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Implementing the Affordable
Care Act – Making the Most for
Agricultural Workers
Joel Diringer, JD, MPH
November 2010
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Acknowledgements
Many thanks to the agricultural industry and
worker representatives in California’s Fresno,
Monterey and Ventura Counties.
Funding from:
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Purpose and process
• To develop a consensus among local agricultural industry and
workforce coalitions on strategies to ensure that
farmworkers receive the fullest benefits from the Affordable
Care Act
• Coalitions include representatives from
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growers – individuals and associations
farm labor contractors
agricultural worker advocates
migrant farmworker clinics and other providers
health insurance – public and private
policy analysts
county health officials
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California’s agricultural workforce
• Approximately 650,000 persons -- 36 percent of the
nation’s farmworkers –– are employed in California
o Nearly all are foreign born, primarily from Mexico
o One-third migrate for work around the state and country
o Nearly two-thirds are married, and one-half have children
o Most (57+%) do not have work authorization
o Nearly all are very low-income
o 57 percent of California farmworkers work fewer than 150
days per year in agriculture
o An estimated 37 percent of farmworkers are employed by
farm labor contractors who contract with growers to
provide crews for particular operations, (e.g. pruning,
harvesting, weeding, etc.)
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Health of the agricultural workforce
• 70% have no health insurance – fewer than 15% have
employer supplied coverage
• Half of farmworkers used no health services in the US in
the past two years – most (83%) said care was too
expensive
• Nearly one in five male farmworkers had at least two of
three risk factors for chronic disease: high serum
cholesterol, high blood pressure, and obesity
• The hazards of farm work lead to occupational injuries
and diseases
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The agricultural industry
• Agricultural employers range from large multinational
growers to small family farms who sell on the local market.
There are many variations in the middle such as large
coastal fresh produce growers to smaller family grape and
tree fruit farmers in the central San Joaquin Valley
• Non-grower employers include packers, processors and
shippers
• While many ag employers provide coverage to full-time
workers, far fewer are able to cover seasonal workers
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Principles for ensuring that health
reform benefits the agricultural
workforce
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Shared responsibility
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Affordable cost
•
Comprehensive scope of benefits emphasizing
prevention
•
Support for “safety net” programs and providers
•
Broad eligibility for all workers and their families
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Provision for portability and bi-national coverage
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Prevention education and beneficiary assistance
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Principles for making health reform
work for agricultural workers
1. Shared responsibility
Principle
Affordable Care Act
Agricultural employers
(including farm labor
contractors) and employees
should share in the cost of
coverage. In addition, it is
critical that there also be
public support to make health
coverage available to the lowwage workers in the volatile
low-margin agricultural
industry.
• Individual mandate to have
insurance
• “Pay or play” for large
employers
• Government subsidies for low
income workers (tax credits
and Medicaid) and tax credits
for some small businesses
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Principles for making health reform
work for agricultural workers
2. Affordable cost
Principle
Costs need to be reasonable
and affordable for employees
and employers and out of
pocket costs (e.g.
deductibles, co-payments,
etc.) should be structured to
encourage early, preventive
care.
Affordable Care Act
• Lowest income (<133% FPL)
will be enrolled in Medicaid
(legal residents only)
• Premiums and co-pays for
employees are scaled to
income; (legal residents only)
• No cost-sharing for preventive
services
• Employer costs are based
upon the market, presumably
more competitive in the
Exchange, particularly for
small business market
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Principles for making health reform
work for agricultural workers
3. Comprehensive scope of benefits emphasizing
prevention
Principle
Affordable Care Act
The benefits need to be as
comprehensive as possible to
meet as many basic needs of
families as feasible, with
special attention to
preventive and primary care,
and prescription drugs.
• The Exchange will offer four
different plans with varying
levels of benefits (to be
determined). Competition will
be based on price and quality.
• Dental and vision coverage
are not part of the basic plans
• Medicaid benefits will mirror
Exchange benefits
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Principles for making health reform
work for agricultural workers
4. Support for “safety net” programs and providers
Principle
The safety net of programs and
services from which farmworkers
and their families currently
receive care should be
protected, integrated and
strengthened.
