Migrant workers’ access to medical service providers in Pennsylvania

Abstract

The H-2A Temporary Agricultural Workers program brings hundreds of thousands of foreign workers into the United States to work in the agricultural sector each year. It is well documented that H-2A workers are susceptible and subjected to unsafe working conditions and other workplace abuses. Employed in the agricultural sector, H-2A workers are exposed to higher rates of workplace hazards and riskier workplace settings, including risk for human trafficking. As foreign-born workers living on the same farms in which they are employed, they face language and information barriers when accessing resources outside of those provided by their employer. All these factors contribute to creating significant barriers for H-2A workers when accessing healthcare. This paper uses ArcGIS software and publicly available information to analyze the proximity and accessibility of healthcare resources to H-2A workers in Pennsylvania. We find that less than half of H-2A workers in Pennsylvania in 2021 resided within a 15-minute drive of the types of healthcare providers best suited to address their particular needs. We also posit that this methodology could be used in the future to better allocate and prioritize resources to create intervention points and address the unique needs of this at-risk worker population, including health care interventions for human trafficking victims.

Introduction

The H-2A visa program was originally established by Congress in 1986 to address seasonal labor shortages that have been an ongoing problem in the agricultural sector since the 1940s (Luckstead and Devadoss, 2019). This program allows foreign workers to temporarily work for agricultural employers in the U.S. (Bier, 2020). Workers are limited to seasonal jobs and can remain in the US for 8 months up to 3 years, though they are required to return to their home countries between work assignments (Bier, 2020). Since 2014, the total number of H-2A jobs has increased every year and totaled 317,000 positions in 2021 (Bier, 2020; Castillo, 2022). In fact, H-2A workers account for up to 25 % of total farmworker jobs in the U.S. (Bier, 2020; Castillo, 2022). Employment is particularly concentrated in labor-intensive agricultural industries (e.g., fruits, tree nuts, vegetables) (Castillo et al., 2021). Although there are no statistics demonstrating the frequency with which participants return, there is evidence to suggest that H-2A workers attempt to return and repeatedly participate (US Department of State 2007).

H-2A workers exist at the intersection of multiple structural issues that set them up to be susceptible to exploitation. This community - like other migrant worker communities - often experiences language barriers in the U.S. that have been associated with workers’ difficulty in understanding their rights, claiming wages due, and advocating for themselves more broadly (T.A. Arcury et al., 2015; Costa and Rosenbaum, 2017). As a result, “a lack of knowledge about the rights that come with an H-2A visa and lack of information about the conditions in which workers will be working have made it easier for contractors to commit abuse” (Jornaleros Safe 2013). Power dynamics, such as ‘blacklists’ through which employers vet H-2A workers through subjective standards of productivity, can predispose H-2A workers to a servile attitude that stems from the fear of not being rehired (Lopez and Dormody, 2018). Further exacerbating the situation are subpar policies currently in place regarding fair working conditions (Justice, 2011). Additionally, there are limited government and public interest resources available to investigate violations and enforce what regulations are in place (Bernhardt et al., 2020; Gleeson, 2011). With limited negotiation capacities and the requirement to only work for one employer, workers are unable to seek alternative solutions to poor working conditions and abuse, including human trafficking (Lopez and Dormody, 2018).

Beyond occupational conditions, H-2A workers are also impacted by substandard living conditions. Participants often live in remote employer-provided housing with broken appliances, damaged windows, rodent infestations, mold exposures, lack of heated water, and leaky doorways (Chadde and Hettinger, 2023). Workers are subjected to hazards such as pesticide exposures, limited access to resources, and lack of safety regulations (T.A. Arcury et al., 2015). Their health is further compromised as “workers feeling ill or having work injuries are not always credited with an acceptable excuse to stop working, unless the illness, wound, or injury is considered as severe to the employer’s eye” (Lopez and Dormody, 2018; Migrant Clinician Network 2015). Moreover, agricultural workers are excluded from many of the paid time off, overtime, minimum wage, and other laws which protect workers and afford more resources to deal with health or other complications.

