nation’s agricultural industry. 

Nearly three million workers earn their living through migrant or seasonal farm labor. Migrant 

and seasonal farmworkers and their families confront health challenges stemming from the 

nature of their work, their extreme poverty and mobility, and living and working arrangements 

that impede access to health coverage and care. This brief provides an overview of migrant and 

seasonal farmworkers and the health challenges they face and considers options for improving 

their health coverage and access to care. 

Overview of Farmworkers and their Health Coverage and Care 

Almost all migrant and seasonal farmworkers are foreign-born with only 6% reporting being 

born in the United States. The majority (70%) permanently reside in the United States. 

Although concentrated in certain areas of the country, migrant and seasonal farmworkers reside 

in all states. They travel frequently between states for their employment. As a group, migrant 

and seasonal farmworkers face significant language barriers—about 9 in 10 say they read and 

speak little or no English. They are predominantly male (88%), over half are married (52%), and 

over four in ten have children (44%). Even though migrant and seasonal farmworkers report 

working five to six days a week, they are extremely poor. In 2000, the median income for 

migrant and seasonal farmworkers was $6,250, compared 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

Medicaid and the Uninsured

Figure 1

Migrant Farmworkers:

Median Annual Income

$6,250

$42,000

Migrant and Seasonal

Farmworkers

U.S. Workers

Source: National Agricultural Workers Survey, 2000

Migrant and seasonal farmworkers and their families are overwhelmingly uninsured. In 2000, 

85% of migrant and seasonal farmworkers were uninsured, compared to 37% of low-income

adults nationally (Figure 2). Further, nine in ten children in migrant and seasonal farmworker 

families were uninsured compared to less than a quarter (22%) of low-income children 

nationally. 

1
K A I S E R C O M M I S S I O N O N

Medicaid and the Uninsured

Figure 2

Migrant Farmworkers:

Health Coverage for Adults

5%

10% 18%

33%

85%

37%

12%

Migrant and Seasonal

Farmworkers

Low-Income Adults Nationally

(<200% FPL)

Uninsured

Other

Private

Public

Note: Low-income is less than 200% of the federal poverty level $2,682 per 

month for a family of three.

Source: National data from Kaiser Commission on Medicaid and the Uninsured,

”Health Insurance Coverage in America: 2000 Data Update,” February 2002;

Farmworkers estimates from 2000 NAWS.

Reflecting their low levels of coverage, migrant and seasonal farmworkers and their families use 

very little health care compared to other low-income people. In 2000, only 20% of migrant and 

seasonal farmworkers reported using any healthcare services in the preceding two years. 

Further, one study found that only 42% of women in farmworker families reported seeking early 

prenatal care compared to over three-quarters (76%) nationally (Figure 3). Data show a nearly 

one in four incidence of undesirable birth outcomes and elevated rates of low birthweights and 

pre-term births among the farmworker population. 

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

Medicaid and the Uninsured

Figure 3

Migrant Farmworker Families:

Utilization of Health Care

42%

76%

Migrant Farmworkers United States

SOURCE: Maternal Care Coordination for Migrant Farmworker Women: Program 

Structure and Evaluation of Effects on Use of Prenatal Care and Birth Outcome 

(Resource ID# 2988)

Percent of pregnant women that sought care during the 

first trimester of their pregnancy:

The low utilization patterns among farmworkers are not a reflection of limited health care needs. 

Migrant and seasonal farmworkers are often in poor health and they are at elevated risk for an 

enormous range of injuries and illnesses due to the nature of their jobs. The two most significant 

reported barriers to care among migrant and seasonal farmworkers are cost and language. 

2
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 health centers received funds specifically 

targeted to meet migrant health needs. These centers serviced some 670,000 migrant and 

seasonal farmworkers and their families. An additional 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 centers that receive migrant funding also rely on general health 

center grants and serve the overall low-income population. Because they serve both 

farmworkers and other community residents, they are similar to health centers that do not receive 

special migrant funding in terms of the insurance distribution of both their 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 offer services tailored to migrant and seasonal 

farmworkers families’ needs, such as outstationed services. 

In 2002, some 15 health centers were funded exclusively with migrant grant funding and did not 

receive general health center grants. These centers tend to be far smaller than other health 

centers, and, because the overwhelming majority of their patients are uninsured (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 cannot provide Medicaid coverage to non-disabled 

low-income adults without dependent children. 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 eligibility perspective, some states use monthly 

budgeting rules and have restrictive asset tests, which make it difficult for low-income 

workers with fluctuating incomes and assets needed for employment (e.g., a truck) to qualify. 

