Access to Health Care for Migrant Farmworkers: Needs, Barriers and Remedies

Transcription

1 Access to Health Care for Migrant Farmworkers: Needs, Barriers and Remedies Rachel Gunsalus, Macalester College, MDH Minnesota Rural Health Conference June 25 th, 2013

2 (Carrol, Georges, and Saltz 2011; Jacobs and Skocpol 2010) The ACA and Immigration Politics and policymaking behind the ACA Would undocumented immigrants be able to purchase health care coverage? Provide insurance to an additional 11% (83% 94%) One third of those that remain uninsured will be undocumented 48% of migrant farmworkers are undocumented immigrants

3 (U.S. Census Bureau 1995; The World Bank 2011) Rural landscape U.S. Agricultural industry is dependent on migrant labor Estimated 3-5 million migrant workers make up a third of the agricultural industry s labor force Evacuation of the rural farmland due to post-wwi overproduction and decline Dust Bowl of the 30 s 1900: 60% of the U.S. were residing in rural areas Today: only 18%

4 Health status of MFWs Access Defined The Affordable Care Act & MFWs Research Design Findings: Barriers to Care Findings: MHSI Solutions Persisting Gaps in Current Health Policy

5 (US DOL 2010; Contreras, Duran and Gilje 2001; Hansen and Donohoe 2003; Rosenbaum and Shin 2005) Health Status of MFW a seasonal laborer that must travel more than 24 hours from their permanent residence to their job 20-35,000 farmworkers annually Occupation causes poor health Pesticides: rashes, vomiting, headaches, neurological damage, birth defects, cancer Occupational harm Low wages: Low quality housing: poor temperature control, close living quarters, communicable disease Inability to purchase and prepare nutritious food Widespread lack of health insurance throughout population

6 Access and the ACA Affordable Care Act passed March 28 th, 2010 Goals: to increase the rate of health insurance coverage and promote favorable health outcomes Population historically barred from health care services, with continuing health disparities Transient nature Ethnic composition Legal status How will the ACA affect their access to health care?

7 Health status of MFWs Access Defined The Affordable Care Act & MFWs Research Design Findings: Barriers to Care Findings: MHSI Solutions Persisting Gaps in Current Health Policy

8 Access Defined The Concept of Access, Penchansky, R. & J. W. Thomas (1981) a concept representing the degree of fit between the clients and the system

9 Access Defined Availability Volume and type of existing services Accessibility Location of supply and the location of the client Accommodation Organization of supply of resources Affordability Prices of services and providers insurance or deposit requirements Acceptability Clients attitudes about personal and practice characteristics of providers, as well as provider attitudes about acceptable personal characteristics of clients Penchansky, R. & J. W. Thomas. (1981). "The Concept of Access." Medical Care 19(2):

10 Health status of MFWs Access Defined The Affordable Care Act & MFWs Research Design Findings: Barriers to Care Findings: MHSI Solutions Persisting Gaps in Current Health Policy

11 (KFF 2012; Carrol, Georges, and Saltz 2011) The Affordable Care Act and MFWs Era of national Health Care Reform Affordable Care Act: Signed into law on March 23, 2010 Provisions that specifically affect MFWs Medicaid Expansion 2014: Optional for States Health Insurance Exchanges Increased Funding to Community Health Centers: Increasing access to health insurance options: Medicaid Expansion (2014): Nationally qualifies all individuals in households making up to 133% of the FPL 2012: $15,415 for an individual, $30,657 for a family of four NAWS data: $12,500-14,999 per individual, $17,500-19, Supreme Court case Medicaid Expansion now OPTIONAL for states Texas: will not be participating Minnesota: will, and has already undergone expansion 2011: MA covers childless adults making up to 75% of FPL

12 (KFF 2012; Carrol, Georges, and Saltz 2011) The Affordable Care Act and MFWs Personal Responsibility and Work Opportunity Reconciliation Act of 1996: Medicaid only covers U.S. citizens or legal residents who have lived in the U.S. for 5 years or more Texas: As is Minnesota: 2009, Children s Health Insurance Program Reauthorization Act allows states to expand Medicaid to cover legally-residing children and pregnant women that have been in the U.S. for less than 5 years Medicaid eligibility table for migrant farmworkers Medicaid Expansion? U.S. Citizen or legal resident living in the U.S. for 5+ years Legal resident living in the U.S. for less than 5 years Undocumented individual Texas Medicaid NO Yes, given age and income qualifications No No Minnesota Medical Assistance YES Yes, given age and income qualifications Only pregnant women and children (due to CHIRPA) No

13 The Affordable Care Act and MFWs Era of national Health Care Reform Affordable Care Act: Signed into law on March 23, 2010 Provisions that specifically affect MFWs Medicaid Expansion 2014: Optional for States Health Insurance Exchanges Increased Funding to Community Health Centers: Increasing access to health insurance options: Health Insurance Exchanges Citizens and legal residents making between % FPL eligible for an exchange-created tax credit Do not discriminate on account of years lived in the U.S.

