By Alejandra Cancino – Associated Press | Mon, June 20, 2016

DUNN, N.C. (AP) — Some seasonal agricultural workers were finishing a meal after a long day of planting sweet potato seeds when Julie Pittman pulled into to their camp.

Up since dawn, they had worked through an 80-degree day that was just beginning to cool off. Now, Pittman, a paralegal with the Farmworker Unit of Legal Aid of North Carolina, wanted to get their attention.

The health care law passed in 2010 requires you to have health insurance, she told them in Spanish. If you don’t get it, she said, you could be fined.

“Cuánto cuesta?” said one worker, wanting to know the cost.

These farmworkers, living in the United States legally through the H-2A visa program, must be insured, like most U.S. citizens and legal residents. But reaching them is an uphill battle. They live in cinder block homes built by employers in isolated areas. They work long days, and often, a full week.

The majority come from Mexico to work in Florida, Georgia and North Carolina. The countdown clock starts when they enter the country. They have just 60 days to learn about coinsurance and copayments, and decide whether to purchase a high- or low-deductible plan.

Alexis Guild, a migrant health policy analyst at Farmworker Justice, an advocacy group based in Washington, said North Carolina has been “very successful” in enrolling H-2A farmworkers, thanks to a yearslong partnership among various nonprofits and health centers.

In the camp near Dunn, about one-third of the 31 residents showed up for Pittman’s presentation, gathering in a small dining room with two picnic tables and cement floors.

The cost of health insurance depends on the type purchased, income and family size, Pittman told them. Some people don’t have monthly payments; others could pay $40 per month. Consider, she added, that this year’s fine is $695 or 2 percent of wages, whichever is greater.

Antonio Flores, of Veracruz, said he worried about the cost. He is in the U.S. for six months and has a wife and son to support. Like other farmworkers based in North Carolina, he makes $10.72 per hour

“Would I need to pay the fine?” said Flores, 29.

It’s a difficult question because some workers qualify for an exemption or are offered insurance through their employer.

Mackenzie Mann, a health educator with North Carolina Farmworkers Project, said the only way to be sure is to fill out a form.

On a recent Wednesday, Mann and a co-worker traveled through a narrow road to a camp in Angier, where workers were waiting for them with insurance letters and payment questions.

On its way to surpass last year’s enrollment totals, the group has signed up about 150 workers since February and they still have two months to go.

First in line at the camp was Apolinar Castillo, of Zacatecas, Mexico, who got a bill in the latest batch of mail he received from his boss.

Castillo, 44, said that after 15 years toiling in the nation’s fields he didn’t think twice about paying $10.55 per month for health insurance. “I feel confident that, if there is an emergency, I can dial 911 and use my (insurance) card,” Castillo said.

After some confusion, Castillo was told that he had already made the monthly payment and the bill he had was old.

Farmworkers receive their mail sporadically, which means deadlines can be missed, further complicating the process. To avoid further delays, Mann submits electronic copies. She uses a smartphone as a hotspot to connect to the internet, a spotty service that requires time and patience.

“I’m hungry,” grumbled a man in a whisper as he waited for Mann to finish up with yet another worker.

Workers under the H-2A visa program are a small minority of the nation’s more than 2.4 million farmworkers, many of whom are in the country illegally and don’t have access to health insurance.

Agriculture ranks among the most dangerous industries, according to the Occupational Safety and Health Administration. Farmworkers face exposure to pesticides, and risk heat exhaustion and heatstroke.

Outside of emergencies, farmworkers can use community health centers, which receive federal funding to care for the poor and uninsured. In North Carolina, about 10 percent of the centers’ more than 450,000 patients in 2014 were agricultural workers.

Dr. Eugene H. Maynard, of the Benson Area Medical Center, said providing care for farmworkers is a challenge. Many procedures can be done at his office, where prices are based on a sliding fee scale. But some problems require specialists, whose steep prices are out of the reach to most workers.

Often, Maynard said, he places workers on waiting lists for charity care, but these lists are so long that workers return to Mexico before seeing a specialist.

“Insurance makes that process a lot easier,” Maynard said.

Alice Pollard or the North Carolina Community Health Center Association, said access to health insurance also opens the door to preventive care for, say, diabetes and high blood pressure, two chronic conditions that are prevalent among farmworkers.

Some are skeptical, though, that access to health insurance would translate into better health care.

Thomas Arcury, director of the Center for Worker Health at Wake Forest Baptist Medical Center, said farmworkers work long hours, don’t have access to transportation or accumulate paid sick days, which is why many ignore their illnesses.

“There are a lot of roadblocks,” Arcury said.

What’s more, if they purchase insurance in one state and then move to another, the insurance may not work in the new state.

Large farmers are required to offer health insurance for their workers. They have raised the issue of cost, arguing that they already provide workers’ compensation, which covers work-related injuries.

U.S. Rep. Renee Ellmers, R-N.C., has twice introduced a bill to exclude farmworkers under the H-2A visa program from the employer mandate. In a statement, she said the cost would put many farmers out of business.

“As North Carolina is the number one producer of sweet potatoes and tobacco in the country, it is imperative that we listen to our farmers when they relay a problem that could cause significant harm to their farming operation and our state’s economy,” Ellmers said.

Steve Davis of Greene County Health Care, a community health center that enrolled nearly 800 workers last year, said most farmworkers know of workers who were injured in a soccer game or got violently ill while in the U.S. and landed in the emergency room.

The bottom line, he said, is that there is a tremendous need to provide health services to farmworkers and health insurance is a step in that direction.

Last October, for example, Feliciano Gonzalez was picking sweet potatoes when he felt an unbearable pain in his arm and chest. In his 17 years picking and planting food in the U.S., Gonzalez, 50, said he never felt so sick.

He underwent a number of tests in the hospital emergency room. Doctors kept him overnight and told him to take a couple days off, he said.

The hospital billed $14,900. It wasn’t a work injury, so his boss’ workers’ compensation insurance didn’t cover the expense. Luckily, Gonzalez had health insurance. His portion of the bill was $750.

“We need to be protected,” Gonzalez said.

EDITOR’S NOTE – Alejandra Cancino is studying health care and long-term care issues as part of a fellowship at the AP-NORC Center for Public Affairs Research, which joins NORC’s independent research and AP journalism. The fellowship is funded by The SCAN Foundation, an independent nonprofit that supports research and other initiatives on aging and health care.