Medicaid and migrant farmworkers: why the state residency requirement presents a significant access barrier and what states should do about it.

Author:Hetrick, Malea


Medicaid is failing to meet the health needs of qualified migrant farmworkers because of their migratory lifestyle. This population moves frequently, following various agricultural harvests, and the state residency requirements imposed by Medicaid create a significant access barrier that most migrant farmworkers cannot overcome. Migrant farmworkers are unable to overcome the state residency requirement for several reasons: language and cultural barriers, the difficulty in applying, and statutory impediments such as the five-year ban and the proof-of-citizenship requirement. Several states have attempted to integrate migrant farmworkers into both their state-run Medicaid and general public health systems with varying degrees of success. Both Texas and Wisconsin have implemented creative solutions to this Medicaid coverage problem and these existing models will be examined for both strengths and weaknesses. Finally, after assessing whether the Equal Protection Clause of the Fourteenth Amendment requires that a state provide U.S. citizen migrant farmworkers with access to Medicaid despite their transient lifestyles, I will propose three possible solutions to the problem--the ACA Medicaid Expansion, a hybrid Wisconsin/Texas model, and individualized solutions tailored to each state.

CONTENTS INTRODUCTION I. POPULATION DEMOGRAPHICS II. MEDICAID OVERVIEW A. Medicaid for Migrants B. A CA Impact III. ACCESS BARRIERS FOR MIGRANTS A. Language, Knowledge and Cultural Understandings B. Federal and State Based Eligibility Criteria C. Mobility of Group IV. UNIQUE STATE MODELS A. Texas B. Wisconsin V. A LARGER SOLUTION A. What Does the Law Say? B. Policy Argument for Extension C. Policy Argument Against Extension VI. SOME RESOLUTIONS A. Accept the Federal Solution Inherent in the ACA Medicaid Expansion B. Implement a Hybrid Wisconsin/Texas Model C. Create a New Innovative Solution, Tailored to Each State CONCLUSION INTRODUCTION

The health care of farmworkers is an issue of human rights. We're exposing farmworkers to work-related health problems. We're exposing them to these dangers and then not providing them with access to health care to identify and solve their problems. The health of farmworkers is a moral issue.

Dr. Ed Zuroweste, Medical Director (1)

Ramona and Consuelo are both farmworkers who have spent years working in agriculture in the United States. (2) Consuelo is a skilled grafter, (3) working with citrus and avocado trees, and has acquired her skill with years of practice. (4) She works both indoors and outdoors in a specialized field of agriculture. (5) Ramona worked over a decade as a fruit and vegetable picker, cutter, and packer. (6) The work Ramona did was what is more commonly imagined when one imagines migrant farm work--long days in the field, bent over picking or cutting produce from muddy patches of field. (7) Ramona worked with pesticides and needed to wear long sleeves and a handkerchief over her nose and mouth to protect her from the hazardous fumes. (8)

Both Ramona and Consuelo are married and both have children. (9) Both work hard for little pay. (10) But despite their apparent similarities, when it comes to health care, Ramona and Consuelo could not be more different. Consuelo is one of the lucky few farmworkers who have health coverage through their employers. (11) She has been at the Brokaw Nursery in California for over forty years, and she is now a permanent employee. (12) As such, she has health care for herself and she had health care for her children when they were young. (13) Her employer-provided medical insurance covered almost 90 percent of the costs when her young son died. (14) Consuelo considers "this kind of insurance ... essential for a farm worker family, because medicine and doctor visits are so expensive.... That health plan was necessary to continue working." (15) Consuelo's employer-provided health coverage was a creative solution that Brokaw Nursery provided for its own farmworker employees.