Remote housing and lack of reliable transportation pose a particular challenge for H-2A workers (Caxaj et al., 2023; Keim-Malpass et al., 2015). In addition to language barriers and limited understanding of the U.S. medical system, H-2A workers face significant challenges accessing care due to the system’s inherent complexity, fragmented service delivery, and restrictions on eligibility for many health programs. Unfortunately, there is a well-identified gap in research surrounding the health, living, and working conditions of H-2A workers in the United States, which impedes our ability to effectively address these injustices (Lopez and Dormody, 2018; Migrant Clinician Network 2015). Understanding health care proximity also helps us to target medical-system-based anti-trafficking prevention and intervention resources for H-2A workers. Many of these challenges are shared between H-2A and migrant agricultural workers broadly. However, as part of the process for applying to contract H-2A workers, employers must report the addresses of the residences where the H-2A workers they plan to employ will live during their employment in the United States. This information is made publicly available by the U.S. Department of Labor (DOL). This allows for a detailed level of analysis that is otherwise very difficult to achieve for migrant agricultural workers broadly, with possible implications to the migrant agricultural worker community at large. This provides an opportunity to add to the often limited literature regarding health outcomes for agricultural workers. In this project, we will consider geographic information system mapping (GIS) to visually and quantitatively analyze H-2A workers’ access to health care resources in Pennsylvania in 2021.

Methods

Data

Data regarding the geocoded residential addresses of H-2A workers were obtained from the Texas Rio Grand Legal Aid (TRLA) publicly available tool that scrapes the U.S. Department of Labor job postings, number of approved H-2A workers for each site, and employer-provided housing data (DeCicco, 2021). Pennsylvania was selected as the study site due to its agricultural activity involving H-2A workers and its relevance to the non-governmental organization collaborating on this project. These data were collected in May of 2022, for the state of Pennsylvania. Shape files delimiting urban areas of Pennsylvania were obtained from TIGER census 2021 data (United States Census 2023). Public transportation maps from PennDOT were used to correlate worker habitation location with access to public transportation. Data regarding the location of hospitals, rural health centers, and trauma centers were obtained from publicly available shape files provided by the Pennsylvania Department of Health (DoH), also accessed in May of 2022 (Pasda 2024). Online data from Federally Qualified Health Clinics (FQHCs) - including federally funded migrant health centers - in Pennsylvania was obtained from the U.S. Health Resources & Services Administrations in May 2022 as a source of data regarding more accessible and affordable medical services (HRSA 2024).

Data processing and analysis

Health care facilities from the above data sources were categorized into 1) hospitals, 2) trauma hospitals, 3) Federally Qualified Health Clinics (FQHC), 4) targeted FQHCs, 5) and rural health clinics (RHC). ‘Targeted FQHCs’ were determined by sorting the FQHCs data, excluding those with names suggestive of not offering services relevant to H-2A workers (e.g., pediatric clinics, administrative buildings, temporary locations no longer open)from the analysis. The list of FQHCs was further reduced to “RHC’s” by selecting only those whose name referenced being a rural or agricultural service provider and those with Spanish titles. These details were considered proxies for clinics that would be best equipped to address the specific medical needs of immigrant, largely limited English proficient agricultural workers in rural areas. The distinction between categories 4 and 5 then is important, as it may provide further information regarding the access not only to healthcare providers, but those with the resources to address the specific accessibility issues of temporary agricultural workers.

All data were projected to WGS 1984 Web Mercator (auxiliary sphere), joined spatially, and clipped to the state of Pennsylvania. Drive time service areas (polygons) for each type of health care facility identified were created utilizing the Create Drive-Time Areas tool within the Network Analyst Toolkit in ArcPro. These were created using the rural driving time tool, and no specific time of day was specified. Overall, 5-, 15-, and 30-minute drive-time layers were created for each type of medical provider. Spatial Join was then used to determine the number of H-2A worker housing locations located within each drive-time layer polygon for each type of health care facility. The Summary Statistics Tool was then used to calculate the total number of workers within each drive-time layer for each health care facility type, based on the number of H-2A workers reported to be living at each location as listed in employer-provided job orders accessible through the TRLA tool.

