Pamphlets at the Proteus Inc. office in Iowa City help migrant workers understand health care opportunities while in Iowa. Photo taken July 27, 2018. Credit: Lily Bohlke/IowaWatch

Briana Reha-Klenske starts helping migrant farmworkers lacking insurance who need medical care by asking: for how long are you in Iowa?

The bilingual health care manager at Proteus Inc., Reha-Klenske’s patients are migrant farmworkers who are only in Iowa during the summers, which limits her ability to help.

“When we get them, for a period of time, we become their medical home and we’re able to see them over the course of the summer,” said Jesus Soto, chief executive officer of Proteus, a job training, health care and assistance organization that works with immigrant, minority and low-income populations. “But then they leave us, and so that makes it difficult for them,” he added.

“We’ll do our best to connect with them and stay connected with them, but then, hopefully they continue their care wherever they come from.”

Having continued insurance for health care from job to job is one of many unique health challenges migrant farmworkers face because of the workers’ frequent movement from state to state without portable health insurance, which leads to a lack of insurance coverage, inconsistent professional medical care and confusion about health care services in the area where they are working.

“There’s a lack of familiarity with the U.S. healthcare system,” said Alexis Guild, senior health policy analyst at Farmworker Justice, a national non-profit organization to advocate for and support farmworkers across the country. “If they’re migrating and moving, they may not find that same kind of care, and may not know where to access it when they move.”

A sign at the Proteus office in Iowa City indicates its efforts to provide adequate health care to migrant workers. Photo taken July 27, 2018. Lily Bohlke/IowaWatch Credit: Lily Bohlke/IowaWatch

Reha-Klenske estimated that 5 percent to 10 percent of the patients she sees, either at the Iowa City office or at the mobile clinics, have health insurance. Proteus uses a sliding fee scale, which is common nationally at migrant health centers, for patients who do not have health insurance. Although the cost of care depends on how much patients are able to pay, even this can sometimes be too expensive for someone doing migrant and seasonal farm labor when most of their income is made during a short period of time.

Reha-Klenske asks how long a patient will be in Iowa for several reasons. Because the patient might not have health insurance, Reha-Klenske tries to find out whether insurance is available in the worker’s home state, and whether any medical care could be held off until leaving Iowa. Without insurance, procedures Proteus cannot perform can be too expensive at another Iowa healthcare facility for many migrant farmworkers.

Reha-Klenske told about how, in 2017, a migrant worker went to an Iowa hospital to get a triennial mammogram and pap smear. The procedure is covered by Iowa Care for Yourself, a Department of Public Health program that pays for women over the age of 40 to have mammograms and pap smears every three years.

The worker was also a patient of Proteus because she lacked health insurance.

She had arrived at the hospital with the intention to have basic screening done, but also told doctors about additional pelvic pain, and they decided to do a transvaginal ultrasound. Because of miscommunication among Care for Yourself, the hospital and the patient, the worker received a bill for $500 to cover the ultrasound.

That was too expensive for her, a migrant farmworker, who moves from one location to another over the course of the year for work.

Soto said that approximately 5,000 farm laborers migrate through Iowa every summer. The number of workers who are needed fluctuates year to year, depending on the workload projected by an employer.

Lily Bohlke/IowaWatch

Monsanto Company in Williamsburg hires migrant workers during the summer as temporary workers, to work on corn detasseling and hand pollination. Photo taken July 23, 2018.

Many families work during peak season and return home when the school year starts, Alex Ramirez said. Ramirez supervises pre-foundation work at Monsanto Company, an agrochemical and agricultural biotechnology corporation, in Williamsburg.

Ramirez began coming to Williamsburg from south Texas as a migrant worker in 1999, and became a full-time employee for Monsanto in 2007. Members of his family, however, continue to be migrant farmworkers.