• Eligible migrant and seasonal farmworkers can have difficulty enrolling in Medicaid. 

Migrant and seasonal farmworkers who are eligible for Medicaid may have difficulty 

completing the application and enrollment process. Given their limited English skills, it can 

be very difficult for them to complete long application forms or meet extensive verification 

requirements, particularly if there is limited availability of language assistance. Inaccessible 

site locations can also impede enrollment. 

• Because of their frequent movement among states for work, migrant and seasonal 

farmworkers also face state residency barriers to Medicaid coverage. Medicaid is a 

state-based program. It recognizes state residency among people who live in a state for 

work-related purposes and states also are required to provide out-of-state coverage for their 

3
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 from 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-state providers willing to honor the card. 

Options to Improve Coverage and Access to Care 

Over the years, a few states, including Wisconsin 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 through rapid enrollment, accessible enrollment 

locations, acceptance of out-of-state enrollment cards, and payment for a broad range of services 

provided out-of-state. Federal efforts could be undertaken to improve states’ willingness to 

pursue these initiatives and to improve their effectiveness. 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 in and 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 identifying health centers and other programs to 

serve as enrollment sites. It could be further 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 providers willing to participate and a claims 

administration intermediary. Federal efforts could encourage and improve this model. For 

example, if a regional intermediary were identified, 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 appear 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 enrollment 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 access 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 numbers 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 through 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.

4
I. INTRODUCTION 

An estimated three million workers earn their living through migrant and seasonal farm labor, 

traveling the nation to support an agricultural industry which yielded $28 billion in fruit and 

vegetable business in 2001 alone.1

 Forty-five years ago, farm labor was the subject of Harvest of 

Shame,2 a classic documentary which chronicled the devastating conditions under which migrant 

laborers worked. Much has changed over the past 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 health and healthcare challenges arising 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 and health care especially difficult. 

As part of the 2002 reauthorization of the health centers program, Congress mandated a study to 

examine “the problems experienced by migrant 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 possible solutions, both within the current limits of 

Medicaid and SCHIP and through use of Section 1115 demonstration authority and publicprivate partnerships to develop 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 and 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 comes 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, Health Resources and Services Administration. 

Although other data sources exist for describing the migrant labor force, only these two data sets 

provide information on migrant health 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 health 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, Old Shame” NY Times (1990) Accessed at 

http://www.galaninc.com/press/prharvest.phtml (September 6, 2004) 3

 §404, Pub. L. 107-251 (107th Cong., 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. 

5
Several years of NAWS data were examined in this study. The 2000 NAWS data are based on 

interviews with more than 3,500 randomly selected workers who perform various agricultural 

services. The survey excludes 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 patient data 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 seasonal workers and family members. Among this broader 

group of grantees receiving both general and migrant health center funding, 15 health centers 

received migrant and seasonal farmworker grants exclusively and served a total of 58,350 

patients. The UDS analysis provides information on this small grantee subset as well as the 

broader universe of migrant health centers. 

B. Defining the population 

As with any analysis of population characteristics, an examination 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 healthcare – are relevant. 

Department of Labor definitions: The Migrant and Seasonal Agricultural Worker Protection 

Act6

 (MSAWPA) extends protections to individuals 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 agricultural 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 

work8

 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/programs/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 commodities, including the production of a commodity which 

normally occurs in the fields of a farm or ranch as opposed 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.” 

6
processing operations, and transported, or caused 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 includes 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 work in agricultural employment 

under the Immigration and Nationality Act.12 NAWS provides data on both farmworkers 

employed in their communities as well as those who 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 last 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 Department 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, form of labor, as well as persons who were 

farmworkers in the recent past (presumably and sensibly 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 legal or immigrant status. 

As with the DOL definition, the term “agriculture” under the health centers program focuses on 

farming the land, as well as preparation and processing 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. 

