Policy and Power in Public Health: The Impact of Policy Expansions and Exclusions on Farmworkers’ Health Insurance Coverage

Abstract

Problem Statement: The majority of the two to three million migrant and seasonal farmworkers (MSFW) in the United States are foreign-born, and 47% are unauthorized immigrants. Farmworkers have a markedly lower rate of health insurance coverage compared to the general population. Aims: The quantitative aims for this project are to identify the effects of the 1) Affordable Care Act (ACA) and 2) the Deficit Reduction Act (DRA) and Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) on farmworker and their families’ odds of health insurance coverage. Both aims include a sub-aim: to identify if citizenship and immigration status moderates the effects of these policies on the odds of coverage. The third aim of the research is to explore the state level political environment in Arizona around public health policy expansion. Aim 1 and 2 Outcome Measures: There are three outcome measures in the quantitative research: farmworker health insurance coverage, child health insurance coverage, and household Medicaid use in the prior two years. Methods: For the quantitative aims, logistic regression analyses were conducted with pooled data (1993-2018) of National Agricultural Workers Survey (NAWS) (1993-2018) (N=42,611) to assess the odds of health insurance coverage post-policy implementation. Results: Farmworkers’ odds of coverage were higher post-ACA compared to pre-ACA (OR, 2.92; 95% CI, 2.67-3.19) as were the odds of reporting child coverage (OR, 4.16; 95% CI, 3.39-5.11). The odds of household Medicaid use were higher post-ACA compared to pre-ACA (OR, 1.50; 95% CI, 1.37-1.64). Post-ACA, greater percentages of farmworkers in Medicaid expansion states reported coverage and stratification of the regression models by Medicaid expansion state showed expansion was an important factor. While immigrant farmworkers have lower odds of coverage, the moderation model did not identify a negative effect of immigration status. However, a negative moderation effect for unauthorized farmworkers was observed in Medicaid expansion states. An unanticipated positive moderation effect was observed for authorized immigrant farmworkers in the ACA period. There was no change in odds of household Medicaid use post-PRWORA compared to pre-PRWORA but post-DRA odds were higher than pre-DRA odds of household Medicaid use (OR, 2.19; 95% CI, 2.00-2.40). Aim 3Methods: For the qualitative aim I conducted key informant interviews (N=3). To contribute additional information to the interviews and triangulate information from the interviews, I also compiled secondary sources including newspaper articles (N=298) and recordings of legislative proceedings (N=4). I used a grounded approach to content analysis and implemented both inductive and deductive coding. Results: The analysis provides a description of the health policy environment in Arizona, using Medicaid expansion as a critical event. Salient categories included the role of the economic environment, budget, relationships, personal experience, worldview, and constituency groups. This qualitative aim will explore the perspectives of health policy stakeholders including their attitudes, knowledge, and beliefs about the intent and outcomes of exclusions and inclusions and how these policies operate within a public health framework of creating the conditions (opportunity) for people to be healthy. Conclusion: The health insurance policy expansions implemented by the ACA have benefited farmworkers and their families. However, the rate of coverage for farmworkers remains low and disparities by citizenship and immigration status remain; however, there were mixed results on how the immigration status of farmworkers effects the relationship between policy and coverage. Results indicate that state decisions such as Medicaid expansion and pathways to coverage outside of Medicaid expansion may play an important role for authorized immigrant farmworkers. The qualitative results provide additional insights for public health and health advocacy groups as they embark on future efforts to expand health coverage in Arizona.