The long wait for specialty care

Affordable specialized care can be available but sometimes only after a long waiting period that extends beyond when the worker plans to stay in Iowa. In Des Moines, the Volunteer Physicians Network provides specialized care to people in vulnerable population groups. Several of Reha-Klenske’s patients are receiving treatment through this network now, and several more have been on waiting lists for months.

“What I usually run into, is someone needs specialty care, and there oftentimes are resources that exist. It’s just they have to wait for them a long time and sometimes people don’t have time to wait,” Reha-Klenske said.

Many U.S. citizen migrant workers have publicly subsidized insurance, such as Medicare or Medicaid, because agricultural employers across the nation do not always provide health insurance to their migrant and seasonal employees. This leaves many immigrant migrant workers from other countries with no insurance at all while in the United States, Guild said.

Maria Arredondo, 54, from Edinburg, Texas, has been working at Monsanto in Williamsburg during the summers for six years, and does not have health insurance in Iowa. “Es que me siempre me han hecho el mamograma y siempre ha salido, como me salen una bolita y siempre me llevan a hacer ultrasonido,” she said. In English: She has received mammograms in the past and medical professionals found a lump that needed attention.

Pero, ahora nunca lo han hecho,” Arrendondo said.

Translated: She does not have access to ultrasounds in Iowa.

Migrant workers often under-report their illnesses and injuries, partially because of limited or no access to health insurance, Ashlee Johannes, who has a masters’ degree in occupational and environmental health from the University of Iowa’s College of Public Health, said. Her dissertation was titled, “Health of migrant and seasonal farmworkers in Iowa.” She now works for the University of Iowa’s Iowa Flood Center.

Many of the migrant workers she spoke to during her research process were seeking care for diabetes, hypertension, eye injury and muscle and joint pain, all of which are health concerns that have immediate symptoms.

Other reasons for under-reporting include limited free time or sick leave, financial resources and in some cases, immigration status.

Like all agricultural workers, migrant farmworkers face hazardous factors at work, such as long hours, hot weather, and pesticides and chemicals. However, being migratory can lead to additional obstacles such as limited access to transportation, limited access to food, unstable housing conditions and difficulty in accessing continuous health care.

Iowa’s migrant labor market

A lot of the agricultural work in Iowa is concentrated in producing corn and soybeans, as well as swine. Much of the farm labor can be done using machinery for these products. Corn detasseling and hand pollination, which are required just a few weeks out of the year, and work in swine production, required year-round, are some common tasks for which farmworkers are needed.

For this reason, Iowa has a lower demand for migrant farm labor than some other U.S. states that grow crops like fruits and vegetables, which require much more physical labor for extended periods of time. However, settled farm laborers from nearby communities, or in other words, seasonal farmworkers, are not always available.

Farmworkers who spend their summers in Iowa often come from southern states such as Texas, with employers like Monsanto, whose migrant season is from June to October. The peak is in June and July during which more workers are needed.

Other migrant workers come to Iowa directly from other countries through the H2A visa program, which allows employers to bring workers from another country for the purpose of temporary or seasonal farm labor. Before using the H2A visa program, however, employers must advertise for U.S. workers and establish that there is indeed a labor shortage in their area.

How the health coverage works

Health insurance coverage for migrant workers who are U.S. citizens with Medicare transfers no matter the state in which a patient resides. But U.S. citizen workers with low incomes, and with Medicaid coverage, have limited access to health insurance while moving from state to state because Medicaid is not portable. Rather, the federal government partners with individual states, each of which has its own Medicaid rules for enrollment and portability.

Sanjuanita Ramirez, former migrant worker and current Head Start teacher, sits in the waiting room at Proteus Inc.’s office during the monthly Iowa City health clinic for migrant workers. Proteus holds mobile clinics at locations convenient for workers during the farm season when they are in Iowa. Photo taken July 19, 2018. Lily Bohlke/IowaWatch Credit: Lily Bohlke/IowaWatch

“The transition is hard because you have to close your case in your permanent state and then open it in your new state,” Sanjuanita Ramirez, a former migrant worker, said in the waiting room of a Proteus clinic, where she was accompanying a migrant worker family member. “You would have to go through an application, and then getting approved and what have you. It took time for them (Medicaid-covered workers) to go through the application, and then call you, and then do the interview, and what have you.