Ramona, on the other hand, represents the majority of farmworkers. Although wearing long sleeves and a handkerchief would have protected her from the toxic fumes of pesticides, the handkerchief made it difficult to breathe, and the work was too hot for sleeves. (16) She now suffers from asthma, likely a result of pesticide exposure. (17) "[Her] hands got so swollen that [her] skin began to split. First they swelled up, and then they got extremely dry. [Her] skin would start to crack, and it was extremely painful. [She] never went to the doctor because [she] couldn't afford to." (18) Ramona's employer did not provide health insurance, and because of the incredibly low wage she earned as a farmworker, there was no money to buy health insurance, after paying the rent, transportation costs, and food. (19) As she explained, "we live a stressful life because ... this work is temporary. When the work runs out, [we] don't have unemployment benefits.... It's frustrating, because you don't have a job or unemployment benefits, but the kids are sick, you have to pay the rent and the bills are piling up." (20)

Ramona and Consuelo demonstrate the reality for the vast majority of migrant farmworkers. Their work is hard, low wage, and high-risk in terms of potential health consequences. Consuelo and her employer show that it is possible to provide health coverage for this population, while Ramona's situation reflects the unfortunate reality for most farmworkers. Throughout this Note, migrant farmworkers, health coverage, and access to Medicaid will be discussed in statistics, subjected to constitutional analysis, and weighed financially and morally. Ultimately, however, these are individual people with real lives and real problems.

Migrant farmworkers have been largely grouped together with all immigrants, or at least with the undocumented immigrant population. (21) However, the law distinguishes between seasonal workers and migrant farmworkers, primarily based on whether the workers must be away from his or her permanent place of residence. (22) For example, Consuelo has been with one employer for over forty years, and is most likely a seasonal worker for that reason. (23) Ramona worked multiple harvests, including grapes, onions, lettuce, broccoli, and almonds. She might have been classified as a migrant farmworker, if these harvests took place in different states. (24) While the national political conversation swirls around amnesty and citizenship rights, health care coverage and the new Affordable Care Act (ACA), and media rhetoric of economic burden and public welfare free-loading, (25) migrant farmworkers who are in fact citizens or legal residents of the United States become lost in the shuffle. (26) The conversation skips over them and they fall through the cracks. Largely unable to access public welfare benefits for which they qualify, U.S. citizen or legal resident migrant farmworkers are an incredibly vulnerable population, at risk for suffering significant health problems as a result of their work and for which they cannot receive Medicaid benefits due to their migratory lifestyle. (27)

Migrant farmworkers by definition live a highly transient lifestyle and spend a substantial amount of their time away from their home and permanent residence. Because of this, migrant farmworkers often struggle to meet the state residency requirement for Medicaid, and although they would otherwise qualify for the program, there is often no safety net in place to ensure Medicaid coverage. (28) Medicaid is failing to meet the health needs of this segment of the population, not because they are ineligible to receive Medicaid benefits, but because of their migratory lifestyle. Medicaid's state residency requirement is a significant barrier that many migrant farmworkers cannot overcome. (29)

Wisconsin and Texas have developed unique and noteworthy ways of meeting the Medicaid needs of U.S. citizen migrant farmworkers. (30) While these programs are commendable, there is still room for further modification to allow migrant farmworkers, who are otherwise qualified except for their migratory nature, access to the Medicaid system. It is not common for states to have special provisions to provide Medicaid benefits to migrant farmworkers; Wisconsin and Texas are exceptions to the general trend of extending Medicaid benefits only to bona fide state residents who can demonstrate their bona fide residency in their application for Medicaid, which is subject to state approval.

For migrant farmworkers, the Wisconsin and Texas models fill an important gap in Medicaid coverage where the federal government cannot mandate coverage. Not only is the ACA Medicaid expansion voluntary, but an Equal Protection challenge under the Fourteenth Amendment would likely fail. Infringing on the fundamental right of a class of people to travel--namely, newly arrived residents--requires a compelling state interest like fraud prevention and the application of strict scrutiny. However, even with a compelling state interest, the state must utilize the least restrictive means practicable when infringing on a fundamental right. A court would hold that a forty- five day period (31) for evaluating the bona fides of a Medicaid applicant's state residency is within the definition of "least restrictive," as it is a practicable time period for the state to evaluate the Medicaid application.

Part I of this Note defines the migrant farmworker population and gives some broad background information. Part II provides a summary of Medicaid, its relationship to and impact on migrants, and the relevant impact of the ACA. Part III discusses the access barriers that migrant farmworkers face when interacting with the public health care system. Part IV reviews the state models employed by Texas and Wisconsin in their attempts to provide access to Medicaid for migrant farmworkers. Part V addresses the expansion of Medicaid and whether it is...

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