7
for the purpose of market and delivery to storage.15 The Public Health Service Act does not 

distinguish between immigrants and non-immigrants who perform farm labor duties.16 

These definitional differences mean that the potential eligible migrant and seasonal farmworker 

population at migrant health centers may be larger than the population counted as farmworkers 

by the DOL. This population would include temporary non-immigrants, as well as citizens and 

legal residents for whom migrant farm labor is a principal (but non-exclusive) occupation. The 

eligible population also could include families with a member who worked as a migrant or 

seasonal farmworker within the preceding 24 months but does not do so at the present time. 

Despite these distinctions, experts in migrant health care view NAWS as providing an accurate 

portrait of migrant and seasonal farmworkers for purposes of designing health care services.17 

C. Counting Farmworkers 

Simply calculating the size of the migrant and seasonal farmworker population presents a 

challenge. Because NAWS is a sample-based study, 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 recent national population estimates of migrant and seasonal 

agricultural workers are found in the 1993 “Atlas of State Profiles which Estimate [the] Number 

of Migrant and Seasonal Farmworkers and Members of their Families.”18 The Bureau initiated 

an update of this census in the late 1990s, but the latest estimates are available only for a 10-state 

subset; 19 as a result, the most recent national census data are over ten years 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 accurate trend examination impossible.20 

III. A PROFILE OF FARMWORKERS AND THEIR FAMILIES 

A. Residential Patterns and Demographics 

Residential Patterns. Although concentrated in certain areas of the country, migrant and 

seasonal farmworkers are found in all states. Figure 4, drawn from the 1993 enumeration shows, 

that 68 % of all migrant and seasonal farmworkers 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 Service Act, and specifically health centers, are not considered public benefits 

whose use is restricted under the Immigration and Nationality Act. 

17 For an excellent source of information on farmworkers in a health and healthcare context, see the National Center 

for Farmworker Health, www.ncfh.org. 18 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). 

19 State level analyses were completed in 2000 for Arkansas, 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. 

8
K A I S E R C O M M I S S I O N O N

Medicaid and the Uninsured

Figure 4

Distribution of Migrant and Seasonal 

Farmworkers

<10,000 

(15 states)

10,000-49,000 

(23 states)

50,000-100,000

(4 states)

>100,000 

(8 states)

Includes all 125 health centers that receive migrant health funding.

Source: 1993 enumeration of migrant and seasonal farmworkers. National Center for Farmworker Health,

Migrant and Seasonal Farmworkers Demographics Fact Sheet, table 3. (no estimates for North Dakota,

South Dakota, and District of Columbia).

Approximately 70% of migrant and seasonal farmworkers permanently reside in the US. Figure 

5, drawn from the 2000 NAWS, shows the states in which migrant and seasonal farmworkers 

tend to be domiciled (i.e., reside permanently). As Figure 5 indicates, California is the largest 

domicile state, representing 30% of all farmworkers. Twenty two percent of respondents report 

a domicile in a southeastern state, 17% report a southwestern state domicile, 12% report a 

Midwestern state domicile, 12% report an eastern state domicile, and 5% a northwestern 

domicile.22 These residential patterns underscore that domiciles differ markedly from the states 

in which workers reside for relatively brief periods of time as they travel for employment 

reasons. 

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

Medicaid and the Uninsured

Figure 5

Migrant Farmworkers by Principal 

Place of Residence

5%

12% 12%

17%

22%

30%

California Southeast Southwest Midwest East Northwest

Source: National Agricultural Workers Survey, 2000

 

22 East includes DE, KY, MA, ME, NC, NJ, NY, PA, TN, and WV; Southeast includes AL, AR, FL, GA, LA, and 

MS; Midwest includes IA, KS, IL, IN, MI, MN, MO, NE, OH, SD, and WI; Southwest includes AZ, OK, and TX; 

and Northwest includes CO, ID, OR, WA. California is the only state that is reported separately. 

9
Work Patterns. The NAWS data indicate that among migrant and seasonal farmworkers, 24% 

indicate they had at least two farm jobs more than 75 miles apart. The remaining 76% report that 

they shuttle to two or more crop locations at least 75 miles from their residence. 

