- Medi-Cal policy changes that sustain enrollment and expand covered services benefitted immigrant farmworkers, essential workers throughout the COVID-19 pandemic.
- Federal and state declarations of a public health emergency relaxed certain rules around providing and paying for health care services; some changes will outlive the pandemic.
- Other changes will sunset, resulting in more uninsured Californians. However, the state is planning a new Medi-Cal expansion that will help immigrant farmworkers, many of whom are undocumented.
Major pandemic changes to Medi-Cal and health care
In exchange for enhanced federal funding made available through the federal public health emergency, states were allowed to pause ongoing Medicaid eligibility checks, a change that boosted Medi-Cal enrollment statewide. The pause reduced the burden on enrollees to prove ongoing eligibility.
The public health emergency paused eligibility checks, and Medi-Cal enrollment rose
SOURCE: California Department of Health Care Services Fast Facts, December 2022.
NOTES: The dot denotes the timing of the federal and state declarations of public health emergency due to COVID-19. Enrollment numbers include restricted-scope enrollees who have a limited version of Medi-Cal due to their immigration status.
Medi-Cal matters for farmworkers, who are largely immigrants earning low incomes, with about half undocumented—characteristics associated with lower access to care. Nearly half of immigrant farmworkers with insurance have Medi-Cal, and because a significant share work for more than one employer (about 16%), reducing Medi-Cal income reporting requirements is especially helpful for this group. (Unless otherwise noted, statistics are author calculations from the US Department of Labor’s National Agricultural Workers Survey, Fiscal Year 2020.)
Access to care further improved when telehealth visits—including audio-only calls—became reimbursable for Medi-Cal enrollees at the same rates as in-person visits. This change, together with new flexibility on the kinds of software that could be used, allowed health care providers to pivot quickly to telehealth. Medi-Cal telehealth use jumped dramatically in March 2020. For farmworkers and others in less flexible work environments, telehealth can make care more accessible by eliminating barriers around transportation and scheduling.
The federal public health emergency has also ensured that COVID-19 testing, treatments, and vaccines are free during the emergency, regardless of immigration status. Over four out of five uninsured immigrant farmworkers are undocumented, making the coronavirus benefits especially meaningful for this group.
Farmworkers and health care during the COVID-19 pandemic
Throughout the pandemic, farmworkers have contributed to the state’s economy and food supply as essential workers. Although many farmworkers work outdoors, tasks such as packing cherries or leafy greens can take place indoors. Whether indoors or not, farm work can involve crowded conditions where contracting COVID-19 becomes more likely. And because farm work is physically demanding, extended illness and long-COVID pose threats to worker livelihood.
A 2022 PPIC report found that cost or lack of insurance is farmworkers’ greatest barrier to accessing care—and being uninsured has been a particular liability during the pandemic. Nearly half (48%) of immigrant farmworkers lack health insurance, and of that group, a large majority (82%) are undocumented. Among those who have insurance, about 46 percent have Medi-Cal.
Nearly half of immigrant farmworkers lack health insurance, and most who are uninsured are undocumented
SOURCE: National Agricultural Workers Survey, fiscal year 2020.
NOTES: Values shown are weighted means. Immigration status is self-reported.
After recent changes to state Medi-Cal policy (see text box), nearly one-quarter of undocumented farmworkers would be able to enroll in comprehensive Medi-Cal if their income is low enough to qualify. However, the excluded age group (26 to 49) are workers in their prime years, a well-represented age group in physically demanding jobs, as well as workers with incomes above the eligibility threshold. Most undocumented farmworkers (78%) have remained ineligible during the pandemic due to their age.
During the pandemic, one-quarter of undocumented, uninsured farmworkers were in age groups covered by Medi-Cal expansions
SOURCE: National Agricultural Workers Survey, fiscal year 2020.
NOTES: Values shown are weighted means. Members of eligible age groups must meet income limits to enroll in Medi-Cal. Low-income, undocumented young adults ages 19–25 became eligible for Medi-Cal on Jan 1, 2020, and low-income, undocumented older adults ages 50+ became eligible on May 1, 2022. About 1 percent of undocumented, uninsured farmworkers are younger than 19; this group became eligible on May 1, 2016. Immigration status is self-reported.
