Community Health Care -- Private Clinics for Migrant Farmworkers -- David Lighthall
Community Health Care by Private Clinics for Migrant Farmworkers:
The Case of the Sablan Medical Clinic
California Institute for Rural Studies
April 28, 2000
One of the most unfortunate problems facing migrant farm workers in California and the rest of the nation is their lack of access to affordable health care. Agriculture is recognized as one of the most hazardous occupations and migrant farm workers are often particularly vulnerable to those hazards. In addition to many workplace-related sources of acute and chronic health problems, migrant workers typically face a range of structural constraints to health care accessibility. These include:
1. Very low wages resulting in an inability or d to pay for their own health care;
2. Lack of employer-provided health care, most recent California data from 1997-98 found that only 5 per cent had employee-provided health insurance;
3. Lack of transportation compounded by geographic isolation to public clinics and hospitals that will grant them care in lieu of cash payment;
4. Undocumented status for at least 50 per cent of workers compounded by lack of formal education and mastery of written and spoken English;
5. Even in states like California where farm workers are covered by Workers Compensation, these claims often are not pressed due to occupational maladies that are often either difficult to diagnosis as workplace related, e.g. the case of pesticide exposure, and/or are incremental in onset, e.g. musculoskeletal strains or repetitive motion ailments;
6. Very high incidence rates of diabetes among Mexican farm workers in the United States that reflects a genetic predisposition compounded by lack of preventative education, early diagnosis, and maintenance care;
7. Bureaucratic inflexibility in programs such as Medi-Cal that often make it difficult to gain year-round eligibility or to access care in a new location (lack of portability).
In addition to this range of constraints to accessing health care, it can also be said in a more fundamental sense that the United States and, by implication, other signatories of the 1998 Summit of the Americas Declaration, do not explicitly recognize access to health care as a human right in the Plan of Action. We would strongly argue otherwise—that the inability of foreign workers to acquire the health care they need is indeed a violation of the most basic of human rights.
Rationale and Background: The Sablan Medical Clinic of Firebaugh
As is apparent, in the area of migrant farm worker health care it is much easier to focus on what is wrong with the system rather than identifying existing best practices. Our response to this quandary is to highlight the experiences and practices of a specific private rural clinic that stands as an exemplar in the area of migrant health care, the Sablan Medical Clinic of Firebaugh, California.
Prior to discussing the specifics of this case, some background on the migrant health delivery system is in order. First, the Federal government, under the auspices of the Bureau of Primary Health Care, Dept. of Health and Human Services, provides funding of $930 million for community and migrant health centers. Of this total, $79 million is earmarked specifically for the migrant health clinics and is administered by the Migrant Health Program. Because these funds are used to reimburse clinics and to provide special support services, this network of clinics provides the highest level of health care accessibility for this population.
However, when the National Agricultural Workers Survey (NAWS) posed the question, "In the U.S.A., if you are injured or get sick, where do you receive medical or health care?", responses make it clear that the publicly-supported clinic system provides care to a relatively small proportion of farm workers (the response tallies did not distinguish between migrant and seasonal farmworkers). Averaging the responses of U.S. citizen, LPR, other authorized, and undocumented workers, the NAWS found in 1996 and 1997 that only 9 per cent used community health clinics and 4.5 per cent used migrant clinics. In contrast, 45 per cent used private physicians and 52.5 per cent used emergency rooms. In the case of undocumented workers, 75 per cent stated that they obtained their health care from emergency rooms, 3 per cent identified migrant clinics, 3 per cent saw community health clinics, and 11 per cent visited private physicians. More recent survey data collected by the NAWS in 1997-98 indicates that undocumented workers now compose 52 per cent all farm workers in the United States.
While much can be inferred from these responses about what is wrong with the current system of health care delivery, our primary point is that private physician-run clinics and hospitals are providing a much larger share of health care to migrant farm workers relative to community or migrant health clinics. For this reason we have chosen to focus on a private clinic that is addressing the special needs of migrant farm workers in the absence of federal support from the Bureau of Primary Care.
The Sablan Community Clinic
In 1999, CIRS contracted with the Sablan Medical Clinic to provide physical exams and laboratory tests to 267 farm workers who were participants in a larger health needs assessment survey of California hired farm workers. During this same year, CIRS also developed similar working relationships with five other clinics across the state as part of the same study. During these extended professional relationships, CIRS field staff had the opportunity to observe a range of practices employed by private and non-profit clinics in meeting the health care needs of migrant farm workers. A comparative evaluation of these clinics’ practices led to our selecting the Sablan Medical Clinic (SMC) as a best practice example in migrant health.
