The foreign-born population in the United States has quadrupled, growing from 10 million individuals in 1960 to 40 million in 2010, and Latin American immigrants represent a substantial proportion, with most coming from Mexico and Central American countries.

Much of that immigration has been driven by U.S. policies over decades, say Postdoctoral Fellow Rebecca Schut of the University of Chicago and LDI Senior Fellow Courtney Boen.

In this Q&A, the researchers give an overview of U.S. agriculture workers, from the nature of their work and health coverage to how U.S. policies have encouraged their migration.

Their new research finds that even those workers who are naturalized U.S. citizens report less use of health care and greater barriers to treatment. 

Schut and Boen have recommendations for how policymakers can improve the health of immigrants.

Here’s more of what they had to say:

Can you give us an overview of how U.S. policies have historically encouraged migration?

Researchers argue that the current wave of Latin American immigration to the U.S. began with key policy changes in the early 20th century that enabled (and even encouraged) labor migration from Mexico and Central America.

By the 1940s, the Bracero program was jointly adopted by the U.S. and Mexico, creating a guest worker program that allowed Mexican laborers to seasonally migrate to fill U.S. labor shortages caused by World War II. The program was vital for sustaining both the U.S. economy and Mexican communities. It made U.S. industries reliant on low-wage immigrant workers, and local economies in Mexico and Central America reliant on the seasonal emigration of workers to the United States. Migration became embedded in the social and economic systems of a growing group of migrant-sending and migrant-receiving communities.

In 1964, the Bracero Program expired, and the U.S. passed major reforms via the Hart Cellar Act of 1965. This act drastically altered the U.S. immigration system, in part by implementing a visa cap that allocated only 20,000 immigration visas per country. This law—and the visa cap it introduced—fit poorly with the migration flows of the time and did not account for the structural forces that led U.S. employers and Mexican and Central American communities to rely on temporary, seasonal migrations of workers.

Loopholes in the law exempted businesses from being fined for employing unauthorized workers from Mexico and Central America. U.S. employers continued to do so, spurring mass unauthorized migratory flows. Economic downturn, civil war, and widespread violence also led to mass emigration from Mexico and Central America.

As subsequent U.S. legislation in the latter half of the 20th century increased militarization of the U.S./Mexico border, Mexican and Central American immigrants, who would have seasonally returned home, came to remain permanently in the U.S. Unable to find a pathway to legal U.S. residency, many of these immigrants arrived in the U.S. as undocumented or became so over time. As structural forces increased undocumented migration, the U.S. population of undocumented immigrants reached about 11 million individuals by 2017.

For more on this topic, see How Anti-Immigrant Rhetoric Affects Health Care Utilization: Chart of the Day by Aaron Glickman, MPA, Why Are Immigrants in Detention Facilities Hospitalized by Christine Weeks, and Health Care Safety-Net Programs After the Affordable Care Act by Mark A. Hall, JD and Janet Weiner, PhD, MPH.

How has the work changed because of technology?

Immigrant agricultural workers are usually employed on farms that plant or harvest crops that require a greater degree of manual labor. These are crops that require constant bending over, reaching up, or climbing ladders, for long parts of the day—think strawberries, grapes/raisins, citrus, and peppers.

It’s intensive and backbreaking work that’s still largely done by hand. An intimate portrait of what it looks like for farmworkers and its effect on health appears in Fresh Fruit, Broken Bodies by Seth Holmes. The United Farmworkers Twitter accounts posts photos/videos and stories of migrant farmworkers harvesting these crops.

What do we know about health insurance coverage for agricultural workers?

Estimates of health insurance status among agricultural workers vary. Preliminary estimates from a paper that we are writing suggest that between 2002 and 2018, only 36% of workers had health insurance (this is among the non H-2A workers, who are not represented in the U.S. Department of Labor’s National Agricultural Workers Survey (NAWS) data).