Demographic Characteristics. Figure 6 shows that migrant and seasonal farmworkers are 

overwhelmingly foreign-born and as a group tend to speak and read little or no English. Six 

percent of NAWS respondents identify themselves as U.S. born, while 67 percent identify 

themselves as first generation farmworkers.23 

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

Medicaid and the Uninsured

Figure 6

Migrant Farmworkers:

English Skills and Country of Origin

87% 90% 92%

67%

Speak little to no

English

Read little or no

English

Born in Mexico First generation

migrant worker

Source: National Agricultural Workers Survey, 2000

Most migrant and seasonal farmworkers are male, and 52% are married (Figure 7). Somewhat 

fewer than half of all migrant and seasonal farmworkers have children, while about half live in 

households with parents and other family members. Among migrant and seasonal farmworkers 

with children, 66% migrate with their children and an estimated 250,000 children migrate with 

their parents each year. 24

 

23 First generation migrants report parents did no farm work. 24 National Center for Farmworker Health, Maternal and Child Health Fact Sheet (Buda Texas) (Accessed 

September 6, 2004 at http://.www.ncfh.org) 

10
K A I S E R C O M M I S S I O N O N

Medicaid and the Uninsured

Figure 7

Migrant Farmworkers:

Gender and Family Composition

88%

52%

44% 46%

Male Married Parent with

Children

Live with Parents

or Other Relatives

Source: National Agricultural Workers Survey, 2000

Poverty among migrant and seasonal farmworker families is very deep. In 2000, U.S. workers 

earned a median annual income in excess of $42,000.25 Figure 8 shows that the 2000 median 

income of migrant and seasonal farmworkers stood at $6,250, even as they reported working 5 to 

6 days a week. Further analysis of income data show that 91% of migrant and seasonal 

farmworkers reported annual income below $15,000 in 2000, while 56% reported earnings lower 

than $5,000. Income trends drawn from NAWS data show the proportion of migrant and 

seasonal farmworkers with annual family incomes 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

Medicaid and the Uninsured

Figure 8

Migrant Farmworkers:

Median Annual Income

$6,250

$42,000

Migrant and Seasonal

Farmworkers

U.S. Workers

Source: National Agricultural Workers Survey, 2000

 

25 U.S. Census Bureau. http://www.census.gov/hhes/income/income00/inctab1.html (Accessed September 2004) 

11
B. Health Coverage, Utilization, and Status 

Health Coverage. Compared to workers generally, migrant and seasonal farmworkers and their 

families are overwhelmingly uninsured. Figures 9 and 10 illustrate the extent to which

farmworkers and their families lack coverage. In 2000, 85% of migrant and seasonal 

farmworkers were completely uninsured, compared to 37% of all low-income adults nationally 

(i.e., adults with family incomes at or below 200% of the federal poverty level).26 Ten percent of 

migrant and seasonal farmworkers reported private coverage, while 5% reported coverage 

through Medicaid. Children of migrant and seasonal farmworker families similarly were 

pervasively uninsured compared to low income children nationally; nearly 90% were completely 

uninsured in 2000, compared to 22% of all low-income children that year.27 Trends over time, as 

shown in the NAWS data, suggest that despite the advent of major Medicaid reforms for 

children, Medicaid coverage among children in migrant and seasonal farmworker families 

remains very low, although Medicaid represents the dominant form of health insurance for 

migrant and seasonal farmworker children. 

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

Medicaid and the Uninsured

Figure 9

Migrant Farmworkers:

Health Coverage for Adults

5%

10% 18%

33%

85%

37%

12%

Migrant and Seasonal

Farmworkers

Low-Income Adults Nationally

(<200% FPL)

Uninsured

Other

Private

Public

Note: Low-income is less than 200% of the federal poverty level $2,682 per

month for a family of three.

Source: National data from Kaiser Commission on Medicaid and the Uninsured,

”Health Insurance Coverage in America: 2000 Data Update,” February 2002;

Farmworkers estimates from 2000 NAWS.

 

26 U.S. Department of Labor, “National Agricultural Workers Survey”(Release 3.0) and Kaiser Commission on

Medicaid and the Uninsured, “Health Insurance Coverage in America: 2000 Data Update,” February 2002. 27 U.S. Department of Labor, “National Agricultural Workers Survey”(Release 3.0) and Kaiser Commission on

Medicaid and the Uninsured, “Health Insurance Coverage in America: 2000 Data Update,” February 2002. 

12
K A I S E R C O M M I S S I O N O N

Medicaid and the Uninsured

Figure 10

Migrant Farmworkers:

Health Coverage for Children

10%

78%

90%

22%

Children in Farmworker Families Low-Income Children Nationally

(<200% FPL)

Uninsured

Insured

Note: Low-income is less than 200% of the federal poverty level $2,682 per 

month for a family of three.

