MIGRANT HEALTH IN THE UNITED STATES Presented by: Bobbi Ryder, CEO October 29, 2008

1. MIGRANT HEALTH IN THE UNITED STATES Presented by: Bobbi Ryder, CEO October 29, 2008 Photography by Alan Pogue

2. Presenter Disclosures Bobbi Ryder (1)The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: NO RELATIONSHIPS TO DISCLOSE

3. Presentation Outline • Historical Overview of Migrant Farmworkers in USA • Navigating Health Care System – Pt. Perspectives • Access Barriers in the US • Overview of Community and Migrant Health Centers in the US

4. 1917 “Immigration and Nationality Act” 73,000 Mexicans migrate to the US 1930’s “The Dust Bowl” Displaced farm workers and “share croppers” begin the phenomenon of domestic agricultural migration 1942: “Bracero Treaty” The Mexican contribution to the Allied war effort during WWII I. Historical Perspective of Agricultural Migration to and in the US in the 20th Century

5. Historical Perspective (Cont.) • 1951 Public Law 78: Re-authorization of Bracero Treaty • 1952 Establishment of the H-2 Program: Similar to the Bracero Treaty, but requiring a certificate verifying that domestic workers are not available. • 2008 Continuation of H-2 • Today Emmigration of populations to the US from Mexico continues, with and without documentation.

6. 1942 4,203 1943 52,098 1944 62,170 1945 49,454 1946 32,043 1947 19,632 1948 35,345 1949 107,000 1940’SBRACERO PROGRAM These men had learned through newspapers and word of mouth about the opportunity to work in the United States. Many had been standing for five days and five nights when the photo was taken. December 7,1941 The Japanese attack on Pearl Harbor brings the United States into World War II. January 1942 President Franklin Roosevelt informed the United States Congress of the necessity of implementing a military infrastructure capable of producing up to 50 thousand airplanes each year. For the size of this war production, the Unites States utilized all of its available resources. Men and women of all ages worked day and night in factories and the healthiest and strongest young people were sent to the front lines. August 4, 1942 The governments of the United States and Mexico signed what came to be known as The Bracero Treaty for the recruitment and employment of Mexican citizens in order to alleviate the shortages of manual labor in the agricultural fields and to help maintain the American railways. Thousands of impoverished Mexicans abandoned their rural communities and headed north to work as Braceros. After the physical examination, men assembled in the bleachers to hear the terms of their work contracts. A labor department official explained the work contract, paragraph by paragraph, in Spanish. The men then went back inside to sign contracts in quadruplicate. One copy each went to the worker, U.S. Immigration, Mexican Immigration, and the eventual U.S. employer. A large area inside the stadium included stations for processing by U.S. Immigration, Mexican Immigration, and Social Security Administration (for railroad but not farm work recruits); issuance of ration books and train tickets; preparation of contracts; and official stamping of documents. Fingerprints were taken for the contract and the identification card. Applicants were photographed in groups of four. Each man received an identification card containing his picture. The first step was the line-up for smallpox vaccinations administered by nurses, followed by physical examinations that began with a chest x-ray. Medical staff included doctors from both the U.S. and Mexican Federal Health Departments. Examination went from head to toe. The men were questioned about their agricultural experience. A preliminary examination was made for calluses on their hands and other indications of agricultural work. Year # of Braceros At the end of the line all papers, ration books, and forms were taken from the workers. Portions were put into an official envelope that served as passport and transportation ticket to the U.S. border.

7. Waiting to Enter the US

8. Registration Lines, 1942

9. The Process Begins

10. Finger Printing

11. Vaccinations

12. Physical Exams and X-Rays

13. Preparing the Contract

14. Waiting for Work

15. Bracero Treaty

16. Agricultural Workers in the US(Circa 1940s)

17. Today’s Agricultural Workers

28. “Immigrant” - A person who arrives in a new country to establish residence. “Emmigrant” - A person who leaves his/her country to establish residence in another. “Migrante” (MX) - A Mexican resident leaving Mexico to go to another country in search of work in any occupation. “Migrant” (US) - An ag workerwho makes a migratory circuit in order to work in agriculture. “Seasonal Farmworker” - An ag worker who does not migrate. Lost in Translation – Popular Use:

29. Migrant Characteristics - Mobility • Nomadic • Generally foreign-born young single males working in the United States and sending money home • Travel to wherever there is work • Usually do not know when or to where next move will be

30. ???? VeteSano Regresa Sano

31. Manténgase Sano VeteSano Regresa Sano

32. II. Navigating US Health Care “System” General Population Challenges Even for those with Insurance • Isolated islands of care • No medical home • Limited focus on prevention services • Fragmentation of services • Lack of inter and intra institutional coordination • Recordkeeping, manual vs EMR, vs EHR • High cost of premiums, co-pays, deductibles, specialty care and pharmacy • Other?