Results

In 2021, 28 of Pennsylvania’s 67 counties had at least one H-2A worker housing location in 2021. The distribution of H-2A workers across the state was uneven. Up to 71 % of H-2A workers lived in rural areas. Of the 28 counties with at least 1 H-2A worker, 92 % (23 counties) had fewer than 100 H-2A workers. The maps below summarize H-2A worker distribution in Pennsylvania in 2021.

Map 1 shows the locations of H-2A employer-provided housing throughout PA in 2021. It is important to note that these locations may not include additional housing locations provided by employers, due to how the data scraper tool used extracts the data from publicly available DOL publications. For example, if employer provided housing consists of several apartments in a housing development, or some barracks-style housing and some apartment-style housing, only the first housing address listed by the employer will appear as worker housing for that specific H-2A job order. However, since all workers must be housed close enough to their places of employment to be transported to and from their worksites each day, the primary housing locations provide a good proxy for where workers are being housed for the purposes of state-wide analysis. Map 2 shows the same housing locations as Map 1, weighted according to the number of H-2A workers to be housed as requested by employers in their job orders for H-2A workers to the DOL. This provides a more accurate picture of the distribution of H-2A workers across the state, and highlights how the vast majority of H-2A workers in PA are employed in the Eastern and Southeastern regions of the state.

Map 1.

Housing Locations of H-2A Workers in PA in 2021.

Map 2.

Housing Locations of H-2A Workers in PA in 2021 Weighted by Number of Workers.

Map 3 includes the same housing location information as Map 1, with the addition of shaded areas denoting urban areas in the state.

Map 3.

H-2A Worker Housing Locations vs. Urban Areas in PA.

Map 4 includes the locations of hospitals (red dots) throughout PA as well as the housing locations of H-2A workers. In addition, it includes shaded areas showing the portions of the state that are within a 5-, 15-, and 30-minute drive from them. Map 5 mirrors Map 4, but only for those hospital locations that have specialized trauma centers that would be able to assist in cases of severe injuries, as sometimes occur among farmworkers. Finally, Map 6, Map 7 mirror Map 4, Map 5, although for FQHC’s and Targeted FQHC’s and Rural Health Clinics, accordingly, and using 5-, 10-, and 15-minute drive times for the additional shaded regions.

Map 4.

H-2A Worker Housing Locations and Drive Times to all Hospitals in PA.

Map 5.

H-2A Worker Housing Locations and Drive Times to Specialized Trauma Centers in PA.

Map 6.

H-2A Worker Housing Locations and Drive Times to FQHC’s in PA.

Map 7.

H-2A Worker Housing Locations and Drive Times to Specialized FQHC’s and Rural Health Clinics.

Table 1 lists the 5 counties with >100 H-2A workers in 2021. Table 2 summarizes the number of H-2A worker housing locations, number of H-2A workers, and respective percentage of total H-2A workers that were within given drive times of each type of medical service provider in Pennsylvania in 2021.

Table 1.

PA Counties with >100 H-2A Workers in 2021.

Rank	County	H-2A Workers
1	Adams	699
2	Franklin	168
3	Schuylkill	120
4	Chester	101
5	Columbia	101

Table 2.

Summary Statistics for of Proximity of H-2A Workers to Different Types of Healthcare Providers in PA in 2021.