Source: National data from Kaiser Commission on Medicaid and the Uninsured,

”Health Insurance Coverage in America: 2000 Data Update,” February 2002;

Farmworkers estimates from 2000 NAWS.

Utilization of Health Care. Migrant and seasonal farmworkers and their families use very little 

health care compared to other low-income people. The 2000 NAWS data indicate that only 20% 

of migrant and seasonal farmworkers reported the use of any healthcare services in the preceding 

2 years. Although the NAWS does not inquire about related reasons for use or nonuse of 

services, it does ask about barriers. Survey respondents identified cost and language as the two 

most significant barriers to care, as borne out by smaller studies of farmworkers in selected 

states.28 Additionally, one study found that only 42% of farmworker women reported early 

prenatal care (i.e., within the first 3 months of pregnancy) compared to 76% nationally (Figure 

11). Researchers have noted that even where services are available, extreme mobility means that 

families may leave an area before treatment is furnished. 29 Extreme mobility leaves families at 

particularly great risk for limited and interrupted health care. 

 

28 M. Perez, G. Reuben, H. Pinzon, "Northern California Hispanic migrant farm workers health status: a case study," 

Migration World Magazine, 26(1-2), 1998. 29 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. 

13
K A I S E R C O M M I S S I O N O N

Medicaid and the Uninsured

Figure 11

Migrant Farmworker Families:

Utilization of Health Care

42%

76%

Migrant Farmworkers United States

SOURCE: Maternal Care Coordination for Migrant Farmworker Women: Program 

Structure and Evaluation of Effects on Use of Prenatal Care and Birth Outcome 

(Resource ID# 2988)

Percent of pregnant women that sought care during the 

first trimester of their pregnancy:

Health Status. The limited use of health services by migrant and seasonal farmworkers cannot 

be attributed to a low need for health care. Indeed, by virtue of their extreme poverty, their 

mobility in search of work, and hazardous living and housing conditions under which they work, 

migrant and seasonal farmworkers have an extraordinary need for health care. Farmworkers are 

at elevated risk for an enormous range of injuries and illnesses. According to a review of data 

from the Bureau of Labor data, while agriculture-related employment comprised only 2% of 

overall employment, agricultural and livestock-related production, along with agricultural 

services, comprised 13% of all occupational deaths over a 1994-1999 time period.30 Risks arise 

as a result of work-related conditions, the use of equipment, and exposure to chemicals, with 

resulting elevated rates of chronic conditions, musculoskeletal injuries, serious disabilities, and 

fatalities. 

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

Respiratory illnesses such as asthma and bronchitis are relatively common, as are skin problems, 

exposure to infectious diseases such as tuberculosis and parasites, and diseases related to 

unsanitary and close living conditions in substandard housing.32 Higher rates of cancer are 

suspected, as are elevated rates of eye and vision problems.33 Pesticide exposure and its 

consequences represent one of the best documented risks, although experts believe that there are 

insufficient studies examining the effects of multiple pesticide exposure. 34 

The families of farmworkers also appear to have poor health status and to be at high risk for 

illness. Exposure to chemicals can result in contamination, which, in turn, is brought home to 

 

30 Alice Larson, Environmental/Occupational Safety and Health, “ Migrant Health Issues Monograph Series 

(National Center for Farmworker Health, Buda Texas, 2001) (Accessed September 6, 2004 at http://www.ncfh.org) 31 Id. 32 Id. See also Christopher Holden, “Housing,” Migrant Health Issues (National Center for Farmworker Health, 

Buda Texas, 2001) (Accessed September 6, 2004 at http://www.ncfh.org) 33 Id. 34 Id. 

14
the children of migrant and seasonal farmworkers.35 Research has documented a rate of selfreported fair-to-poor health status among farmworker mothers that stands 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 diminished weight gain, a nearly one-in-four 

incidence of undesirable birth outcomes, elevated rates of low birthweights and preterm births 

among farmworkers.37 

Health problems among farmworker children are extensive, with studies showing a high 

incidence of intestinal parasites, severe asthma, 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 twice 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 health centers received funds specifically 

targeted to meet migrant health needs; these centers served 670,000 migrant and seasonal 

farmworkers and their families. Another 247 health centers, which do not receive a specific 

migrant subsidy, served an additional 39,000 farmworkers and family members. That year, 44% 

of all health centers served 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 receiving 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. 