14 (National Association of Community Health Centers 2010) The Affordable Care Act and MFWs Era of national Health Care Reform Affordable Care Act: Signed into law on March 23, 2010 Provisions that specifically affect MFWs Medicaid Expansion 2014: Optional for States Health Insurance Exchanges Increased Funding to Community Health Centers: Additional funding to Community Health Centers Est. by the Migrant Health Act, 1966 ACA: $11 billion distributed by HRSA Increase health care access to 20 million + especially in rural areas HRSA granted Migrant Health Service, Inc. with $90,000

15 The Affordable Care Act and MFWs U.S. Citizen or legal resident living in the U.S. for 5+ years Legal resident living in the U.S. for less than 5 years Undocumented individual Texas Medicaid Yes, given age and income qualifications No No Minnesota Medical Assistance Yes, given age and income qualifications Only pregnant women and children (due to CHIRPA) No Health Insurance Exchange tax credit Yes, given income qualifications Yes, given income qualifications No Community Health Centers Yes Yes Yes

16 The Affordable Care Act and MFWs Era of national Health Care Reform Affordable Care Act: Signed into law on March 23, 2010 Provisions that specifically affect MFWs Medicaid Expansion 2014: Optional for States Health Insurance Exchanges Increased Funding to Community Health Centers: Features of Health Care Reform Provisions Minnesota: qualifies citizens/legally residing >5 yrs up to 133% of the FPL Texas: will not participate in Medicaid expansion Tax credits given to citizens and legal residents between % FPL MHSI received two HRSA grants totaling $90,000 in 2011, 2012

17 Health status of MFWs Access Defined The Affordable Care Act & MFWs Research Design Findings: Barriers to Care Findings: MHSI Solutions Persisting Gaps in Current Health Policy

18 Research Design Migrant Health Services, Inc. Based in Moorhead, MN Nine clinics (including two mobile units) Primary care services Texas Medicaid provider through the Texas Migrant Care Network Six interviews with staff from four clinics of MHSI Included members of administration, medical personnel (e.g. nurse practitioners), and outreach workers Interview questions sought commentary on: barriers to care & effect of the ACA s passage Participants: provider staff due to their perspective of health care reform for this population

19 Health status of MFWs Access Defined The Affordable Care Act & MFWs Research Design Findings: Barriers to Care Findings: MHSI Solutions Persisting Gaps in Current Health Policy

20 (Castillo-Morales, Pergament, and Durkin 1995; Rosenbaum and Shin 2005; HRSA 2012b) Findings: Barriers to Care Castillo-Morales, Pergament, and Durkin 1995: percent obtain consistent health care services NAWS data 2000: 20 percent sought any sort of health care in the last 2 yrs HRSA estimates 2011: Community Health Centers serve about one fourth of the total migrant population living in the U.S. What factors are preventing the majority of this population from accessing health care?

21 Findings: Barriers to Care Barrier to Care Language barrier Explanation MFW population is largely Spanish speaking They can t explain what they need and they don t get it, or they just don t go Theresa, Site B Mirrors NAWS data : Can t speak English at all : 35% Can speak English a little : 27% Can speak English somewhat : 8% Can speak English well : 30%

22 Findings: Barriers to Care Barrier to Care Immigration Status Explanation Misconception that immigration officials coordinate with health centers Migrant farmworkers with citizenship status seek medical attention at higher rates than undocumented migrant workers Monica, Site A Insurance: undocumented or legally residing for less than 5 years are ineligible for state-based insurance

23 (HRSA 2012b) Findings: Barriers to Care Barrier to Care Affordability Explanation MFW lack state-based and employer-based health insurance Widespread lack of health insurance: 87% of MHSI patients were uninsured in 2011 No employer-based insurance due to temporary employment No one in the agricultural industry provides health care insurance at all, and never have they. Jeanette, Site A They can t afford care. They don t have jobs that can help them. Theresa, Site B