H-2A workers are a special group: they have a temporary legal status and can apply for ACA insurance, so they’re more likely to have coverage than other agricultural workers, particularly those who are undocumented. Estimates from the National Center for Farmworker Health indicate that 48% of workers have health insurance; among them, nearly 40% have insurance through a government program, 26% through their employer, and the remainder through other means (e.g., through a spouse or another relative).

How did you both get into this research and do this study? Why does it matter?

We got into this work because we’re both concerned about the health and well-being of farmworkers—who are especially vulnerable given their precarious positions in their jobs and legal status. We are also interested in broadening the scope of research on structural disadvantage and health, to focus more on structural nativism—that is, how laws, policies, and states exclude immigrants from social incorporation in ways that likely matter for health, and how immigrants are targeted by these policies on the basis of not only their birthplace, but also their race and legal status.

Our study came about because we noticed there are important gaps in the literature on the role of state immigration regulations and the health and well-being of Latinx immigrants, and especially the undocumented.

First, much research in this area focuses on the impact of immigration policies and environments on Latinx individuals only as a broad group. But we still don’t know a lot about how state immigration policy contexts affect individuals by nativity, race/ethnicity, and legal status—and in their social stratification. Latinx immigrants are a diverse group, yet we don’t know how they might be impacted by state policies across race and legal status.

Second, we know undocumented immigrants are often underreported in administrative and survey data, as many surveys don’t collect information on respondents’ legal status because this is sensitive information that may lead respondents to avoid responding for fear of being identified as undocumented.

Finally, most studies in this area have focused on specific state policies implemented in specific years; they haven’t looked across the country, over time, at how policy contexts shape immigrants’ lives.

State legislatures have passed thousands of laws on immigration-related issues in the last decade. The laws vary tremendously variation across both place and time, perhaps shaping patterns of health and health care inequality beyond what research on the implementation or repeal of singular policies in single years can reveal.

Our study fills these gaps by combining data from several sources. It includes restricted-access geocoded data from Gary Reich, a political science professor at the University of Kansas. It also includes data from the nationally representative National Agricultural Workers Survey that uniquely captures the legal status of U.S. agricultural workers. This enabled us to assess how agricultural workers representing various races, nativities, and legal status were affected by state immigration policies across time and space.

Describe the two or three most important findings of your study, and what is unique? Why are naturalized farmworkers missing out?

We find that state level immigration policy contexts are associated with health care utilization among U.S. born and naturalized U.S. citizen non-White Latinx agricultural workers who report lower levels of health care utilization and greater barriers to care seeking in more restrictive policy contexts.

By contrast, we find little evidence that state policies shaped health care utilization among undocumented workers. We argue these findings advance understanding of how “policies of exclusion” impact the lives of marginalized groups and underscore the importance of racialized legal status.

We think the disadvantage that naturalized farmworkers of color are experiencing may be due to their “racialized legal status,” as Stanford researchers Asad Asad and Matthew Clair describe it. This is the concept that those who are not undocumented may get “lumped in” with the undocumented immigrants because of their perceived social, nativity, racial/ethnic, and language proximity.

That means they may be similarly targeted by Immigration and Customs Enforcement and the police, even though they have legalized status. Therefore, these individuals may avoid seeking health care and social services for fear that they or their undocumented relatives will be targeted in more restrictive policy environments.

Overall, are large numbers of farm workers missing care, getting delayed treatment, and even dying?

Our estimates suggest that there’s a steep gradient in the proportion of farmworkers who aren’t getting health care; we found that 84% of U.S.-born White agricultural workers sought care in our study period compared to only 42% of undocumented non-White Latinx workers. This is a huge disparity.

Also, we’re not sure what workers are seeking care for. One concern is that workers aren’t getting the primary, preventive care they need—like cancer screenings, blood pressure monitoring and medications. This kind of care may be seen as less necessary than care for acute health conditions caused by farm work, but it’s certainly important for maintaining health and encouraging healthy aging.