The farmworker clinics which
provide cost effective models
should be supported and
expanded.
Public programs should be
designed to maximize the
matching funds available from
the federal government.
Affordable Care Act
• Community health centers
receive $11 billion in new
funding over 5 years to
expand capacity.
• Medicaid eligibility will be
expanded to all citizens and
legal residents below 133% of
the federal poverty level
(approx. $30,000 for a family
of 4) in 2014.
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Principles for making health reform
work for agricultural workers
5. Broad eligibility for all workers and their families
Principle
Affordable Care Act
Coverage should extend to all
agricultural employees who meet
employment related eligibility
criteria, regardless of
immigration status.
• Only citizens and legal residents may
have insurance through the Exchange
or receive full-scope Medicaid. All may
receive employer coverage.
• Coverage obligations apply to all
employees, although seasonal
employees are not counted toward
definitions of “large” and “small”
employers.
• 90 day waiting periods allowable.
• Workers with multiple employers
will presumably access coverage
through the Exchange
• Farm labor contractors are covered
as employers
Criteria need to be developed for
farmworkers who are seasonal
and work for multiple employers
during a season.
Farmworkers who are employed
by farm labor contractors must
also be covered in a plan.
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Principles for making health reform
work for agricultural workers
6. Provision for portability and bi-national coverage
Principle
Affordable Care Act
Coverage should be
geographically portable for
those farmworkers who
migrate for work and spend
time out of the state and
country. Locally based plans
need to provide for out of
area benefits. Also, any plan
should consider coverage for
workers while they are in
Mexico.
• Unclear if plans in the
Exchange will cover out of
state and out of country care.
One plan in the Exchange is
supposed to be a multi-state
plan. Employers continue to
have the option.
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Principles for making health reform
work for agricultural workers
7. Prevention education and beneficiary assistance
Principle
Affordable Care Act
To ensure appropriate utilization of
coverage and preventive services,
farmworkers should be provided
assistance in accessing services. With
the high rates of preventable chronic
conditions, the reticence to access
care, and the unfamiliarity with
health coverage, a comprehensive
beneficiary assistance should be
made available. Prevention
education and early use of health
care will not only improve health but
manage costs.
• Plans in the Exchange must
contract with navigators to
conduct outreach and enrollment
assistance. In addition, states are
required to establish an office of
health insurance consumer
assistance or an ombudsman
program to assist people with
private coverage in the individual
and small group markets.
• Employer wellness programs
can receive grants.
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Farmworker Health Coverage
under the Affordable Care Act
in 2014
Annual income
below 133%
FPL (app
$30,000 family
of 4)
Legal
authorization to
work
Annual
income above
133% FPL
(App $30,000
family of 4)
Agricultural
worker
Employer
supplied
insurance
No legal
authorization to
work
Reliant on
safety net and
emergency
Medicaid
Private
insurance
Eligible for
Medicaid
Employer
supplied
insurance (ESI)
through
Exchange (if <100
FTE)
ESI (min.
standards, max.
cost sharing)
available through
Exchange (<100
FTE)
Insurance through
Exchange if no ESI
that meets
standards
Forgo insurance;
individual pays
penalty if
affordable
insurance is
available
Free choice
voucher is
alternative to
ESI for
workers under
400% FPL and
plan costs
between 8
and 9.8% of
income
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Conclusion
• For agriculture to survive in the US, a stable and healthy
workforce is crucial.
• This means that health care for farmworkers must be available,
affordable and appropriate.
• Health reform has the potential to benefit the agricultural
workforce but it must be structured to meet the needs of
predominantly immigrant, low-income farmworkers and the
economically fragile industry in which they work.
• By emphasizing preventive and primary care delivered in culturally
appropriate, community based settings, health reform can benefit
the agricultural workforce and ensure a safe and healthy domestic
food supply.
• Critical to health reform is immigration reform.
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Discussion
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For more information
Diringer and Associates
PO Box 14822
San Luis Obispo, CA 93406
805-546-0950
joel@diringerassociates.com
www.diringerassociates.com