24 Findings: Barriers to Care Barrier to Care Affordability Explanation MFW lack state-based and employer-based health insurance Widespread lack of health insurance: 87% of MHSI patients were uninsured in 2011 No state-based insurance due to immigration status Financially, all patients would qualify for MN Medical Assistance, but immigration status keeps many ineligible, including: undocumented immigrants, newly immigrated men and non-pregnant women

25 Findings: Barriers to Care Barrier to Care Affordability Explanation MFW lack state-based and employer-based health insurance Widespread lack of health insurance: 87% of MHSI patients were uninsured in 2011 No state-based insurance due to transient nature MN Medical Assistance only functions within state borders. Texas Medicaid only functions within MHSI. Complexity of the application process deters enrollment.

26 Findings: Barriers to Care Barrier to Care Affordability Explanation MFW lack state-based and employer-based health insurance Additionally, lack of personal or public transportation

27 Findings: Barriers to Care Barrier to Care Language barrier Immigration status Affordability Explanation MFW population is largely Spanish speaking Misconception that immigration officials coordinate with health centers MFWs lack state-based and employer-based health insurance

28 Health status of MFWs Access Defined The Affordable Care Act & MFWs Research Design Findings: Barriers to Care Findings: MHSI Solutions Persisting Gaps in Current Health Policy

29 (HRSA 2012b) Findings: MHSI Solutions Barrier to Care Language barrier Explanation MFW population is largely Spanish speaking MHSI Solution MHSI employs bilingual staff and interpretation workers year-round 2011 HRSA UDS Report: more than 90% of MHSI patients were of Hispanic or Latino identity Communicating in preferred language by hiring bilingual staff Providing Bilingual Health Operators to interpret at outside specialty clinics MHSI increases available providers

30 Findings: MHSI Solutions Barrier to Care Immigration status Explanation Misconception that immigration officials coordinate with health centers MHSI Solution Federally-funded health centers do not ask for citizenship status or legal documentation Nondisclosure of immigration status Mandated by Title VI as a federally-funded organization Supply medical attention to patients regardless of immigration status MHSI is an acceptable provider

31 Findings: MHSI Solutions Barrier to Care Affordability Explanation MFWs lack state-based and employer-based health insurance MHSI Solution Sliding scale payment system for clinic and outside specialty services With ACA funding purchased new mobile units MHSI increases accessibility Assists with MA applications MHSI increases affordability Sliding-scale payment system & voucher program Up to 200% FPL, only pay a $10 copay within and outside of clinic MHSI increases affordability

32 Findings: MHSI Solutions Barrier to Care Language barrier Explanation MFW population is largely Spanish speaking MHSI Solution MHSI employs bilingual staff and interpretation workers year-round Immigration status Misconception that immigration officials coordinate with health centers Federally-funded health centers do not ask for citizenship status or legal documentation Affordability MFWs lack statebased and employerbased health insurance Sliding scale payment system for clinic and outside specialty services

33 MHSI and Access Availability Providing bilingual staff Accessibility New mobile units, and mobile dentistry operation Accommodation Hiring additional staff to decrease time until next available appointment, and lengthen hours of operation Affordable Care Act Affordability Sliding-scale payment system & voucher program Acceptability Immigration status does not influence eligibility for care a high degree of fit between the client population and provider

34 Health status of MFWs Access Defined The Affordable Care Act & MFWs Research Design Findings: Barriers to Care Findings: MHSI Solutions Persisting Gaps in Current Health Policy

35 The Affordable Care Act and MFWs Era of national Health Care Reform Affordable Care Act: Signed into law on March 23, 2010 Provisions that specifically affect MFWs Medicaid Expansion 2014: Optional for States Health Insurance Exchanges Increased Funding to Community Health Centers: Features of Health Care Reform Provisions Minnesota: qualifies citizens/legally residing >5 yrs up to 133% of the FPL Texas: will not participate in Medicaid expansion Tax credits given to citizens and legal residents between % FPL MHSI received two HRSA grants totaling $90,000 in 2011, 2012

36 Persisting Gaps in Current Health Policy Optional Medicaid Expansion Minnesota Medical Assistance Expansive eligibility Smaller geographic range Texas Medicaid Limited eligibility Larger geographic range

37 Persisting Gaps in Current Health Policy Health Insurance Exchanges and a low-income population No tax credit subsidies for those making less than 100% FPL 91% of MHSI patients in 2011 were within this financial category. Will insurance be affordable?