We haven’t seen any mortality estimates for immigrant agricultural workers; we imagine they are probably healthier in their working years than their U.S. counterparts—because they’ve been healthy enough to migrate to the U.S. and maintain a physically taxing job. But over time, they’re much more likely to face illness and injury, with little access to preventive care. They may also be more likely to develop cancers related to exposure to pesticides and other chemicals used in agriculture. All of this can shave years from life expectancy, or lead to greater levels of disability.

You didn’t find much effect on undocumented workers. But is that because they get so little care to begin with, given fears that they will be arrested and deported?

That’s right. We also think some of the lack of effect on the undocumented is because, as much work has already identified, immigrants are often healthier than U.S. natives in a selection process known as the “immigrant health paradox.” That is, despite just arriving to the country and having in general fewer socioeconomic resources, immigrants tend to be healthier (and live longer, although there’s some debate about this) than their U.S. native counterparts.

You say states have much more control over immigration, restricting access to such programs as Medicaid and SNAP. Have states become more significant than the federal government? Which states have been most aggressive?

States are powerful in shaping the health and well-being of the U.S. population. For example, we’ve seen this play out recently in the Dobbs abortion decision and Medicaid expansion. Similarly, we find states have a lot of power in shaping immigration contexts and whether they’re going to make it difficult for immigrants and block their access to resources and services that can help them incorporate into U.S. society.

The Immigrant Legal Resource Center has this great map showing which states are more restrictive towards immigrants and which are less so. Among the more restrictive are states with large immigrant populations like Texas and Florida. Alabama, Georgia, and Iowa have high concentrations of agricultural workers and also are pretty restrictive.

What long and short-term recommendations do you have for state and federal policymakers, and for health leaders?

Our research isn’t prescriptive from a policy standpoint, but it does point to two general recommendations. For one, our paper showed that hostile and restrictive immigrant policies harm people, especially those who are already vulnerable. Restrictive policies reduce health care utilization for many groups, including U.S. citizens and those with legal status.

If policy makers want to improve the well-being of their residents, rolling back these policies is a first step. Policies that aim to exclude or otherwise marginalize already vulnerable groups ultimately undermine our population’s health and well-being. Our paper highlights the critical importance of Medicaid policy, as just one example. When states failed to extend coverage to immigrants beyond the federal minimums, health care utilization declined even for U.S.-born Latinx workers.

By contrast, our results showed that when states passed inclusive, or accommodating policies, disparities in health care utilization dropped. Our paper highlighted the importance of drivers’ license laws—which are critical if we want people to access care—but there are many examples. Work by LDI Senior Fellow Atheendar Venkataramani has shown how extending protections to undocumented immigrants through Deferred Action for Childhood Arrivals (DACA)—which protects eligible immigrants who came to the United States when they were children from deportation—conferred substantial mental health benefits. So it’s not just about rolling back restrictive policies. States can also pass accommodating and inclusive policies if they care about improving the health and well-being of their population.

Where are you headed next in your research?

We’re continuing our work on agricultural workers and the impacts of different state and local immigration contexts on health, health care/social services access, and well-being.

Right now we’re finishing a project with Nick Graetz, a postdoctoral fellow at Princeton University, on the impact of local, county-level Immigration and Customs Enforcement activity on use of social services (e.g., SNAP benefits, worker’s compensation) and on experiences of pain.

We find that heightened county Immigration and Customs Enforcement rates are associated with declines in the use of both contributions-based and needs-based benefits, which we know are vital for providing access to health-promoting resources (e.g., healthy food).

We also find that agricultural workers, particularly those with undocumented legal statuses, are more likely to report physical pain, and severe physical pain, in contexts with heightened enforcement rates. We argue these findings indicate how changes in the sociopolitical landscapes faced by immigrants can maintain racialized legal status hierarchies, with important consequences for population health and well-being for agricultural workers, but also workers in similar industries, such as construction or food service.

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The study, State Immigration Policy Contexts and Racialized Legal Status Disparities in Health Care Utilization Among U.S. Agricultural Workers, was published on November 16, 2022 in Demography by Rebecca Schut and Courtney Boen.

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