Within…	Number of Housing Units	Number of Workers	Percent Total
Pennsylvania	194	2321	100 %
Urban Areas	59	680	29 %
30 Mins of a Hospital	185	2253	97 %
30 Mins of a Trauma Hospital	73	751	32 %
15 Mins of a Trauma Hospital	26	320	14 %
15 Mins of a FQHC	100	1373	59 %
15 Mins of a Targeted FQHC	38	778	34 %
15 Mins of a Rural Health Clinic (RHC)	17	212	9 %
15 Mins of a RHC or Targetted FQHC	55	990	43 %

In 2021, over 70 % of H-2A workers brought into Pennsylvania resided in rural areas across the state. While 97 % of workers lived within a 30-minute drive of a hospital, only 32 % lived within a 30-minute drive of a hospital with a specialized trauma unit. Additionally, close proximity to more accessible forms of healthcare was much lower. Fifty-nine percent (59 %) of workers lived within a 15-minute drive of a FQHC, 34 % within 15 min of targeted FQHC, and only 9 % of H-2A temporary agricultural workers lived within a 15-minute drive of a rural health clinic. Less than half of all workers in the state live within a 15-minute drive of either a specialized FWHC or a Rural Health Center.

Discussion

Through this project, we utilized GIS analysis to better understand H-2A workers’ access to healthcare resources in 2021. H-2A workers face considerable occupational and personal hazards (Villarejo et al., 2010). Further, research has found that these workers are likely to accept more unsafe work conditions and fewer safety precautions as per their employers’ expectations (M. Keifer et al., 2009; Soto, 2022). A literature review exploring the health status of migrant workers–including H-2A guest workers-found the most common health problems to include: “mental health, heat-related illnesses, chemical exposures, non-communicable diseases, and musculoskeletal issues” (M. Keifer et al., 2009). As a result, of the occupational risks and intensity of manual labor, H-2A workers endorse facing musculoskeletal issues as well as largely working through injury and illness. Workers often feel as though their employers prioritize fast cheap labor, which is at least partially based on the piece rate work model (Gillen et al., 2002; T.A. Arcury et al., 2015). This focus on cheap, fast labor lends itself to the de-prioritization of work safety and proper safety equipment utilization by H-2A workers (DeCicco et al., 2023). Aligning with this context, our study showed that H-2A workers often required specialized emergency care services in the setting of severe injuries [286].

Although the vast majority (97 %) of our study population lived within a 30-minute drive of a hospital, there are significant obstacles that impede workers’ access to medical care. Only 32 % of the H-2A workers in our study lived within a 30-minute drive of a Trauma Hospital, which is particularly important given the prevalence of work-related injuries experienced by this population (Arcury et al., 2012). Access to medical care is further limited by the travel time that obstructs patients’ ability to present to healthcare settings. Up to 71 % of H-2A workers in our study were residing in rural areas, which inherently limits access to public transportation. Employers may cover the cost of transportation, though often that coverage is contingent upon workers’ ability to fulfill contractual obligations, which can be challenging depending on the nature of injury or illness (T.A. Arcury et al., 2015; Tonozzi and Layne, 2016). If an employer refuses to assist with transportation, an injured worker may have no way of getting to a medical service provider. When considering proximal hospitals (15-minute drive) with Trauma Care services, only 14 % of the H-2A workers in our study appeared to have realistic access to the care they might need.

It is important to note that this study uses physical proximity (as measured by drive-time) as a measure of access to health care for H-2A workers. This does not account for other factors that affect H-2A workers’ access to healthcare, such as whether a clinic has evening or weekend hours, sufficient staffing, interpretation services available, or a mobile clinic. Furthermore, the unique needs of H-2A workers must be taken into account, as there are significant obstacles that impede these workers’ access to medical care specifically. H-2A workers tend to earn lower wages, not benefit from state minimum wage laws that other industries must adhere to, generally do not earn sick time or get paid overtime wages, lack formal education, speak indigenous languages for which interpretation services may not be available on-demand, and are separated from their families/communities (National Center for Farmworker Health 2020). These barriers may mean that rural health clinics or FQHC’s that focus on serving immigrant communities may be best suited to treat H-2A patients, as these provide affordable healthcare, target low-income as well as uninsured individuals, and often have outreach programs specifically designed for these populations (Flocks, 2020). We ultimately found that less than half (43 %) of H-2A workers in Pennsylvania were within a 15-minute drive of either a targeted FQHC or a rural health clinic in 2021. We found that 59 % of H-2A workers were within a 15-minute drive of a FQHC in 2021.

