Demographics and Demagoguery:

Transcription

1 Demographics and Demagoguery: Implications for the Health of California Farmworkers and their Families Ed Kissam, WKF Fund Public Health Law Summit-2017 Western Region March 24, 2017, Sacramento, CA

2 California Farmworkers: An Overview 550,000 FW s with 650,000 dependents=1.2 million in population Almost all (91%) foreign-born, more than half of all FW s (56%) unauthorized, more than one-quarter (29%) are LPR, and 6% naturalized. But many mixed-status families. Rapidly aging: Direct-hire average age up from 31 to 39 in period from , Average 16 years of FW experience, few newcomers (4% w/ <1 yr. experience). More than half of FW s (58%) live in HH s with their children. About one out of ten family HH s is headed a single-parent. More than one in four FW s (28%) is a woman. Women s employment is more seasonal than men s. Days of FW/year: Up from 155 in 2000 to 205 in 2014, an increase of one-third. With average earnings of $10.09/hr., yearly farm labor earnings of about $20K. Average family annual income $20K-24K. There is much less migrancy now than in the past (<15%). FW s have worked longer with current employer (now 7 years). Less turnover (now 74% have only 1 ag employer) and less seasonality of farmwork more pre-harvest, post-harvest, semi-skilled work than in the past.

3 FW Health Insurance Coverage: (pre-aca, pre-sb 4) There s been substantial progress in recent years. -- #of FW s with health insurance increased a good deal: from 23% in 2000 to 36% in But coverage is still very low compared to overall U.S. population (93%) and even compared to overall immigrant population (78%) Of the FW s who have health insurance, one-third to a half have a policy from their employer. Coverage for work-related injury high but exact level unclear since workers who have not been injured may, in fact, be covered but not know it. Unauthorized FW s are much less likely than others to be covered by an employer-provided health policy (only 9% covered) probably because more are short-term seasonal workers. Younger workers are also left out (only 11% covered). FWs employer-provided policies don t always cover spouses (although about three-quarters do) or children. Medi-Cal is the primary source of health insurance for FW children, most of whom are US-born (covering 78% of those who have insurance). Another 13% of children were covered by an employer-provided policy and 9% by an insurance policy a parent purchased themselves.

4 Current FW Health Care Utilization Most recent visit for health care (past 2 yrs.): FW or family member Percent No visit 50% Community/migrant health center 13% Private medical provider (MD or clinic) 26% Hospital 4% Dentist 7% Payment for visit Out-of-pocket 22% Medi-Cal/Medicare 11% Employer-provided health plan 10% Self-paid plan 1% Public clinic-no charge 4% Other 2% No visit/no payment 50%

5 Factors currently affecting FW health care access Low earnings and lack of health insurance are major barriers to seeking care but lack of transportation, clinic hours, and language are also an issue for some FW families. Understandably frequency of access and where FW s go for care is very sensitive to cost. (Insured workers are >50% more likely than uninsured to visit a health care provider). The ACA employer mandate is not very useful for most FW s exemptions from mandate for small employers and exemption for seasonal workers. Moreover, many ACA-compliant employers have probably provided coverage already. And of course, unauthorized workers are not eligible to buy insurance on a state exchange or receive subsidy. Overall, they are much less likely to have insurance and less likely to visit a health care provider (odds ratio unauthorized vs. authorized worker having visited=.063) Worker turndown rate of insurance offered by employer is probably high. Employee contribution at 9.5% of $20K annual earnings is almost $2K. For Bronze policy with $5K deductible not a good deal! SB4 extends coverage to the 10%-15% of FW children who are undocumented. Almost all FW families with children are income-eligible for Medi-Cal FQHC s play an important role, as does limited-scope Medi-Cal, especially for undocumented.