15
K A I S E R C O M M I S S I O N O N

Medicaid and the Uninsured

Figure 12

Geographic Distribution of 

Migrant Health Centers

None

(10 states & DC)

1-2 Centers

(28 states)

3-5 Centers

(7 states)

6-10 Centers

(2 states)

National Total of 843 Health Centers

Source: Health Resources and Services Administration, Uniform Data System, 2002

> 10 Centers

(3 states)

The vast majority of health centers receiving migrant funding (110 out of 125 in 2002) are 

“mixed grant” centers; that is, they also receive general health center grants. This dual status 

permits health centers to serve the general population, as well as furnish continuing care to 

families after they leave farm labor. Approximately 27% of patients served at “mixed grant” 

centers nationally are migrant and seasonal farmworkers and their family members. In terms of 

both insurance distribution of patients and revenue distribution, these “mixed grant” health 

centers resemble those that do not receive migrant grants. At the same time, mixed grant health 

centers also offer services which are tailored to migrant and seasonal farmworker families, in 

particular, outstationed services in accessible locations, Medicaid enrollment assistance, and 

services which are geared to addressing the unique health conditions and needs of migrants (see 

text box on next page). 

Some 15 migrant health centers were funded exclusively as migrant health centers, that is, 

without mixed grants. These 15 health centers were located in Alabama, Georgia, Iowa, Illinois, 

Kansas, Kentucky, Massachusetts, Maine, Michigan, Minnesota, Montana, New York, North 

Carolina, South Carolina, and Wyoming. Although these centers are as likely as their “mixed 

grant” colleagues to be located in rural areas and provide similar services, the 15 migrant health 

centers tend to be far smaller. Approximately two-thirds reported fewer than 5,000 patients and 

only one exclusively migrant health center reported serving more than 10,000 patients. 

16
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, Intercare has grown into a six-site health network serving 

more than 40,000 patients. More than one in four Intercare 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 obstetrical care; maternal and infant support services; 

breast and cervical cancer screening and testing; 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 Medicaid. 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 assistance has been a central feature of Intercare’s patient 

support services. Farmworker families are included in this support 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 assistance 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 documents related to eligibility determinations, and ensuring that applicants are 

able to get to local welfare offices to complete the enrollment process. The state requires in-person 

appearances by all applicants and does not outstation eligibility 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 inadvertently enrolled in managed care. Because of 

confusion that surrounds Medicaid enrollment, farmworker families incorrectly assume that they must 

enroll in managed care plans, even though the plan networks are not accessible 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 disenroll from managed care and reenroll in the basic 

Medicaid fee-for-service system before leaving the area.

Figure 13 shows the age distribution of farmworkers and their family members served at health 

centers. Because adults are more likely to travel and work, a large proportion of migrant health 

center patients are working-age adults. However, 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%). 

17
K A I S E R C O M M I S S I O N O N

Medicaid and the Uninsured

Figure 13

Migrant and Seasonal Farmworker

Health Center Patients by Age

Elderly

1%

Children 

<19

38%

Adults 19-

64

61%

Source: Health Resources and Services Administration, Uniform Data System,

2002. Estimates from 13 health centers that serve only migrant users.

Health centers that do not rely solely on migrant health grants report that approximately 35% of 

their total patients receive Medicaid. The picture is much different at health centers funded 

solely by migrant health center grants. As Figures 14 and 15 show, health centers receiving 

migrant-only grants are far more likely than health centers generally to report uninsured patients, 

and experience vastly reduced levels of Medicaid revenues. In health centers that receive both 

general and migrant grants, migrant and seasonal farmworkers comprise 27% of the total 

registered patient population; this relatively low presence helps explain why “mixed grant” 

health centers continue to register relatively high proportions of Medicaid patients. Other factors 

may be the greater likelihood of “mixed grant” health centers to see Medicaid-eligible migrants 

and the resulting greater level of assistance furnished in Medicaid enrollment. 

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

Medicaid and the Uninsured

Figure 14

Health Center Patients by Payor Source 

and Health Center Type 

36% 36%

7%

39% 39%

25% 25%

1%

92%

All 843 Health Centers 110 Health Centers With

Migrant and Other Funding

15 Health Centers With

Migrant Funding Only

Other

Uninsured

Medicaid

Source: Health Resources and Services Administration, Uniform Data System, 2002.

