Health insurance coverage among farmworkers in California before and after the introduction of the Affordable Care Act (ACA): A mixed methods study

Abstract Background: Previous studies have found that although health insurance coverage expanded for farmworkers after the introduction of the Patient Protection and Affordable Care Act (ACA), coverage levels were lower than the general population. California recently introduced policies to expand coverage for previously excluded undocumented workers. This study examines the impact of the ACA on insurance coverage for farmworkers and identifies barriers to further expansion.Methods: A mixed methods approach was utilized. Weighted statistical analyses were conducted on the National Agriculture Worker Survey (NAWS) data for 2011-12, 2015-16 and 2017-18 to study health insurance coverage before and after the introduction of the ACA. Qualitative interviews were conducted with growers, healthcare providers and community-based organizations to examine ACA related changes in health insurance for farmworkers.Results: The ACA led to doubling of health insurance coverage for farmworkers in California (32.0%: 2011-12 to 64.8%: 2017-18), with higher rates for documented (43.0%: 2011-12: to 77.7%: 2017-18) than undocumented workers (2011-12: 26.0% to 2017-18: 46.8%), which were lower than rates for non-agricultural workers (73%). Barriers to obtaining coverage include the high cost of insurance for growers, high deductibles and copays for farmworkers and distrust of government agencies.Conclusions: While the ACA led to significant improvements in health insurance coverage for farmworkers in CA, significant barriers remain for farmworkers seeking to obtain insurance and for growers seeking to provide coverage.Policy Implications: States should consider funding a farmworker specific Medicaid program to provide health insurance coverage and care coordination across counties and states