A new study finds that the Affordable Care Act helps agricultural workers get better medical care—and avoid the ER.
More than 2.5 million agricultural workers help maintain the United States’ abundant food supply. They play a vital role in the economy, but their job is hard and often dangerous.
“Everything from the heavy machinery they use to the pesticides and other chemicals that they’re exposed to make it easy to get hurt on the job,” says Kwabena B. Donkor, an assistant professor of marketing at Stanford Graduate School of Business and a fellow at the Stanford Institute for Economic Policy Research.
This low-income, largely immigrant workforce has some of the worst health outcomes in the US. Traditionally, farm workers have had difficulty getting routine preventive care because they’re often itinerant, working for a succession of employers who don’t provide health benefits.
“By the time they get to a physician, whatever health problems they’re dealing with are often far along,” Donkor says.
Farm workers who don’t seek treatment until their symptoms are too severe to ignore often check into emergency rooms, which are required under federal law to treat anyone, even if they are uninsured.
Fewer workers skip health care
The Affordable Care Act, (ACA) the sweeping package of health care reforms signed into law by President Barack Obama in 2010, was designed to bring health insurance and medical care to millions of people who previously could not access them.
“If you want a poster child for the sort of person that the ACA is intended to help, that would be a seasonal farm worker,” Donkor says.
Donkor wanted to find out what effect the ACA has had on the health of this chronically underserved group. As he explains, one of the key unanswered empirical questions about the ACA was how its benefits would affect the behavior of previously uninsured people.
Would they visit ERs less because they were receiving preventive care, as the law’s authors had hoped? Or would they go to the ER more often because they would assume that their insurance would cover the cost? Both scenarios were plausible, Donkor notes.
In the new paper, Donkor and colleagues conclude that Obamacare is helping farmworkers in a significant way—while also reducing economic stress on the health care system. The researchers found Obamacare has not only substantially raised the share of seasonal farm workers with medical insurance, it also has increased their use of preventive medical care and decreased their use of hospitals, including emergency care.
The study looked at 2,265 adult farm workers from 2010 to 2016. Donkor and coauthor Jeffrey M. Perloff, a professor in the agricultural and resource economics department at the University of California, Berkeley, calculated that a quarter had preexisting conditions that might have made it difficult for them to afford coverage before health care reform.
“One of the main selling points of the ACA was that before it was passed, insurance companies could charge you a different premium depending on your health status,” Donkor says. “If you had a preexisting condition, you best believe that you were going to have to pay a really high premium.” For low-income farm workers, that often put coverage—and preventive care—out of reach.
The study found that farm workers who were eligible for Medicaid, which some states expanded under Obamacare, were around 11% less likely to be uninsured than ineligible workers. Those eligible to buy insurance on Obamacare-sponsored exchanges were 5.5% less likely to lack insurance. The ACA’s tax penalty for not having coverage reduced the probability of being uninsured by as much as 8.6%. (Congress eliminated the penalty in 2019.)
The ACA also reduced the likelihood of a farm worker forgoing medical care. Medicaid-eligible farm workers were nearly 19% less likely to go without care; those eligible for an insurance subsidy under the law were nearly 9% less likely. Hospital use, including emergency room visits, decreased by 4.4% for Medicaid-eligible farm workers and 1.5% for those eligible for subsidies.
These effects didn’t significantly differ between people with and without preexisting conditions, which suggests that the ACA has benefited farm workers’ health across the board.
Good for farm workers, good for all
Getting an accurate picture of the ACA’s effect on farm workers was a complex endeavor, which may be why relatively little research had been done on the subject.
“There are a lot of moving parts to the ACA,” Donkor says. “And depending upon which state you were in, the law might be applied differently.” The law required states to expand Medicaid coverage to low-income households, yet a 2012 Supreme Court decision allowed some states to opt out of this mandate.
The researchers also had to factor in how the ACA applies to different people. The law requires citizens and legal residents to maintain health insurance but provides subsidies for people who make less than a certain income. “If you have a green card, for example, depending upon how long you’ve been in the US, you may not qualify for the premium subsidy,” Donkor explains.
Donkor would like to see additional research that builds upon these findings. For example, he thinks it’s important to take a closer look at farm workers with preexisting conditions to see how they fare over time. Additionally, he’d like to see whether having access to preventive care reduces the percentage of farm workers with chronic health issues—potentially a big win for both the workers and the system that takes care of them.
What’s good for farm workers ultimately benefits all of society, Donkor says.
“This has a direct impact on how we manage hospitals,” he says. “If you want to lower the burden on our ERs, this could help. If we provide people with what they need, what we’re paying in taxes might actually be lower.”
Source: Patrick J. Kiger for Stanford University
