Undocumented workers are now eligible for health care program

GREENFIELD, CA - APRIL 27: Farm laborers from Fresh Harvest working with an H-2A visa maintain a safe distance as a machine is moved on April 27, 2020 in Greenfield, California. Fresh Harvest is the one of the largest employers of people using the H-2A temporary agricultural worker visa for labor, harvesting and staffing in the United States. The company is implementing strict health and safety initiatives for their workers during the coronavirus pandemic and are trying a number of new techniques to enhance safety in the field as well as in work accommodations. Employees have their temperature taken daily and are also asked a series of questions about how they feel. Despite current record unemployment rates in the U.S. due to COVID-19-related layoffs, there have been few applications to do this kind of work despite extensive mandatory advertising by companies such as Fresh Harvest. (Photo by Brent Stirton/Getty Images)

Luis Lopez, 50, who has worked the strawberry fields in Santa Maria, California, for the last couple of decades, recently received good news: He was now eligible for full Medi-Cal coverage and had been automatically enrolled in the program by the state.

For the first time since he arrived in this country as an undocumented worker, he could breathe easier knowing he had health care coverage.

“I feel lucky,” he said recently. Lopez is one of the 286,000 undocumented Californians over 50 who recently gained full coverage under Medi-Cal, California’s public health insurance program that services low income individuals.

Before the current expansion, most undocumented people in the state could get only restricted Medi-Cal, which only covers emergencies and, in the case of women, services relating to a pregnancy.

This expansion has been a commitment of Gov. Gavin Newsom and represents the work of many legislators past and present, as well as a coalition of community groups, the Health4All Coalition, that worked on it for more than a decade.

Before this coverage reached him, Lopez had avoided private or public clinics due to the potential cost; he talks about regularly using the local botánica to buy pharmaceuticals brought from Mexico.

“I just got the flu recently, and I paid $40 for four shots of eucalyptus at the local store; it’s better than paying $400,” he says, referring to a common treatment in Mexico for respiratory infections, the injectable cough medicine Eucaliptine. “But if the illness is serious, one runs a risk.”

The recent Medi-Cal expansion is good news for people like Lopez. But even after the full expansion occurs in January of 2024, to include undocumented farmworkers between 26 and 49 years old, advocates and researchers warn that there will still be a big gap due to income eligibility.

Lopez said he is aware that he was eligible thanks to his family of five. With his income of $2,500 per month, he needed at least two dependents to be able to get coverage for himself.

“I have four dependents; if it weren’t because of that … I would supposedly make too much to get it,” he said, adding that his wages “barely cover the rent.”

Others haven’t been that lucky. Thirty-twoyear- old Sara Renteria, a date-packing worker in the Coachella Valley, said her dad, a farmworker in Mecca, California, was told he did not qualify for the benefit.

“He tried to get it but didn’t qualify,” she said. “He is 51 years old and makes minimum wage — which in California is $14 an hour. He makes about $600 per week and sometimes works on Saturdays.”

Eligibility for Medi-Cal is based on the federal poverty guideline. For an adult to qualify, he or she must make less than 138% of the poverty level. “Which means if you’re an individual making more than about $18,700 a year, you’re out. A family of four is $38,300, and you are out,” said Joel Diringer, a consultant researcher for a study completed this year that concluded that around 40% of farmworkers, many of them undocumented, would be unable to take advantage of the expansion due to income. “Farmworker Health in California,” a study funded by the California Department of Public Health and The California Endowment, and conducted by researchers at the University of California, Merced, surveyed over 1,100 workers and studied health access and utilization.

A previous health coverage expansion implemented after 2014, following the passage of the Affordable Care Act (ACA), did benefit farmworkers, but mostly documented ones, concluded a report released by the Public Policy Institute of California (PPIC) in April of 2022.

“For documented farmworkers there was an increase in 2014, but we didn’t see anything like that for the undocumented ones,” said Paulette Cha, principal author. The report does not include any expansion since 2020. “We don’t know the impact yet.”

Being a farmworker is tough, back-bending work. In California, average income for farmworkers is about $500 per week: too much for an individual worker to qualify for Medi-Cal but not adequate given California’s high cost of living, said Cristel Jensen, a staff member for the California Institute for Rural Studies.

“The fact that they are telling farmworkers that they don’t qualify because they make too much money is not a supportive way to tell farmworkers, ‘Your health is our priority, and we want to take care of you.’” The UC Merced report examined broadly the challenges facing farmworker health and it concluded that policymakers need to further expand access and close the loopholes in access that affect farmworkers.

Some of their challenges are unique to their profession, said Paul Brown, co-author of the report and an economist at UC Merced. “We know from research over time that farmworkers face special problems that other people who are just not documented don’t face necessarily.”

One of those problems is losing Medi-Cal eligibility due to income fluctuations throughout the year, explained Alondra Mendoza, a community health worker or promotora for the Mixteco/Indígena Community Organizing Project.

“In fieldwork, the salary is not something stable. Sometimes the fruit is good, and workers are earning well for a week or several weeks, and then it’s over. That’s where the health system still needs to improve,” she said, noting that increases in income can suddenly put workers over the eligibility threshold.

The UC Merced study has already fueled further research as well as discussion among California policymakers, who increasingly believe they need to reassess the plight of farmworkers if the state is to meet Gov. Newsom’s promise of universal access to health care coverage regardless of immigration status.

Democratic Assemblymember Joaquin Arambula, a former emergency room doctor who represents Fresno and surrounding rural areas, says that one possible solution would be for the federal government to issue a waiver allowing undocumented residents to purchase coverage through the state’s Affordable Care Act marketplace, better known as Covered California.

When the Affordable Care Act was passed in 2010, undocumented residents were left out and unable to purchase coverage though the ACA marketplaces.

Along with state Sen. Maria Elena Durazo (DLos Angeles), Arambula sponsored the legislation that authorized the various expansions of Medi-Cal during budget negotiations with Gov. Newsom over the last few years.

Asking for such a federal waiver to allow farmworkers to buy into Covered California with subsidies is something that former state Sen. Ricardo Lara, one of the champions of removing all exclusions in access to health care, had been considering a few years ago.

But California legislators abandoned their efforts when Donald Trump won the presidential election in 2016, knowing there would not be support for it in Washington, said Arambula.

Another possible way to address this issue is to increase the income levels required to qualify for Medi-Cal, in order to be consistent with the wages and the cost of living in California, said Diringer.

A combination of those two moves “should cover most farmworkers,” he added in an email.

When Lara, the son of undocumented workers and now the insurance commissioner of California, was a state senator, he worked with the Health4All Coalition to introduce SB 1005 in 2014. It would have extended Medi-Cal to everyone under 138% of the poverty level. But the ambitious bill failed to pass, and advocates and policy makers decided to push little by little, said Jose Torres, policy and legislative advocate of Health Access California, part of the coalition, explaining why they pushed the effort in parts.

Various estimates indicate that close to 60% of farmworkers in California are undocumented, and they have no Medicare waiting for them in their golden years. Experts believe farmworker health issues are likely to be exacerbated in the coming years due to public health crises such as the COVID-19 pandemic and climate change, which will manifest in increasingly severe and frequent heat waves and wildfire smoke, among other ill effects.

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