38 Persisting Gaps in Current Health Policy No employer-based insurance requirement The ACA does not require employers to provide insurance to seasonal employees, i.e. employees that work less than 120 days in a year The ACA: fails to provide employer-based, state-based, or private health insurance to MFWs Limited to Migrant Health Centers for care

39 The Affordable Care Act and MFWs Era of national Health Care Reform Affordable Care Act: Signed into law on March 28, 2010 Provisions that specifically affect MFWs Medicaid Expansion 2014: Optional for States Health Insurance Exchanges Increased Funding to Community Health Centers: Features of Health Care Reform Provisions Minnesota: qualifies citizens/legally residing >5 yrs up to 133% of the FPL Texas: will not participate in Medicaid expansion Tax credits given to citizens and legal residents between % FPL MHSI received two HRSA grants totaling $90,000 in 2011, 2012 Effect on MFWs in Minnesota Does not cover MFW population outside of MN No additional MFW eligible for Medicaid Undocumented are excluded; MFW making less than 100% of FPL will not be able to afford insurance Increases to capacity and capital; Hiring more nurse practitioners and purchasing two new mobile units

40 References Arcury, Thomas A., Antonio Marin, Beverly M. Snively, Mercedes Hernandez-Pelletier, and Sara A. Quandt Reducing Farmworker Residential Pesticide Exposure: Evaluation of a Lay Health Advisor Intervention. Health Promotion Practice 10(3): Bracero History Archive About. Retrieved March 28, 2013 ( Carrol, Daniel, Annie Georges and Russel Saltz Changing Characteristics of U.S. Farm Workers: 21 Years of Findings from the National Agricultural Workers Survey. Presented at the Immigration Reform and Agricultural Conference, May 21, University of California, D.C. Campus. Retrieved March 2, 2013 ( Carson, Katherine L., Anastasia Snyder, and Leif Jensen The Health and Nutrition of Hispanic Migrant and Seasonal Farm Workers. The Center for Rural Pennsylvania Special Report. Legislative Agency of Pennsylvania General Assembly. Retrieved October 5, 2012 ( Castillo-Morales, Lupe, Shannon Pergament, and Debrah Durkin Into the Fields. Pp. 5-8 in Into the Fields: A Report on Migrant and Seasonal Workers in Minnesota, edited by Gary Schiff and Shannon Pergament. Minneapolis: University of Minnesota. Coburn, Katie, Sonia Lara and Jana Blasi The Texas Migrant Care Network: Policy Context and Program Implementation. Retrieved April 3, 2013 ( Contreras, Victor, Jaime Duran, and Kathryn Gilje Migrant Farmworkers in South-Central Minnesota: Farmworker-Led Research and Action for Change. CURA Reporter, February. Retrieved September 20, 2012 ( Cover, Matt HHS: Obamacare-Funded Health Centers for Migrants Won t Check Immigration Status. CNSNews, August 10. Retrieved September 20, 2012 ( Davila, Santiago, Shannon Pergament, Dincy Hynes, and Debrah Durkin A (third) World of Difference. Pp in Into the Fields: A Report on Migrant and Seasonal Workers in Minnesota edited by Gary Schiff and Shannon Pergament. Minneapolis: University of Minnesota. Grey, Michael R Dustbowls, Disease, and the New Deal: The Farm Security Administration Migrant Health Programs, Journal of the History of Medicine and Allied Sciences 48(1):3-39. Hansen, Eric and Martin Donohoe Health Issues of Migrant and Seasonal Farmworkers. Journal of Health Care for the Poor and Underserved 14(2): Health Resources and Services Administration. 2012a. Health Center Quality Improvement FY 2012 Grant Awards. Retrieved October 4, 2012 ( Health Resources and Services Administration. 2012b. Special Populations. Retrieved September 15, 2012 ( Health Resources and Services Administration. 2012c. UDS Summary Report- 2011: Migrant Health Services, Inc. Retrieved November 1, 2012 ( Henry J. Kaiser Family Foundation. 2012a. The Individual Mandate: How Sweeping? Retrieved March 2, 2013 ( The Henry J. Kaiser Family Foundation. 2012b. A Guide to the Supreme Court s Decision on the ACA s Medicaid Expansion. Retrieved March 28, 2013 ( The Henry J. Kaiser Family Foundation. 2012c. Explaining Health Care Reform: Questions About Health Insurance Subsidies. Retrieved March 28, 2013 ( Internal Revenue Code, 26 U.S.C (2012). Jacobs, Lawrence R., and Theda Skocpol Health Care Reform and American Politics: What Everyone Needs to Know. New York: Oxford University Press. Kaiser Health News Table: Caring for Migrant Farmworkers. Retrieved March 4, 2013 ( Kandel, William Profile of Hired Farmworkers, A 2008 Update. Economic Research Service. Washington, DC: US Department of Agriculture. Retrieved March 6, 2013 (