Compared to the general population in Pennsylvania, H-2A workers appear to face notably reduced proximity to healthcare resources, particularly to specialized services such as rural health clinics and targeted FQHCs. According to HRSA data, over 90 % of Pennsylvanians live within a 30-minute drive of a hospital, which aligns with our findings for H-2A workers (97 %). However, the general population has substantially higher rates of access to primary and specialized outpatient care. For example, a 2019 state health assessment reported that approximately 80–85 % of rural residents in Pennsylvania had a primary care provider within a 15-minute drive, compared to only 43 % of H-2A workers in our sample living within that range of targeted FQHCs or rural health clinics (Polaris 2021; Zarnowky, 2022; Lin et al., 2024; Pennsylvania Department of Health 2025; Rankin et al., 2024; Davis, 2023). This suggests that, while general hospital access may appear similar, access to appropriate, affordable, and culturally responsive outpatient care for H-2A workers is substantially more limited.

Beyond the healthcare needs and barriers experienced by H-2A workers themselves, these individuals are additionally at higher risk of recruitment into labor exploitation and, more broadly speaking, human trafficking. This exploitation starts in H-2A workers’ home countries where workers are often hired via recruiters that charge high fees with substantial interest loans that lead to lofty debts faced by workers as they begin their seasonal employment [(Bernhardt et al., 2020; Gleeson, 2011; Schmitt, 2007; Cheng, 2025; Polaris 2025; Centro de los Derechos del Migrante (CDM) 2025; Southern Poverty Law Center 2025)]. H-2A workers frequently incur substantial debts due to recruitment fees and related expenses, which, coupled with the restrictive nature of the visa program, can lead to conditions that severely limit their freedom and make them vulnerable to exploitation (Schmitt, 2007; Johnston, 2022; Rothenberg, 2020). Further, H2A employers have been shown to threaten workers with deportation and loss of employment as a means to support exploitative demands (Johnston, 2022; Rothenberg, 2020; Polaris Project 2025). While employers are required to meet certain standards regarding wages and housing, H-2A workers are excluded from key labor protections such as overtime pay and work hour limits under federal law, and enforcement of housing and safety standards is often inconsistent or insufficient (Rothenberg, 2020; Vengoechea Barrios, 2013). As a result, Polaris has noted that “the vast majority of foreign labor trafficking victims hold H-2 temporary work visas, with 87 % of 3600 identified trafficking victims between 2015 and 2019 holding either a H-2A agricultural or H-2B non-agricultural work visas (Polaris, 2020)” (Polaris 2021). This further highlights how medical providers within a 30-minute drive may not be accessible to workers in exploitative situations where employers refuse or actively hinder workers’ access to transportation.

Given the clinical touchpoints most needed by H-2A workers, as well as their higher susceptibility to human trafficking, we hope that the results of our study can inform identification and intervention efforts for this population from the clinical setting. Firstly, FQHCs and RHCs located in areas that hire H-2A workers, and particularly those located in the geospatial regions identified by our GIS analysis, are best positioned to identify H-2A workers at high risk for recruitment into labor trafficking (Zarnowky, 2022). We hope that this inspires implementation of human trafficking education for healthcare workers so that those most likely to identify victims of human trafficking are best equipped to do so. Secondly, FQHCs are well-identified intervention points by the anti-trafficking space, but these centers are limited by a lack of resources and inadequate capacity (Lin et al., 2024; Van Putten et al., 2018). We posit that financial efforts also be invested on increasing resource allocation to these sites. Thirdly, we propose that the methodology used by our study be considered by other researchers to evaluate geospatial patterns and better inform targeted allocation of resources for those patients who are most in need.