33. Mending Texas’ Fractured Health Care System – The Primary Care Coalition, 2008 The Primary Solution

34. “ In the absence of a health care delivery system that supports cost-effective, coordinated, high quality care for patients, a fractured system has evolved that provides inefficient and expensive care to those who can afford it and allows those less fortunate to fall between the cracks.” “The United States spends 16% of its GDP on health care - $7,600 a year for each person, yet nearly 47 million people are uninsured.” The Problem

35. “Children receive only 47% of recommended care overall, and just 41% of the preventive services they need.” “Only 34.9% of Texas adults age 50 or older received recommended screening and preventive care in 2004.” “10% of the population account for 70% of health care expenditures.” “The healthier 50% of the population consumes only 3% of health care expenditures.” The Problem (Cont.)

36. Recent immigrants from Mexico and CA From landless rural poor families Young population Historically mostly male, recent rise in numbers of young females Poorly educated, may not be literate in or even speak Spanish Limited English proficiency (LEP) Many undocumented General Population Characteristics

37. Increasing number of H-2A workers nationally More males traveling alone Fewer families traveling together More workers establishing themselves in rural communities as seasonal workers Less trans-border migration More working in other industries, such as construction, meat processing and dairy, during the non-agricultural season Farmworker Migration Today

38. III. Access Barriers in the US

39. Population Specific Access Barriers • Feeling unwelcome in provider’s office • Mobility • No paid sick time • “Leave it and Lose it” jobs • Lack of health insurance • Limited knowledge of the system • Not knowing where to go • Limited income resources • Lack of transportation • Language limitations • Varying levels of literacy • Limited level of health literacy • Cultural and fear issues • No continuity of history and treatment

40. Institutional Access Barriers High cost of health care in US Uninsured patients pay higher prices (no network discounts) Limited points of access for primary care Location and operating hours Closed or limited practices Lack of transportation systems in rural areas English as dominant language, no interpreters Waiting period for appointments

41. Commercial Insurance Seldom provided by employers High premiums & co pays Hospital Access Not appropriate for primary care access Prohibitively expensive Uncompensated Care Specialty Care Access Providers demanding payment in advance Limited access in rural areas Community and Migrant Health Center Program Geographic gaps in availability Greater demand than availability Medicaid, SCHIP, Medicare Documented residents only (exceptions do exist) Not portable from state to state Financial Barriers and Challenges

42. Federal program administered by individual states Varying eligibility & enrollment criteria Payment of SCHIP monthly premiums Varying provider payment rates Mixed family resident status (parent/child) Varying presumptive eligibility policies No interstate portability or reciprocity Medicaid and SCHIP

43. IV. Overview of Community and Migrant Health Centers in the US

44. 1937 – Establishment of the Farm Security Administration 1950’s – PHS Established the Migrant Health Unit 1962 – Migrant Health Act: Legislative authorization creates the Migrant Health Program Federal Development of Community and Migrant Health Services

45. Federal Development of Community and Migrant Health Services (Cont.) • 1967 – Community Health Center Act: Legislative authorization creates the Community Health Center Program • 1996 – Health Centers Consolidation Act: Legislative consolidation of community, homeless, and migrant programs • 2001 – Presidential Initiative – Plan of current administration is adopted to expand the Community Health Center Program

46. The “Migrant Health Act” is passed in 1962 under President John F. Kennedy’s Administration

47. 1960’s EDUCATION LABOR HEALTH April 1965 The Elementary and Secondary Education Act is passed which creates the Migrant Education Program. 1965 Migrant Health Program is extended for three more years and necessary hospital care is added as an available health service under this Program. 1962 The National Farm Workers Association is formed by Cesar Chavez. 1969 118 migrant health projects are in operation, serving 317 counties in 36 states and Puerto Rico. 1964 The Bracero Program is officially terminated. 1964 The Housing Act of 1964 provides assistance for construction of new migrant farm labor housing. Summer 1966 The National Farm Workers Association and the Agricultural Workers Organizing Committee merge to form the United Farm Workers Organizing Committee. May 18, 1965 The Migrant Headstart Program is enacted. 1966 The minimum wage provisions of the Fair Labor Standards Act are extended to farmworkers.

48. Manténgase Sano VeteSano Regresa Sano

49. Private Non-Profit Corporations Federal funding = 15-25 % of budget Consumer majority of community board of directors, Comprehensive team managed primary care Emphasis on continuity and case-management Culturally and linguistically appropriate Health education and prevention services Geographically accessible services, under one roof Fees charged in accordance with the income and size of the family (sliding fee scale) Innovative service delivery model fitting area need The Health Center Model

50. Service Delivery Models • Migrant Health Center • Community/Migrant Health Center • Migrant Health Voucher Programs • Coordination of Services • Nursing Model • PA and NP Model