Health Care and Health Insurance Access for Farm Families in the United States during COVID-19: Essential Workers without Essential Resources?

Abstract

In the midst of the COVID-19 pandemic, farmers and farm workers have been deemed essential workers across the world. Yet, despite working in one of the most dangerous occupations, and despite being especially vulnerable to the virus (due to existing health risk factors and risk of infection stemming from difficulties adopting control measures), many farmers and farm workers in the United States have long lacked essential resources to ensure they can meet their health needs: affordable and accessible health insurance and health care. In this commentary, we draw on our own research focused on farm families and collective experiences to discuss three main challenges farm families have faced meeting their health needs: reliance on off-farm work for health insurance coverage, the need to forecast income when purchasing a plan on the health insurance marketplace, and barriers to health care in rural areas. As we discuss these challenges, we highlight the ways in which the COVID-19 pandemic is likely exacerbating these pressures. Recognizing that major crises in the past have led to major shifts in economic, social, and political systems, the disruptions brought on by COVID-19 could be leveraged to work toward increasing access to affordable and adequate health insurance and health care. As such, we conclude our commentary by outlining policy reforms and research efforts that are needed to ensure that those working in the farm sector have access to essential resources to preserve their health and safety.

Introduction

Agriculture is one of the most dangerous occupations, as well as one that experiences some of the highest stress, depression, and suicide rates.¹ As such, access to timely, high-quality health care, along with comprehensive health insurance, are essential resources for the health and well-being of the farm population. Yet, as farmers, farm families, and farm workers have been deemed essential workers across the world in the midst of the COVID-19 pandemic, the pandemic and associated lockdowns are illuminating the deep inequities in our social, political, economic, and food systems. In the United States, COVID-19 is accentuating the reality that many farm families and farm workers have lacked accessible and affordable health insurance and health care² while being especially vulnerable to the virus. This vulnerability to the virus first stems from existing risk factors such as older average ages of farmers and high rates of pre-existing conditions of farmers and farm workers.^1,2 This vulnerability also stems from difficulties adopting control measures such as keeping safe distances, staying home when sick, and lack of personal protective equipment, with variations in the ability to adopt control measures based on living arrangements, financial resources, farm commodity, farm structure, and marketing channels. In this commentary, we discuss three main challenges farm families face meeting their health needs and highlight the ways in which the pandemic is likely exacerbating these pressures. While this commentary does not address the situation of farm workers, we acknowledge the harsh and unjust realities that farm workers, in particular undocumented workers, will continue to face until major reforms address the problematic underpinnings of our immigration and agricultural systems. Furthermore, while this commentary is focused on farm families, many of the difficulties these families face are reflective of the challenges low- and medium-income Americans face. Unless otherwise noted, farmer-level data are from the work of the first two authors on the U.S. Department of Agriculture funded Health Insurance, Rural Economic Development and Agriculture (HIREDnAg) project with insights drawn from survey data and interviews with key stakeholders and farm families in 10 U.S. states pre-COVID-19.³

Vulnerability due to reliance on off-farm employment for health insurance coverage

Off-farm employment has long been an important source of income for farm families, but for about half of farm families in our sample, health insurance coverage was their main reason for having an off-farm job. Off-farm employment creates competition for time and resources between the off-farm job, farm work, and household needs. In turn, it can become a source of stress that negatively impacts farm productivity, farm safety, and family quality of life.

Most recently, COVID-19 has shed further light on the deep yet fraught connection between employer-based health insurance and farm wellbeing. This is because COVID-19-related disruptions to labor markets have led to massive lay-offs, furloughs, and decreases in work hours. In early May 2020, an estimated 27 million Americans had lost employer-sponsored health insurance (either for themselves or through the loss of dependent coverage).⁴ Additionally, the U.S. Bureau of Labor Statistics reported the loss of nearly 1.3 million local education and non-education government jobs.⁵ Nearly half of all farm families reliant on employer-based health insurance are insured through public-sector jobs (health, education, government). In rural areas, public-sector jobs tend to offer the highest wages and most generous benefits. Changes in public- and private-sector employment options and benefits can directly affect access to health care, financial stability, and the social well-being of farm families, with impacts felt throughout rural communities.

