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After a rural California hospital closes, farmworkers pay the price

A person picking grapes wearing a large straw hat.
United Farm Workers
This woman picking grapes in a California vineyard is one of roughly a million farmworkers working in U.S. agriculture. Lack of health insurance, historically unequal labor laws and now the closure of a rural hospital in an agricultural area of California are contributing to a farmworker health crisis.

This story was produced from a partnership between PBS NewsHour and KVPR. 

FRESNO, Calif. – Jose Villa was 41 years old when he began to feel almost too exhausted to work. He was endlessly thirsty, and he found himself getting up as many as eight times a night to use the bathroom.

“My colleagues noticed,” he said in Spanish. “They told me to get checked out because it could be something serious.”

It was diabetes.

In fact, by the time he made it to the doctor, Villa says his blood sugar was so high he was at risk of going into a diabetic coma.

“I was in shock,” he said. “What immediately came to mind was the people I remember seeing sick and dying from diabetes.”

One of those people was his father.

Villa is a farmworker in an impoverished area of Tulare County, located in California’s rural San Joaquin Valley, where his eleventh-hour diabetes diagnosis is just one indication of a health crisis within the greater farmworker community. He’s one of hundreds of thousands of low-wage employees in California who grow and harvest the nation’s food, yet are commonly overburdened with chronic disease.

He was fortunate to find an appointment at a clinic only eight miles from his home. For many others, however, care is much further away, and finding the time and money to visit the doctor is a struggle.

Gaps in health care access have placed Central California’s farmworkers – an already vulnerable population that has worked through the pandemic, extreme heat, wildfires and recent periods of extreme rain and flooding – in a precarious position.

A health crisis for the backbone of U.S. agriculture

According to the Farmworker Health Study, published earlier this year following in-depth interviews with more than 1,200 farmworkers across California, between one-third and one-half of farmworkers surveyed suffer from chronic diseases, including diabetes and hypertension. The vast majority are considered either overweight or obese.

Many of these conditions are linked to ‘social determinants of health’ including socio-economic status, lack of access to primary care and health insurance coverage, cultural and linguistic barriers, transportation, affordable housing, legal status, and other factors,” the authors write. Paradoxically, food deserts and low wages also commonly reduce farmworkers’ access to fresh fruits and vegetables.

The study, conducted by the Community and Labor Center at the University of California, Merced, with $1.5 million in state funding, is believed by the university to be the country’s largest-ever academic survey of farmworker health.

The survey also revealed that in the previous year, nearly half those surveyed lacked health insurance at some point–most are not offered health care coverage from their employers–and more than a third had been admitted to either a hospital or an ER.

“I think we should be concerned with the prevalence of chronic conditions that do exist among farmworkers, as well as the lack of health insurance coverage that they experience,” said Edward Flores, faculty director of the Community and Labor Center and co-author of the study.

Villa, the farmworker, works year-round harvesting oranges, grapes, almonds, pistachios and peppers in a region that, by some estimates, produces as much as three-quarters of the fruits and nuts served at kitchen tables around the country.

A man in a baseball cap looks down at three pill bottles in his hands.
Jose Villa
Jose Villa stands in an almond orchard in California’s San Joaquin Valley with the medications he takes long-term to manage his diabetes. Villa, who has been a farmworker for 14 years, picks produce, applies pesticides and manages irrigation in agricultural fields.

Depending on the season, he works five to seven days a week, and spends some of his off days volunteering with a nonprofit organization that serves farmworkers. The now-42-year-old recently earned his GED and is already thinking about what’s next.

“Going to college could open doors for me,” he said. “Pursuing higher education and being the first in my family to graduate university, that's my dream.”

After 14 years as a farmworker, Villa understands why staying healthy can be so challenging.

Under federal labor laws, many laborers like him aren’t required to receive paid sick leave, vacation time or employer-sponsored health insurance. The flip side of a 2016 state law guaranteeing agricultural workers overtime pay means that many earn too much income to qualify for Medicaid, known in the state as Medi-Cal, a form of government-sponsored health insurance for low-income residents. Many farmworkers also carpool to the fields and don’t own their own cars or drivers’ licenses.

As a result, many, like Villa, don’t seek care until an ailment forces an emergency.

“We go to work, and sometimes we put off going to the doctor,” Villa said. “We just don't have the money or the time, those are the biggest challenges.”

A lack of hospitals and ‘tremendous neglect’

The sprawling San Joaquin Valley has long been short on medical providers. According to a 2019 report published by the California Future Health Workforce Commission, the region is served by 40% fewer primary care physicians than the wealthier San Francisco Bay Area, and fewer than half the number of specialists.

The situation was exacerbated earlier this year when a hospital serving a disproportionately low-income county 90 miles north of Villa shuttered. The closure of Madera Community Hospital, as well as three associated clinics, left Madera County’s 160,000 residents with no general hospital and only a small handful of clinics operated by other providers.

 Medical carts with drawers and computer monitors line a wall in the hospital.
Soreath Hok
Medical work spaces sit empty and powered down inside Madera Community Hospital, which served a low-income, rural and agricultural region of California for 50 years before closing its doors in January 2023.

According to the American Hospital Association, the U.S. is served by an average of two to three hospital beds for every 1,000 U.S. residents. Using that calculus, Madera County would offer 320 to 480 beds - or at least three times the number of beds its former hospital had.

Now, there are zero.

Before it closed, the hospital reported around 30,000 emergency room visits each year, which now must be shouldered by the two next closest hospitals, each more than 20 miles out of county. Madera County issued an emergency declaration due to the resulting strain on first responders.