“You had two to three weeks without any type of insurance, but then we’re blessed with Proteus,” Ramirez, currently a teacher at Head Start, an education, health services and nutrition organization that works to support impoverished youth, said.

Guild said Medicaid’s lack of portability can have additional consequences for health concerns that require continuous care. For example, Type 2 diabetes, an illness to which migrant workers are at higher risk than the general population because of limited food options, requires care over time. That care can become difficult without healthy food options, a primary medical home, refrigeration access to store medicines or time for self-care during the workday.

“When you don’t have that on a consistent basis it’s very difficult to manage any kind of disease you may have,” Guild said.

Amid challenges to accessing health care, organizations across the country work to help provide care to farmworkers, with or without insurance. Proteus is the main health care provider for Iowa’s migrant farmworkers who do not have insurance. It has offices in Des Moines, Iowa City, and Fort Dodge, as well as in Nebraska, where doctors and other medical professionals often hold clinics after work hours to accommodate migrant workers who cannot afford to visit medical professionals during the day.

At Monsanto, for example, temporary workers can take time off from work, but do not receive paid sick leave. During the summer, many of Proteus’s migrant worker clinics are mobile, held in locations that are convenient for the workers, such as motel rooms, community centers, parks or migrant labor housing camps.

Proteus connects with workers and crew leaders to decide on locations, the company’s CEO Soto said. “We provide primary health care to wherever we can find pockets of farmworkers,” Soto said.

When Proteus clinics are not available, local doctors sometimes can help. In Williamsburg, Ramirez said local doctors’ offices offer reasonable hours, with the office open until around 5 p.m. and the doctor seeing patients until around 4.

“It’s not as long as some people would like, because in the fields or at the warehouses, they work until 9, 10 sometimes,” Ramirez said.

Responding to the need

Even before Proteus established a connection with Iowa’s migrant workers, there was awareness about the necessity for medical care for migrant workers outside of the work day. Ramirez said she worked as one of her camp’s trained health aids once she finished working in the fields for the day when she was a migrant worker.

Family Health/La Clinica, which Ramirez referred to as its original name, La Clinica de los Campesinos, Inc., is an organization that works to improve health conditions for vulnerable population groups, and trained health aides like Ramirez to work at the camps after hours.

Lily Bohlke/IowaWatch East Camp, one of the migrant labor housing camps in Williamsburg, Iowa, about a five-minute drive from Monsanto Co. in Williamsburg. Photo taken July 23, 2018. Lily Bohlke/IowaWatch Credit: Lily Bohlke/IowaWatch

Finding migrant farmworker data is difficult for a variety of reasons when it comes to chronic illnesses related to things like exposure to pesticides, intense labor or poor diet over a long period of time. A big reason is that the workers are not represented in most health studies.

For example, an agricultural health study done in Iowa and North Carolina only tracks over time the health of enrolled farmers and exposures to certain aspects of farm labor, such as pesticides and chemicals. These farmers primarily are seeking approval to use restricted-use pesticides, and most tend more land than the average Iowa farmer, Dr. Charles Lynch, professor of epidemiology at the University of Iowa’s College of Public Health, said.

The farmers had an incentive to enroll and were tracked over a long period of time. The study showed associations between certain pesticides and certain cancers, as well as other illnesses, Lynch said.

Johannes said that, while data from migrant farmworkers could contribute much to a study like this, collecting it would be challenging. One reason is the migrant farmworkers’ transiency, so collecting census data is difficult. Another is that for organizations like Proteus that work with migrant workers, getting access to the population also has challenges, as migrant laborers are only in Iowa for a short time, and may be unfamiliar or uncomfortable with certain locations of clinics, such as community health buildings.