In 1981 Drs. Marcia and Oscar Sablan were assigned to the Firebaugh Community Health Center as part of a three year obligation to the National Health Service Corps. Firebaugh is located in Fresno County within the San Jaoquin Valley, both of which contain a very high concentration of migrant farm workers, primarily from Mexico. After several years of frustration with their inability to provide adequate health care accessibility due to rules imposed by the county-funded clinic, the Sablans obtained a loan of $400,000 and opened their own private clinic in Firebaugh. Since that time, the SMC has had a patient payment mix based on 30 per cent Medi-Cal, 15 per cent MediCare, 25 per cent private insurance, and 30 per cent uninsured.
The Sablans have overcome a host of serious obstacles to their success. In particular we can identify several areas of achievement that represent stand-alone best practices for migrant health delivery by all clinics, both private and non-profit. First, the Sablans have invested a considerable amount of time and money in overcoming the bureaucratic red tape involved in securing Medi-Cal reimbursement. Second, they have worked equally hard to gain access to a range of public and private supplemental programs for migrant health care. Third, they have hired and trained bilingual staff from the local population. Fourth, they have also made the effort to gain Spanish language skills. And fifth, they have extended hours and open access to walk-ins in order to maximize health care accessibility and minimize farm workers’ use of emergency rooms.
One of the primary challenges for Medi-Cal use by migrant farm worker relates to its monthly-based eligibility requirements. For seasonal and migrant farm workers whose work is rarely year round, eligibility fluctuates accordingly. In addition, the system lacks geographic portability, forcing migrant workers to reapply for the system when moving to another county. The SMC has added extra staff in order to make full use of the cumbersome Medi-Cal system.
The SMC has been particularly successful in finding supplement programs to lower costs and increase accessibility for migrant and seasonal farm workers. For example, they have had their staff trained in order to qualify for Healthy Family enrollment, a federally-funded program to provide health care to low-income children. It is generally recognized that a major constraint on Health Families participation is the enrollment process. The Sablans have also had staff trained to qualify the clinic for the State Only Family Planning program, allowing them to gain reimbursement for contraceptive and gynecological services. Women over 40 are given free mammograms via SMC participation in a breast cancer early detection program. The SMC has also availed itself to the extent possible for free chronic disease medications provided by pharmaceutical firms such as Parke-Davis. They have also made use of the Child Health Disability Prevention program (CHDP) in order to provide free immunizations to the children of migrant farm workers.
Underlying these efforts by the SMC is a strong ethos of service to all members of the community, including migrants who are temporary residents. While employing bilingual staff is a relatively common practice on the part of rural clinics that serve farm workers, the Sablans have taken the extra steps to gain Spanish proficiency. This eliminates a critical barrier in the patient/provider relationship that plagues many clinics, particularly private clinics. The clinic staff typically works one or two hours past closing in order to process all patients, including walk-ins, and is also open on Saturday mornings. This flexibility is particularly important for farm workers forced to work extended hours during periods of peak labor demand.
By using the Sablan Medical Clinic as a case example, we have identified a range of best practices for private clinics to employ in respect to migrant and seasonal farm workers. The rationale for focusing on a private clinic and its practices is based on the fact that private clinics provide a substantial portion of health care to hired farm workers overall. While we recognize that federally-supported migrant and community clinics provide the widest range of services to migrant farm workers, they are simply not enough of them to meet even a large fraction of the demand. For the foreseeable future, private clinics will continue to play a critical role in providing health care to this population.
In the case of the SMC, the net result of these best practices is a reasonable degree of health care being delivered to a population that is particularly constrained in terms of their ability to pay for health care despite facing a number of serious health threats both in and out of the workplace. However, the Sablans would be the first to state that achieving these goals has been very difficult and time consuming. Underlying the considerable achievements of the Sablan Medical Clinic, therefore, is a concomitant level of dedication and commitment on the part of Marcia and Oscar Sablan. It is difficult not to conclude that they have succeeded in spite of rather than because of the larger system of health care for migrant farm workers.
So the lesson we draw from this case is two-fold: First, the Sablans have demonstrated that it is indeed possible for private clinics that do not have access to federal reimbursement to overcome this and other constraints to serving such a low-income and culturally-isolated population. But on the other hand, it is also clear that the system of medical care for indigent populations such as migrant farm workers represents a patchwork of protection that all too often results in desperate yet often preventable trips to hospital emergency rooms. While the SMC has done a commendable job of filling in the gaps in care, the fact that they have had to work so hard to do so underscores the overwhelming need for reform. As a result, we most strongly recommend that any attempts at reforming or supplementing health care delivery programs for migrant and seasonal farm workers must include mechanisms of support to private clinics as well as continued support for migrant and community clinics. Ideally this would be based on a system of publicly- and privately-supported health insurance based on employment status rather than place of residence or immigration status.