41 MacLaggan, Corrie Texas governor reiterates Medicaid expansion opposition. Retrieved April 4, 2013 ( Mann, Cindy. Center for Medicaid, CHIP and Survey & Certification. Department of Health & Human Services Re: Medicaid and CHIP Coverage of Lawfully Residing Children and Pregnant Women. Retrieved April 2, 2013 ( Merrill, Molly HRSA funds $32M for community health centers. Healthcare Finance News, September 30. Retrieved September 21, 2012 ( Minnesota Department of Human Services Minnesota Medical Assistance expansion. Retrieved September 15, 2012 ( Minnesota Statutes, Section (2012). Minnesota Statutes, Section 256B.06 (2012). National Association of Community Health Centers Community Health Centers and Health Reform. Retrieved September 15, 2012 ( National Center for Farmworker Health, Inc. 2012a. Farmworker Health Factsheet. Retrieved March 4, 2013 ( National Center for Farmworker Health, Inc. 2012b. Demographics. Retrieved March 28, 2013 ( Office of Rural Health and Primary Care ORHPC & MDH News. Monthly Update, August. Retrieved September 21, 2012 ( Penchansky, R and JW Thomas The Concept of Access: Definition and Relationship to Consumer Satisfaction. Medical Care 19(2): Robert Wood Johnson Foundation TB Project Screens Migrant Workers in the Field and Tracks Them From State-to-State. Retrieved March 25, 2013 ( Rosenbaum, Rene P The Direct Economic Impact of Migrant Farmworkers on Southeastern Michigan. JSRI Working Paper 56, The Julian Samora Research Institute, Michigan State University. Retrieved April 2, 2013 ( Rosenbaum, Sara and Peter Shin Migrant and Seasonal Farmworkers: Health Insurance Coverage and Access to Care. The Henry J. Kaiser Family Foundation. Retrieved March 3, 2013 ( Rovner, Julie Medicaid Expansion Goes Overlooked in Supreme Court Anticipation. Minnesota Public Radio, July 27. Retrieved September 20, ( Rural Assistance Center Migrant Health. Retrieved September 16, 2012 ( Simas, Jacob Q&A: Considering Farmworker Health and the Affordable Care Act. Retrieved March 3, 2013 ( Slesinger, Doris P Economic Impact of Migrant Workers on Wisconsin s Economy. Working Paper No I, Center for Demography and Ecology, University of Wisconsin-Madison. Retrieved April 2, 2013 ( Suehs, Thomas Presentation to the Senate Health & Human Services and Senate State Affairs Committees on the Affordable Care Act. Presented at a joint hearing of the Senate Committee on Health and Human Services and the Senate Committee on State Affairs, August 1, Austin. Retrieved April 2, 2013 ( Senate-HHS-ACA-Presentation.pdf). Texas Association of Community Health Centers What is Medicaid? Retrieved April 2, 2013 ( Trupo, Paul, Jeffrey Alwang, and David Lamie The Economic Impact of Migrant, Seasonal, and H-2A Farmworkers on the Virginia Economy. Retrieved April 2, 2013 ( U.S. Census Bureau Table 1. Urban and Rural Population: 1900 to Retrieved September 16, 2012 ( U.S. Department of Health and Human Services Rural Americans and the Affordable Care Act. Retrieved September 16, 2012 ( U.S. Department of Health and Human Services. Assistant Secretary for Planning and Evaluation The Affordable Care Act: Coverage Implications and Issues for Immigrant Families. Retrieved March 28, 2013 ( U.S. Department of Labor Who are Migrant and Seasonal Farmworkers. Retrieved September 16, 2012 ( U.S. Department of Labor The National Agricultural Workers Survey. Retrieved March 26, 2013 ( The World Bank Rural population (% of total population). Retrieved September 16, 2012 ( Ziebarth, Ann Housing Seasonal Workers for the Minnesota Processed Vegetable Industry. Rural Sociology 71(2):

42 Rachel Gunsalus Honors Thesis, Macalester College