Additionally, immigration status plays a role in the limits of farmworker data. Undocumented workers among those doing temporary farm labor may not be as willing to seek care or share information with any U.S. organizations, Farmworker Justice’s Guild said.

“There’s a lot of rhetoric about public benefits, public charge, about immigrants just generally, a lot of discrimination. So this fear really prevents workers from accessing the services in their community, including health care services, because they’re fearful,” Guild said.

“For example, maybe if they’re an undocumented parent but they have U.S. citizen children, and with this current climate, it may be that even though the U.S. citizen child is eligible to Medicaid, eligible to SNAP (Supplemental Nutrition Assistance Program) and other benefits. They may be reluctant to enroll their children or re-enroll their children in these public benefit programs, because of fear of information being provided to the government, of harming any potential pathway in the future for whatever reason.”

For some health concerns, such as dental work, Proteus makes referrals to other health care providers. In the Iowa City area, Proteus has a memorandum of understanding with the University of Iowa’s College of Dentistry and Dental Clinics that allows for Proteus to pay Medicaid rates for one of their patients’ first visits. Medicaid rates are lower than a lot of insurance, and extensive work in that one visit will usually come out to between $100 and $200. However, after the first visit, or for care where there are no beneficial partnerships, Proteus cannot guarantee that specialized care will be affordable.

Training to prevent health problems

Employers are required to provide an Environmental Protection Agency Worker Protection standard training to limit some of the potential harmful effects of agricultural work. Monsanto additionally has “specific training on emergency action procedures to follow in the event of a safety-related incident,” Heather McClurg, senior manager for corporate preparedness and engagement and issues management at Monsanto, wrote in an email to IowaWatch.

Before starting work, Monsanto’s migrant employees go through an onboarding program, at which Monsanto representatives tell the new employees about protection standards, personal protective equipment and how to do their jobs, Monsanto’s Alex Ramirez said.

Proteus works with agricultural employers to provide these training efforts as well. While employers are required to provide safety training to their laborers, options exist for delivering the trainings.

Soto said Proteus will go to the location of the farm work with a culturally appropriate staff, providing convenience to the employers and comfort to the workers. “It’s primarily just making sure they’re aware of the signs, and preventative measures,” Soto said.

These preventative training efforts are primarily for heat and pesticide exposure prevention. For heat exposure prevention, Soto highlighted wearing long sleeved shirts, drinking water and being aware of the signs. The University of Iowa’s Lynch had these suggestions for pesticide exposure prevention: clothing that covers as much skin as possible is also important, as is making sure to change out of that clothing after a day of working in the fields and doing laundry frequently.

On site at Monsanto’s Williamsburg plant, emergency medical technicians (EMTs) and a site nurse take care of any medical needs while workers are present. These health professionals have supplies such as drinking water, portable toilets, personal protective equipment for each worker and first aid kits.

The Monsanto representatives IowaWatch spoke with said EMTs bring people back from the fields to the site, and if necessary, to their housing if they suffer from heat-related illness, and that Monsanto provides workers compensation for any on the job injuries.

But more is needed, Johannes, of University of Iowa, said. Additional preventative trainings for common chronic conditions, such as diabetes, could help, she said.

“Providing safety training, pesticides, heat, getting more chronic conditions in that going forward just because they (migrant farmworkers) are only going to become more and more vital to the food production for the world as our population grows,” Johannes said. “But also we’re going to continue getting more foreign born workers who are coming to the states.”

Migrant Clinicians Network has a program called the Health Network to help organizations like Proteus. It enrolls migrant farmworkers to track their medical progress, with hopes to be able to better provide the continuous care that is often limited, for chronic diseases and disease prevention.

That helps, because the capacity of what places like Proteus can do for migrant farmworkers remains limited. “Even though they’re this great organization that’s really trying to get out there, they have limited resources themselves, and so they probably reach 2 percent of the migrant and seasonal farmworkers,” Johannes said.

“So it’s a hard balance.”

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