Health insurance marketplace and the need to predict income in an unpredictable industry

For farmers and farm families under the age of 65, after employer-based health insurance, the second most important source of coverage is the direct purchase of private plans. Despite half of the farm families receiving a health insurance tax credit in 2016, private plans’ monthly premiums were higher compared to employer-based and public coverage. The need to forecast income for the coming year when purchasing insurance on the marketplace presents important challenges for self-employed farmers. This is largely due to the fluctuating nature of farm income and deductible business expenses. During interviews for our HIREDnAg project, farm families shared about the unexpected financial burden of having underestimated their income. Others spoke of their worries of getting it wrong and “played it safe” by overestimating their farm income, meaning they were likely overpaying for health insurance or forgoing Medicaid eligibility.

When plans are purchased on the insurance marketplace, sudden changes in income can impact monthly premiums, tax credits, and Medicaid eligibility. Therefore, income changes must be reported to the insurance marketplace. For farm families, even in “normal” years, upfront estimations of farm yields, market conditions, and farm income are a form of soothsaying. However, farmers might not be cognizant of the requirement to update their income information. As a global pandemic, COVID-19 has disrupted supply chains and prices for both farm inputs and farm commodity markets. Early estimates indicate that farm income will experience a 20 USD billion loss in 2020.⁶ These impacts are building on top of several years of unstable commodity markets, trade disputes, extreme weather, and a farm income crisis that has weakened the farm economy in many parts of the country. In combination with potential lay-offs and furloughs, COVID-19 related decreases in income may require farm families to re-think their calculus around deductible business expenses vs. health insurance subsidies so that farmers are able to meet their farm and household financial needs in the short term.

Barriers to health care in rural areas

Farmers are often portrayed as stoic, self-reliant individuals who keep their problems to themselves and delay care until the problem can no longer be ignored.^7,8 Behaviors and beliefs associated with these agrarian ethics have certainly come up in our work. Yet, we have found structural barriers to health care in rural areas play a larger role in limiting access to timely care for farm families. In particular, rural areas have long experienced disproportionate health-care workforce shortages, hospital and other facility closures, and infrastructure barriers to accessing care, including transportation and technology.⁹ Such issues are longstanding and will likely continue well beyond the current pandemic. However, early assessments indicate that COVID-19 will likely complicate rural health-care systems’ capacity. As the threat of COVID-19 increased in the spring of 2020, many non-essential medical appointments were cancelled, effectively foregoing vital revenue for rural hospitals while reducing access to care. Changes to telehealth rules to loosen restrictions and increase insurance reimbursements are, at first glance, a promising solution both in the face of COVID-19 and to increase health-care access in general. Indeed, telehealth is a key strategy to increase behavioral care to farmers, as it provides more anonymity while partially addressing the shortage of providers.¹⁰ Yet, until the digital divide and lack of reliable high-speed Internet in rural areas is addressed, the potential for telehealth may be limited.

Where do we go from here?

As essential workers, farmers and farm families need access to essential resources that maintain their health and vitality during the current pandemic but also during “normal” times. Policy intervention is urgently needed to ensure that farmers can access necessary care while continuing to produce food and provide essential services for the population at large. In similar ways that major crises in the past have led to major shifts in economic, social, and political systems (the Social Security Act of 1935 in the midst of the Great Depression is perhaps the best example in the U.S. context), the disruptions brought on by COVID-19 could be leveraged to work toward increasing access to affordable and adequate health insurance and health care. Immediate policy action might include stabilizing farm household incomes, expanding access to affordable and comprehensive health insurance, and additional flexibility in telehealth provision, coupled with the expansion of broadband Internet. Long-term, sustainable, and structural solutions are needed to ensure that farmers can continue to feed the population while also maintaining a humane standard of living that can support their own health and wellbeing.

Policy action requires collective and transparent efforts in which researchers also have a role to play. This includes providing scientifically valid data and communicating about findings broadly beyond the traditional confines of the peer-reviewed literature. Responsive policy requires research that recognizes our agricultural population is diverse and accounts for the lived reality different subgroups experience in meeting their health needs. Such work should directly confront gender discrimination and structural racism embedded within agriculture, and the additional health and economic threats that Black, Indigenous, and other farmers of color face from COVID-19. This also includes the need for researchers, including in the farm health and safety fields, to recognize that too often the focus of US-based research is on individual-level behaviors and attitudes, without adequate consideration of the ways in which larger systems shape those behaviors and attitudes. While a paradigm shift for some, a relational approach to research will open the door to different types of interventions compared to the ones that are commonly prescribed. Last, a particularity fertile area for future research is the exploration of the ways in which different types of health insurance and health-care systems shape farm families’ ability to meet their health needs and bolster these families’ resilience. Given the reliance on farmers as essential workers, not just during COVID-19, but throughout history, we cannot ensure the health and safety of these workers and their families without essential resources like health insurance and access to health care.