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Voucher Systems Extend Care to Agricultural Workers in Remote Locations

An orchard of apples

Health centers that utilize a migrant voucher system, as 330g health centers supported by the Health Resources and Services Administration (HRSA), open the pathway to health care for agricultural workers through a unique service delivery model that focuses on referral, case management, and collaboration with health care service providers. This model is especially well suited to serving large geographic areas. Each voucher system – what services it provides, what area it covers, what providers it partners with -- is unique, tailored to the agricultural worker communities that it serves and the available resources in its service area. Two examples of voucher systems are described here.

Every summer, thousands of agricultural workers harvest crops like strawberries, cucumbers, and potatoes at farms across the Connecticut River Valley. Some agricultural workers live in the region year-round, picking up work at the height of the season. Others migrate to the area specifically during the harvest from other parts of the United States, and then continue to move north as the season progresses. Some are guest workers, flown in by farm owners through the H-2A program from the Caribbean, Mexico, and Central America, to work and live on a farm for a limited time, before returning to their countries of origin. These agricultural workers fill different roles -- harvesting in the fields, tending plants in nurseries and greenhouses, or packing produce in warehouses. Regardless of how they entered the agricultural system or in which area of agriculture they work, these agricultural workers face similar health-damaging determinants, like hazardous working conditions, limited income, substandard housing, social isolation, lack of health insurance, and linguistic and cultural barriers. In the Connecticut River Valley, these determinants of health amount to significant barriers to access health care: despite numerous community health centers in the region, agricultural workers are often unable to get to the clinic when they need care.

The Connecticut River Valley Farmworker Health Program (CRVFHP) was developed specifically to fill the gap in care in the region by providing vouchers to agricultural workers for their health needs. As a 330g health center with a migrant voucher system, CRVFHP does not provide services at a brick-and-mortar location, but instead their contracted Health Center Partner Agency outreach teams travel to the agricultural workers directly, provide health education and screenings, and provide primary care vouchers to their six partner community health centers in Massachusetts and Connecticut, so that agricultural workers can access the services they need. In 2022, CRVFHP Partner Agencies served 2,515 agricultural worker patients, with roughly 68% seasonal and 32% migratory, and 75% of patients best served in a language other than English.

CRVFHP has supported Partner Agencies in building out their mobile health programs to bring health services to the farms. Transportation is one of the largest barriers that agricultural workers encounter, says Erica Hastings, Senior Manager of CRVFHP.

Outreach is a central component of the program. Partner Agency outreach teams provide health education, transportation to medical appointments, interpretation services, and referrals for other needed services. CRVFHP has supported Partner Agencies in building out their mobile health programs to bring health services to the farms. Transportation is one of the largest barriers that agricultural workers encounter, says Erica Hastings, Senior Manager of CRVFHP. To address this need, the CRVFHP has supported the purchase of vans to transport patients to the health centers for their appointments. 

Recently, CRVFHP secured funding to purchase and equip mobile clinics, further expanding their partner health centers’ ability to provide care to agricultural workers.

“We promote access to care, encouraging and educating around ag worker identification, as well as identifying new farms,” including through partnerships with stakeholders, that alert CRVFHP of incoming H-2A workers, explained Hastings. When incoming workers are identified, CRVFHP’s Partner Agency outreach teams mobilize to reach them and help them re-engage in care.

“The thing that really elevates our program is the relationships,” says Alysse Rourke, Clinical Data and Billing Manager for CRVFHP. Outreach workers collaborate with their clinical teams in the health centers, and with each other at other Partner Agency health centers. “Every health center is so different – the way they operate, how they collect data, what their practices are for patients. I think having that collaboration… has supported [CRVFHP Partner Agency teams’] growth, so they can learn from each other what outreach tactics work… It’s not competitive – it’s collaborative.”

Another migrant voucher system model, in Montana, takes a different approach. Ag Worker Health and Services Council started out as a voucher-only program, serving hundreds of square miles across the large and largely unpopulated state, but the program has since grown into a hybrid voucher system, with five primary care clinics across the state. At those clinics, nurse practitioners provide primary care, and if a patient needs any additional care – an ultrasound, a mammogram, mental health services, dental care, or any other specialty care – they are provided with a voucher for that care.

“I think the need was always there,” explained Vicki Thuesen, NP, Clinical Director for Ag Worker Health and Services Council, when explaining why the team expanded into a hybrid voucher system. “As we expanded, we had more patients and we realized, ‘wow, it’s a lot less expensive if we have our own provider doing most of the primary care.’”

An agricultural worker came to one of her clinics last year, for example, with blood in his urine. After initial lab work, his primary care provider determined that he had advanced-stage bladder cancer. The team worked together along with community advocates to help him return to his home in Mexico; meanwhile, the clinic gave him vouchers so he could obtain the medication needed before his journey home. In 2022, Thuesen’s team issued 459 prescription vouchers and 693 vouchers for referrals to specialists.

Both systems illustrate the wide variability in structure and operations among voucher systems, due to their development in response to the unique circumstances and needs of agricultural workers of the region. All voucher systems, however, share a common goal to increase access. Without a health center offering voucher systems, Thuesen noted, agricultural workers in her region with health needs would be left with no -options. “They just wouldn’t get the care,” Thuesen said. “If it’s something that we were unable to provide, it would be care that wouldn’t be provided.”