6 Major Modes of Trump Administration Policy Impact on FW Health Curtailed Use of Health Care Services due to Enforcement Policy Gaze of surveillance decreases FW family willingness to seek health care constraints on physical access and fear of consequences if health care is secured. Primarily recently-arrived FW s (post-2013) but still broader impacts due to elimination of prosecutorial discretion and random enforcement. Employment Policy Mandatory E-verify would have negative impact on unauthorized FW s earnings due to inability to secure new jobs makes either health insurance purchase or selfpayment for health services less feasible. Health Policy and Funding Funding cuts for FQHC s and elimination of Expanded Medicaid threaten to erode service delivery system. Repeal of ACA insurance exchange provisions increases costs for mostly middle-aged LPR and citizen FW s. Stress from anti-immigrant messaging and actions Direct negative impact of greatlyheightened stress on family well-being and functioning. Most immediate impacts are psychological. Medium-term are physiological and include long-term epigenetic changes on current FW family members and their children. Multi-generational effects are a major concern. Degraded living/working conditions Relaxation of workplace health and safety standards increases work-related injuries and illnesses. Potential increase in pesticide exposure. Longterm health impact of relaxed air quality standards on asthma in San Joaquin Valley. Budget cuts to NIOSH jeopardize its provision of training and capacity-building.

7 Details on New Administration Initiatives and Impacts Admin Policy Initiatives Level of Impact Likelihood of impact and Time Frame Interior Enforcement Executive Order and DHS Implementation Memo Protecting Taxpayers draft Executive Order Protecting American Jobs draft Executive Order Eliminate Expanded Medicaid (and CHIP?) Uncertainties re funding for FQHC s Big decrease in health care utilization from messaging at least Catastrophic decrease in health care utilization. Level depends on antiand pro-immigrant messaging Decrease in FW already-low earnings, more barriers to self-pay Major negative impact, especially for kids and middle-aged Many FW HH s in % of poverty range, state efforts offset? At least temporary increased funding, but medium- and long-term loss of revenue Already in place eventual impact depends on ICE funding, litigation, targeting of apprehensions workplaces? Schools? Implementation uncertain but messaging re public charge provisions already worrisome. Extensive litigation! Implementation uncertain political opposition and extensive litigation, slow trajectory, includes threat to census Level uncertain; bipartisan political opposition possible delay to 2020, also depends on Governors races in 2018, litigation from various stakeholders Likely impact in FY17 (possibly more direct funding, but loss in preventive health revenue) and huge impacts by FY19 from loss of Medicaid and ACA policy-holders

8 The Interior Enforcement EO and DHS implementation memo: Uncertainty and Anxiety Elimination of priorities for removal has put ALL unauthorized FW s and mixed-status HH s at risk. Randomness augments sense of risk. If worksite raids begin, will greatly amplify anxiety. Well-publicized apprehensions of low-priority unauthorized immigrants have already greatly escalated stress and begun to curtail trips to some worksites and to clinics. Immigrants in Priority 2 (3+ misdemeanors or unlawful entry/re-entry since 2014) and Priority 3 categories (final order of removal). About 10% of the population likely to have an even higher sense of risk than others (justified as they do have less legal recourse) Expansion of expedited removal major source of anxiety (due to lack of recourse) for undocumented FW s who have been in the U.S. less than 3 years: about 8% of the workforce. Expanded definition of criminality: Entry without Inspection (EWI), use of false documents to obtain work, as well as arrest or alleged gang affiliation even without being charged or convicted of a crime.

9 The Protecting Taxpayers EO: Extending Targeting to Settled Immigrants Threatens deportation of immigrants who have used means-tested programs. This greatly heightens overall community anxiety because it targets legal permanent residents (29% of the FW population) as well as unauthorized immigrant families. Broader definition of means-tested programs includes major ones with widespread use in low-income communities e.g. school lunch programs, SNAP, Medi-Cal, possibly WIC. Unauthorized immigrants will (with reason!) fear being prioritized for deportation or barred from future legalization (or other status adjustment options-e.g. U visa, VAWA, family petition) due to their US-born children being enrolled in Medi-Cal, having receiving emergency services, or pregnant women having used limited-scope Medi-Cal Extent of impact on health care service utilization among middle-aged legalized programeligible FW s is unclear but would almost certainly be significant in part because program utilization might be seen as impacting determinations re family visa petitions. Would receipt of means-tested state-funded services affect future USCIS public charge determinations? Theoretically, not. But not clear. Consequently, possible apprehension even after California s pro-active pro-immigrant initiatives. Health care service utilization will nose-dive especially among the vulnerable populations currently enrolled in maternal and child health programs. Negative impacts on individual FW health, community health, and community health center revenue.