Our understanding of H-2A workers’ experience with the formal healthcare system as well as their work safety environment is lacking due to the exclusion of these workers from the National Agricultural Workers Survey (Chisolm-Straker and Stoklosa, 2017). In addition, as H-2A workers are employed in the agricultural industry, they work and live in areas and within an industry that is more likely employ unauthorized immigrants, who are frequently undercounted and underserved (Mehta et al., 2000). Using similar methods in other contexts may additional information in the future on how to better support to healthcare needs of migrant and agricultural workers.

Pennsylvania presents both comparable and distinctive features relative to other states employing H-2A workers. Like many agricultural states, Pennsylvania relies on H-2A workers for labor-intensive crops such as fruits and vegetables. However, the structure of H-2A employment in Pennsylvania differs somewhat from states like Florida or California, where farm labor contractors (FLCs) are more commonly used. In Pennsylvania, H-2A workers are often directly employed by farms, and housing is frequently more dispersed across rural landscapes. This geographic distribution contributes to reduced proximity to healthcare services and limited transportation options, as seen in our findings. By contrast, some FLC-heavy states may provide more centralized housing and transportation services, which can improve access to care but also raise concerns about oversight and worker autonomy (Young, 2021; Martin, 2022; American Immigration Council 2020). These contextual differences suggest that while the structural vulnerabilities of the H-2A program are national in scope, the barriers to healthcare access for workers may vary by state due to differences in geography, housing policy, employer models, and infrastructure.

While this study focuses specifically on Pennsylvania, the findings offer insights that may apply more broadly. Although a nationwide analysis was outside the scope of this project, the methods used here could be adapted for regional or national studies to assess healthcare access disparities for H-2A and other migrant agricultural workers. Because H-2A job orders require public reporting of worker housing locations, these data provide a unique opportunity to model healthcare access for a broader population of migrant workers, who are otherwise difficult to study due to limited data availability.

Conclusions

The H-2A temporary agricultural worker program is an important component of the agricultural workforce in the U.S. However, H-2A workers face unique challenges in ensuring safe working conditions and accessing medical services. The H-2A program itself is set up in such a way that workers are not only at a disadvantage when advocating for themselves but also prone to exploitation. Additionally, H-2A workers are employed in an industry with significant occupational hazards that are more likely to result in the need for medical care. However, a large subset of H-2A workers employed in Pennsylvania are not within close proximity to a hospital. Furthermore, there are barriers that may make it difficult for H-2A workers to access healthcare, even if it is only a 30-minute drive away. As they live primarily in rural areas, there is often little to no access to public transportation. H-2A workers also face unique challenges such as language barriers, unfamiliarity with the healthcare system in the U.S, and a lack of community and family that may help them navigate new systems - such as public transportation. Thus, these workers may rely entirely on their employers for transportation to - and even information regarding - any resource further than a short drive away - employers who may be heavily disincentivized from facilitating access to resources that may expose unsafe or abusive workplace conditions. As such, close proximity resources are very important to provide H-2A workers with the health support they need. However, there are few such resources within close proximity to many workers, as almost half of the H-2A workers in our study population lived further than a 15-minute drive away from FQHC’s and the type of specialized clinics best positioned to address their health needs. This leaves these workers’ access to medical care at the behest of their employers, on whom they often rely for transportation. More research is to identify intervention points that can promote access to medical services. In addition, those health providers nearest agricultural workers should be equipped with the resources to 1) address the specific barriers faced by H-2A workers, 2) identify workplace exploitations, and 3) provide patients experiencing human trafficking with necessary supports. Lastly, future work could determine how useful most accessible data regarding H-2A workers may be as a proxy for other types of migrant agricultural workers, and the implications this may have for future research.

CRediT authorship contribution statement

Philip Decicco: Writing – original draft, Software, Methodology, Investigation, Conceptualization. Jaya Prakash: Writing – review & editing, Conceptualization. Erica Nelson: Writing – review & editing. Gonzalo Martínez de Vedia: Writing – review & editing. Hanni Stoklosa: Writing – review & editing, Supervision.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.