18
K A I S E R C O M M I S S I O N O N

Medicaid and the Uninsured

Figure 15

Health Center Revenue by

Health Center Type 

35% 38%

25% 25%

20% 11%

30% 26% 11%

7%

2%

80%

All 843 Health Centers 110 Health Centers With

Migrant and Other Funding

15 Health Centers With

Only Migrant Funding

Other

State and Local Grants

Federal Grants

Medicaid

Source: Health Resources and Services Administration, Uniform Data System, 2002.

Reflecting their patient distribution, health centers receiving only migrant grants are more 

dependent on federal funding to care for a largely uninsured migrant and seasonal farmworker 

population. Figure 14 shows that, in 2002, health centers operating exclusively as migrant health 

centers reported that only 2% of their operating revenues came from Medicaid. In contrast, other 

health centers reported Medicaid accounted for more than one-third of their operating revenues. 

Unlike health centers generally, for whom Medicaid is the largest source of financing, migrantonly health centers exist virtually exclusively on grants; their modest size offers a further 

suggestion of the role played by Medicaid in permitting health centers to grow and expand their 

services. 

V. BARRIERS TO MEDICAID COVERAGE

Reforming Medicaid to improve its performance for migrant and seasonal farmworkers and their 

families has been a program focus for some 30 years. The literature on farmworkers and 

Medicaid42 points to a set of problems which are related, specific, longstanding, and well-

 

42 See, e.g., Mary Kennesson, Improving Health Service Access for Medicaid-Eligible Migrant Farmworkers 

(Center for Health Care Strategies, Princeton N.J., 2000); National Health Policy Forum, Policy Options for Serving 

Migrant Children and Families Under Medicaid and SCHIP (The George Washington University, Washington

D.C., 2000); Sara Rosenbaum, Options for Expanding Publicly Financed Health Coverage of Migrant Farmworkers

and their Families, (National Association of Community Health Centers, Washington D.C. 2000); Elizabeth

Kapeller, Farmworker Access to Safety Net Insurance Programs: Harvesting Solutions to a Thirty-Seven Year Old 

Issue, (National Center for Farmworker Health, Buda TX, 2003); E. Gallardo and V. Huang, Expanding Access to 

Health Care Services: A Policy Brief (California Primary Care Association, Sacramento, CA 2002); National 

Immigration Law Center, Guide to Immigrant Eligibility for Federal Programs, 4th ed. (Los Angeles, CA, 2002);

Judith Moore, Policy Options for Serving Migrant Children and Families Under Medicaid and SCHIP (National 

Health Policy Forum, Washington D.C. 2000). In addition, the Congressionally mandated National Advisory 

Council on Migrant Health, the Migrant Clinicians Network (a special network of health center clinicians who 

specialize in farmworker healthcare), and others have recommended changes. In addition, the Health Care 

Financing Administration (now the Centers for Medicare and Medicaid Services (CMS) commissioned a study in

the early 1990s to examine the feasibility of Medicaid reforms. The results were published in 1993. George E. 

Wright, Nancy Fasciano and Hilary Frazer (Mathematica Health Policy), Ian Hill and Beth Zimmerman (Health 

Systems Research), and Nancy Pindus (Urban Institute), Feasibility Study to Develop a Medicaid reciprocity 

19
recognized. Although there are few systematic studies of farmworker Medicaid eligibility and 

enrollment barriers, information gathered by researchers, as well as repeated and widespread 

anecdotal evidence supplied over nearly four decades 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 farmwork serves to elevate and intensify their effect, while adding 

others attributable to barriers created 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 problematic for migrant and seasonal farmworkers. 

One problem is the lack of categorical eligibility for certain groups of low-income people, in 

particular, childless working-age adults without disabilities. A second problem is financial 

eligibility barriers. States have considerable discretion in how they define and count income and 

resources. Use of monthly budgeting rules and restrictive asset tests 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 extremely 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 prohibit all but emergency Medicaid coverage 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 Medicaid 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, extensive verification requirements, and limited to no 

language assistance. 

Barriers related to the lack of state residency. Medicaid is a state-based program; state 

residency requirements, coupled with the problems described above, can lead to nearly 

insurmountable Medicaid access problems for farmworkers. State residency problems arise in 

one of two ways. Medicaid recognizes state residency among persons who live in a state for 

work-related purposes. However, anecdotal evidence 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 regional facilities (e.g., a regional children’s hospital), or to persons 

who travel for brief periods of time and face emergency health care needs. 