10 Potential Impacts: Protecting American Jobs EO Mandatory E-Verify curtails employment options for unauthorized immigrants. Workers would (probably) be able to remain with their current employers but not change jobs. Major negative impacts on agribusiness would have ripple effect on entire communities, affecting U.S. non-ag businesses and U.S. citizens as well as immigrant farmworkers. About 24% of California farmworkers (those with >1 employer each year) would lose >$2000/yr. in farm labor earnings. And 17% of FW s would lose >$1,000/year in offseason non-farm employment earnings. However, mandatory E-verify implementation will face massive political opposition. Even if some implementation is viable, a phase-in period would be required. Currently, studies are the proposed first step.

11 Poison Pill in the Protecting American Jobs EO: Census Question on Immigration Status The draft EO seeks to add a new question to the 2020 decennial census on immigration status part of efforts to suppress immigrant response and, thus, decrease political representation in such as CA (population is 27% foreign-born highest concentration in US) Draft EO is technically flawed due to reference to long form census (which was abandoned in 2000) but could be remedied by making reference to American Community Survey (ACS) which replaced the long-form decennial sample An ACS question on immigration status would have a dramatic negative impact on response and consequent loss of federal funding where allocation is driven by census data most notably Medicaid. For California, if immigration status question added, loss of at least $1 billion/yr. in state federal health-related funding in decade (actual loss depends on impact in other states, possible changes in allocation formulas, etc.). Courts would very likely enjoin this effort -due to 2016 Supreme Court Evenwel decision, the constitutional mandate for a decennial census, and the doctrine that the ACS is an integral component of the constitutionally-protected decennial census. However, a 1999 Supreme Court decision about use of statistical adjustment introduces a measure of uncertainty.

12 Dynamics of Trump administration enforcement policies and practices Scattershot effect Policies nominally targeted toward deportation of unauthorized immigrants will have wider community-level impact-- on citizens and LPR s due to the prevalence of mixed-status families. (About 2out of 5 unauthorized immigrants is part of a mixed-status HH). Shock and awe approach The administration s strategy is based on messaging- designed to catalyze self-deportation. Recent ICE apprehensions are real-world street theater--signaling/messaging to increase the psychological costs of remaining in U.S. Starve them out approach Constrain employment and earnings of individual unauthorized immigrants by implementation of E-verify and constrain state funding for programs serving immigrants (by suppressing census response) and local funding (via retribution against sanctuary cities) Family stress will be greatly increased. For better or worse, most FW families will, hunker down due to many practical and psychological barriers to returning home. Self-deportation strategy will not work but will have huge impact on family well-being

13 Potential impact of budget cuts sought by the administration and/or Republicans in Congress About 30% of FW HH s eligible for Medi-Cal have incomes at % of poverty. Loss of expanded Medicaid makes them and their currently-eligible children ineligible for Medi-Cal. Elimination of expanded Medicaid seems highly contentious, unpredictable. The current bill (American Health Care Act--AHCA) eliminates expanded income eligibility by About 100,000 FW children currently eligible for federally-funded Medi-Cal might become income-ineligible. The state might cover them under Health for All Children provisions currently in place for undocumented children but the cost would be substantial. Currently AHCA includes increases (+$422 million in FY17) in FQHC funding (in part to offset hospital opposition to ACA repeal). But the increase is offset by elimination of PPHF funding ($931 million which includes funding for immunizations, diabetes prevention, REACH). Given the CBO estimate of 14 million low-income families losing coverage immediately, proposed augmentation is likely to be inadequate. A major unknown issue is state response. Recent analyses indicate that deletion of the ACA individual mandate would shrink the pool of insurance subscribers and increase individual policy costs by about 15%, even if state exchanges are allowed to continue. Already unaffordable individual insurance would become more so. Stay tuned! Negotiations ongoing, provisions volatile! Outcome unknown!