For farmworkers, “this is uncharted territory,” UC Merced’s Flores said. “We don’t know the risks to people’s well-being that we’re going to see during major public disasters when there’s a closure of a community hospital in a place like Madera.”

“What we are seeing here is tremendous neglect, lack of infrastructure,” said Mari Perez-Ruiz, executive director of the nonprofit Central Valley Empowerment Alliance. “Hearing that the hospital has been closed is heartbreaking.”

Her organization, which she co-founded in 2019 in a nearby county, distributes food boxes and partners with street medicine teams to serve the region’s farmworkers. “That is our very humble way of trying to address some of these gaps,” she said.

California Democratic State Senator Anna Caballero, an attorney who formerly represented farmworkers and helped secure state funding for the Farmworker Health Study, said the farmworker community is “absolutely devastated” by the absence of a hospital in Madera. Shortly before the ailing hospital closed, she and a Republican legislator secured state funding to try to help keep its doors open, but it was intended as only a stopgap measure until the facility could be purchased by another hospital system - a deal that later fell through.

Farmworker advocates say the health gaps faced by the workers aren’t new, but instead reflect long-standing labor challenges.

“The unspoken assumption here is that our food system’s going to be built on exploitable, low-wage, cheap labor that is in many ways barred from the full protection of the law,” said Antonio De Loera-Brust, a spokesperson for United Farm Workers, an advocacy group that pushes for unionization and labor rights for agricultural workers throughout the country.

Some solutions take shape

Like many legislators, the agricultural community has also taken notice of the hospital closure. In February, a coalition of agricultural employers and trade groups penned a letter to Governor Gavin Newsom demanding attention to the matter.

“It’s a community issue,” said Ian Lemay, author of the letter and president of the California Fresh Fruit Association, a trade group representing more than 300 growers and processors.

Though the letter doesn’t make specific requests of the governor, Lemay said he is advocating for aid in the form of higher payments for patients on public health insurance. The government typically reimburses providers for seeing patients on Medicare or Medicaid, but those payments commonly fall short of actual hospital costs. Lemay also said funding is needed to beef up staffing at area hospitals that have had to absorb the Madera hospital’s patients.

Indeed, nearby Fresno County issued an emergency declaration, which involved requesting state funding to help ensure that its hospitals would have the capacity to take on Madera County’s patients.

“Until this issue is rectified, which to me is a full reopening of Madera hospital, we need the state's help to bolster resources, nursing capacity, physical facility capacity,” Lemay said.

Some groups argue that agricultural employers themselves could do more to help improve the health of their employees.

Hundreds of people carrying red UFW flags march down a street protesting.
United Farm Workers
Farmworkers have a long history of demonstrating and protesting for fair labor practices, immigration reform and health care access. In August 2022, thousands of farmworkers, including civil rights icon Dolores Huerta, seen here wearing a fedora behind the Madonna sign , ascended on the California State legislature in Sacramento to put pressure on Governor Newsom to sign a bill that would make it easier for farmworkers to unionize.

“Sign a union contract that includes employer-provided health care,” the UFW’s De Loera-Brust said. “That's something that most workers in other industries expect.”

In recent years, De Loera-Brust acknowledges he has seen more employers providing their employees with health insurance, as well as paid sick leave and union acknowledgement.

The Farmworker Health Study shows that farmworkers hired directly by farmers have higher rates of health insurance coverage than those hired by contractors. Some of the more successful campaigns to vaccinate farmworkers in this region early in the COVID-19 pandemic were also hosted by farmers.

The government is stepping in as well. In 2022, thanks to a provision of the Affordable Care Act that allows states to expand the population that qualifies for Medicaid, California became the first state to extend Medicaid benefits to undocumented residents of all ages. According to UC Merced, which published the Farmworker Health Study, as much as 75% of the state’s farmworkers are undocumented.

Dozens of people standing in line to receive services at a mobile medical clinic.
Fresno County Department of Public Health
Many government agencies, nonprofits and medical providers are turning to mobile clinics, like this one used by the Fresno County Department of Public Health, to bring medical care to rural areas. Health officials estimate 200 farmworkers lined up for vaccines and routine screenings from this clinic hosted by a large grower in February 2023. The county runs the clinics in conjunction with the University of California San Francisco - Fresno, Saint Agnes Medical Center and Fresno State University.

Health officials in neighboring counties are also seeking to close health care gaps among farmworkers by using mobile healthcare clinics, which are essentially roving vans staffed by doctors or nurses. Many nonprofit organizations have adopted their own mobile health units as well.

De Loera-Brust, however, warns these mobile clinics are too reliant on unstable funding sources, and they don’t address the root of the problem.

Real change, he said, would be long-term, and includes unionization as well as immigration reform to provide health care and labor rights to the non-U.S. citizens that make up the vast majority of the agricultural workforce, in California and the rest of the country.

Villa, from Tulare County, is proud to be a farmworker. It brings him joy to know that the fruit he picked is traveling around the world, he said. But the healthcare issue remains a concern that extends beyond his work.

“We don't feel valued as farmworkers. Our employers only care about what we produce,“ he said. “Expanding health care coverage for us farm workers would really make a difference.”

This story was produced from a partnership between PBS NewsHour and KVPR. 

Kerry Klein is an award-winning reporter whose coverage of public health, air pollution, drinking water access and wildfires in the San Joaquin Valley has been featured on NPR, KQED, Science Friday and Kaiser Health News. Her work has earned numerous regional Edward R. Murrow and Golden Mike Awards and has been recognized by the Association of Health Care Journalists and Society of Environmental Journalists. Her podcast Escape From Mammoth Pool was named a podcast “listeners couldn’t get enough of in 2021” by the radio aggregator NPR One.
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