California has expanded Medi-Cal in stages to undocumented immigrants
Farmworkers are a heavily immigrant workforce, and about half are undocumented, making them ineligible for full-scope Medi-Cal or private plans on Covered California, the state’s health insurance exchange. (Full-scope refers to comprehensive Medi-Cal health insurance, rather than coverage for a medical emergency or related to a specific condition.) Although undocumented farmworkers are eligible for employer coverage, not all have access.
California has made a series of expansions to full-scope Medi-Cal for low-income, undocumented immigrants, with eligibility to enroll phasing in by age group over time:
- Ages 0–18 up to 266 percent of the federal poverty level (FPL): beginning May 1, 2016
- Ages 19–25 up to 138 percent of FPL: beginning January 1, 2020
- Ages 50+ up to 138 percent of FPL: beginning May 1, 2022
- Ages 26–49 up to 138 percent of FPL: beginning January 1, 2024
Changes to Medi-Cal in 2023 and beyond
The state’s public health emergency ended on February 28, continuous Medi-Cal enrollment will end on March 31, and the federal emergency will expire on May 11. California must prepare for changes as the pandemic emergency period comes to a close.
Some will lose Medi-Cal, and the number of uninsured will grow. Medi-Cal eligibility checks will resume on April 1. Congress is restarting the checks while allowing the federal public health emergency to end on a separate timeline. Inevitably, some share of farmworkers enrolled in Medi-Cal will lose coverage. This may happen with workers whose earnings rise above the low-income threshold, while others may face administrative hurdles or have incorrect contact information on file.
An earlier policy analysis estimated that many Californians would lose coverage if eligibility checks restarted in 2022. The checks did not resume in 2022, and enrollments grew steadily. This trend is likely to continue through March 2023, producing peak Medi-Cal participation before disenrollments begin. Given farmworkers’ complex employment arrangements and the fact that enrollees have not had to report income changes for three years, many who enrolled during the pandemic may be dropped from Medi-Cal as reporting requirements restart.
Telehealth flexibilities will continue. One lesson from the pandemic is the value of telehealth. Federal and state government, as well as consumer advocates, are working to make some of the telehealth flexibilities permanent. Audio-only telehealth, which is important for individuals without smartphones or fast internet, is permanently approved for mental health and substance use disorder services.
Following the passage of AB 133, California’s Department of Health Care Services convened a group of experts advising on how to use telehealth beyond the pandemic to increase access and reduce disparities. The Medi-Cal program is working to reduce health disparities along a number of dimensions, including race/ethnicity, a focus that could benefit California’s majority Latino farm workforce.
Uninsured Californians may fall through the cracks in the latter half of 2023. With the federal public health emergency ending, a limited version of Medi-Cal will cover testing, treatment, and all medically necessary care for COVID-19 for the uninsured until the end of May. Vaccines in particular were successfully deployed in farmworker communities. Tests, masks, and vaccines will be available free of charge until the nation’s stockpile is depleted. After that, farmworkers and others will need to get testing, treatment, and vaccination through insurance, pay in cash, or seek charity care.
Some providers—such as community health centers—may be able to offer these coronavirus-related services free or on a sliding scale. The federal government has pledged to make COVID-19 related pharmaceuticals accessible to uninsured children, but has not announced details about serving uninsured adults as of early March 2023.
The Food and Drug Administration proposes moving to annual COVID-19 boosters with new formulations each year that reflect circulating virus variants, similar to annual flu shots. The shots are likely to cost nothing out-of-pocket for the insured. Pharmaceutical companies had planned to charge between $80 and $130 per vaccine dose, but recently have promised ongoing free shots for the uninsured.
Uninsured, undocumented immigrants will gain access to Medi-Cal in 2024. The period between the end of the emergency and the start of broad Medi-Cal eligibility for all undocumented immigrants is tenuous for uninsured individuals, but relatively short. Beginning January 1, 2024, all undocumented Californians, including undocumented farmworkers, will be able to enroll in Medi-Cal in 2024 if their incomes are below 138 percent of the federal poverty level.