14 An Example of Public Health Impact from Decrease in Service Utilization: Diabetes Incidence of diabetes among working-age FWs: 8.7% (Castaneda et al 2015) Nationally, about half of diabetes diagnoses are in the working-age population (CDC). So, ideally, about 4% of the working-age FW population would be diagnosed via quality primary health care. But current FW health care utilization is already very low. Only 50% of FWs have gone to a provider in past 2 years as compared to the national rate of 83% for Hispanics (2014 NHIS). Assume the Interior Enforcement EO decreases 2-year rate of health care utilization by 5%, that the Protecting Taxpayers adds an additional 10%, and tightening of Medi-Cal income eligibility due to loss of expanded Medicaid by another 10%: Projected decrease in 2-year health care utilization rate down to 25% (half of the current rate). Lowered FW income due to mandatory E-verify impact on earnings and likely increase of privately-purchased health insurance further constrains health care use. Consequent decrease in diabetes diagnoses of about 2%=12,000 undiagnosed diabetes cases in California FW population. Similar impacts on diagnosis of other cardiovascular disease factors. Also negative impacts on prenatal care. Also decrease in cancer detection in middle-aged population.

15 Impacts on individual FW s and families access to quality health care Most problematic Decreased access to health care for diagnosis of and treatment of prevalent chronic health issues (e.g. pre-natal care, diabetes diagnosis, CVS diagnosis, cancer diagnosis). Impact likely to increase as FW population ages. Almost as serious psychological, physiological, and epigenetic impacts of greatly heightened family stress. Possible impacts on behavioral health: increased levels of family violence, substance abuse. Loss of ACA-mandated incentives for preventive health initiatives and possible FQHC revenue loss may decrease quality of health services provided by to low-income rural immigrant populations, FW s This overall analysis is based on the composition of the typical FW family. It will be important to look at distribution of impacts (e.g. on female-headed HH s vs. married couples with children, families with young vs. school-age children). Impact will also vary from town to town (e.g. those within 100 miles of border vs. others), specific configuration of county/community health service delivery system, and immigration status of sub-populations.

16 System-level Impacts: Reversing a half century of progress toward improving FW health Clear-cut evidence of anti-immigrant bias and discriminatory intent in Trump campaign, messaging, development of policies, and background documents. Courts may determine intent as being discriminatory even if not explicit in an administrative action (key issue in current Terrorism EO temporary restraining orders). Many bases for litigation. Erasing improvements in FW health care system stemming from OEO War on Poverty and first migrant health clinics, California s Rural Health Care System development to present (including passage of SB 4 Health for All Children ). Loss of occupational health care response system capacity and stalled research on distinctive health risks. A pincer assault on public health initiatives to serve FW s: discouraging willingness to seek care, decreasing FW earnings available to pay for health care, constricting access to affordable health insurance coupled with decreased funding for FQHC s Serious impacts on diagnosis of, and health care for chronic conditions in an aging FW population. Concentrated impacts on maternal-child health. Psychological and epigenetic impact of greatly elevated levels of stress. Research is urgently needed! Major state financial outlays if federal policy change isn t blocked by litigation or political pressure. Expect cascade effects (e.g. from loss of preventive health measures).

17 Solutions? Clear, careful, and strategic communication to help immigrants understand the gap between administration rhetoric/saber-rattling and actual enforcement activity will be essential. Litigation is crucial. States, municipalities, and public-interest groups have already stepped up to the plate. California s response has been, and will continue to be, a leader. But broader and innovative visualization of sanctuary policies will be needed. Current immigrant advocacy groups need help. NILC and ACLU are litigating to defeat the anti-immigrant policies but need help. Public interest legal service providers need help countering efforts to cut LSC funding. Solid policy analysis is crucial. The Center for American Progress and the Partnership for a New American Economy are working vigorously and effectively but still broader involvement will be needed. Critical need for evidence-based policy analysis to counter stereotyping and alt-right mythology about immigrants, their use of public services, and their impact on the national, state, and local economies. Experts need to speak out. Former INS Commissioners have testified and spoken out eloquently about the need for a rational system of enforcement priorities. Members of the National Academy of Sciences have spoken out against President Trump s distortion of their findings. Advocacy by professionals is necessary. Health professionals, professional organizations and associations have a huge role to play. They can communicate effectively with elected officials about impacts of misguided policies, procedures, and funding cuts.

18 Thank you! A summary bibliography is available on request from Ed Kissam (ekissam@me.com)