Federal regulations appear to require states to pay for medical care furnished out of state where it 

is a general practice for residents of certain state localities to use 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 Insurance 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) 

20
state.44 These rules seemingly could apply to farmworkers who live in certain localities of a state 

and who customarily travel to certain other states for work purposes. In the absence of this 

“portability” provision, farmworker families appear to be caught between two diametrically 

opposed problems. On the one hand, farmworkers seeking to apply for Medicaid as they change 

their state of residence for work related reasons 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, farmworkers 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 emergencies. Compounding this restriction 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 contained specific authority for 

grants to serve migrant and seasonal farmworkers.46 In 1979, the Carter Administration 

promulgated regulations which revised the definition of state residence 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 related reasons (either with a job or seeking one). 

No interpretive guidelines applying out-of-state coverage and payment 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 expanded definition of residency. Furthermore, 

community health providers frequently report that even where employment-related residence is 

recognized, the application process poses such serious problems that the residency change alone 

has little impact. 

Moreover, there is evidence that residency-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 each move. 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 endanger 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 state.” 42 C.F.R. §431.52 (b)(4) 45 P. L. 85-61 (85th Cong., 2d Sess.) 46 P.L. 

47 California Primary Care Association, Policy Options Related to the Medicaid Portability for Migrant 

Farmworkers Project (Sacramento, CA, 2002) 

21
letter clarifying that such procedures violate Medicaid statewideness requirements,48 along with 

sustained advocacy, California officials issued a directive to county officials clarifying their 

obligations to allow county-to-county movement 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 notable for having developed a reciprocal rapid 

enrollment system, which automatically extends coverage to any family with a valid out-of-state 

enrollment card, using a shortened application process. Enrollment lasts until the date on which 

the out-of-state enrollment expires, at which time families who continue in-state reapply for 

benefits using normal in-state procedures. Wisconsin also has adopted an income eligibility 

calculation methodology that permits families to annualize 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 portability demonstration project for 

migrant farmworker children. Under the demonstration, the state assured coverage on an out-ofstate basis when migrant farmworker children traveled, signing up out-of-state providers and 

compensating them for customary, not merely emergency services.51 

The pilot project achieved significant “upstream” participation by out-of-state physicians and 

hospitals in several dozen states and involved only a small, manageable number of children. 

State efforts to take the model “to scale” for all migrant farmworker children failed when no 

satisfactory full-risk contractor could be identified.52 The effort also revealed small but 

important state-to-state variations in children’s eligibility and benefit packages, program 

management problems created by the lack of a unique 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, certain lessons can be gleaned. The first is that there are indeed 

handles for making Medicaid work better for eligible 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 available in another state.” 42 C.F.R. §431.52(b). 52 Id. 

22
state uses the Wisconsin approach or the Texas strategy, there are ways to facilitate 

farmworkers’ access to Medicaid coverage. Wisconsin relies on fast-track access to enrollment 

in strategic locations (e.g., migrant health clinics, 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 Wisconsin model of simply exchanging an in-state 

card for an out of state card for the duration of eligibility is hindered by varying eligibility and 

asset rules across the states. The Texas model requires 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 feasible. CMS and HRSA could embark on a “Wisconsin” strategy 

for states that opt to fast-track enrollment and adopt eligibility standards suitable to families 

whose incomes are derived through seasonal agricultural work. Guidelines explaining a fast 

track enrollment option, options for altering existing eligibility criteria, and identifying health 

centers and other farmworker programs to serve as enrollment sites, all might provide a useful 

stimulus. 

In order to facilitate the Texas 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 centers 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 coordinated strategy, states would have two feasible 

approaches to easing entry into Medicaid and better 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 evident 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 population limited at best. A more long 

term solution might be to couple Medicaid access 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 means of enrollment. 

23
VII. CONCLUSION 

For over 40 years, the health of migrant and seasonal farmworkers 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 the analysis

presented here suggests the importance of an intervention and a range of viable options, including 

more energetic Medicaid interventions and other programs to complement 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 borders and state-based healthcare programs. It is 

also evident that additional data would greatly inform any effort to expand insurance coverage 

for migrant and seasonal farmworkers. 

24
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