Organizing for Healthcare Reform and Food Policy in New York with The New York Center for Agricultural Medicine and Health: An Interview with NYCAMH Clinical Case Manager Patrick O’Hara

How does healthcare policy affect or intersect with agriculture and food policy?

As a social worker for The New York Center for Agricultural Medicine and Health (NYCAMH), I provide free and confidential counseling and case management services for anyone in production agriculture. The vast majority of my cases involve providing assistance to disabled dairy farmers. I work with agriculture engineers to design assistive technology to enable them to return to farming, or if they can no longer work, I will apply for Social Security Disability as their representative.  

Despite the bucolic setting, farming is an inherent risky and dangerous occupation, and the lack of health care coverage can be a serious threat to the financial viability of a dairy farm in the event of a traumatic farm accident or prolonged serious illness. The price that farmers receive for their milk has been below the production cost for quite some time which may make healthcare unaffordable. When margins are tight and farmers must decide whether to pay for health care coverage or pay down the grain bill or machinery loan, health care will lose every time. Most farmers are dedicated in maintaining their equipment and managing herd health but will forego medical appointments when sick or injured because they cannot take time away from the farm or cannot afford the cost of medical care. To solve this problem, many farmers have health care coverage through spousal off-farm employment or only purchase catastrophic health care coverage.      

President Obama’s 2010 Affordable Care Act (ACA) and the 2018 Federal Farm Bill have helped those in production agriculture to be able to afford purchasing health care coverage. The ACA helped many of my clients purchase health care coverage on the network. For the first time, two of my clients suffering with debilitating degenerative joint disease were able to get the medical care that they needed. One additional client finally had his knee replaced.  The ACA extended dependent coverage to age 26, offered premium subsidies based upon income, expanded Medicaid, and covered preexisting conditions. The ACA marketplace and ACA navigators made coverage more accessible to the small dairy farmer. However, things have changed for the ACA. The elimination of the individual mandate reduced the pool of insurance enrollees and insurance costs have risen. There is a concern that individuals with preexisting conditions will face unaffordable premiums and deductibles. The ACA remains popular with a majority of the American people, and there is great concern that the progress made by the ACA will be eliminated.

The 2018 Federal Farm Bill has also benefited small dairy farmers and intersected with health care. The bill, signed into law on December 20th, attempts to address the low farm milk price. Farmers provide us with a healthy food supply and need a stable income. Farmers will now pay a lower premium for a federal program which will provide payments when the margin between the milk price and feed cost dips below a specified level. The program is complicated but may increase farm profitability and thereby enable farmers to purchase health care coverage.  

In your opinion, what are the most effective ways we can support mental and physical health in the food system? 

Farmers and agriculture workers face worksite dangers, risk exposure to chemicals and pesticides, and risk respiratory hazards associated with organic dust and microorganisms. They may also be at risk of physical health issues such as preventable hearing loss, arthritis, degenerative joint disease, degenerative disc disease, skin cancer, occupational asthma, chronic bronchitis, COPD, farmer’s lung, repetitive motion injuries, and much more. They also risk traumatic injury from machinery entanglements as well as injury from animals.  

There are external and internal barriers to seeking medical and mental health services in rural farming communities. The external barriers may include accessibility, availability and cost. Rural communities may be at an infrastructural disadvantage and can be isolated from physicians, psychiatrists, medical clinics, urgent care centers, and hospitals. There is a risk that farmers will let driving distance limit and dictate the extent of their medical and mental health care.  

The internal, or self-imposed barriers, are more difficult to solve. Internal barriers may include the farmer’s identity of self, problems associated with leaving the farm, the mindset of saving the farm at all cost, the attitude that stress is just an acceptable part of the game of farming, and concern and fear over confidentiality and stigma associated with mental illness. Dairy farmers identify as hard working problem-solvers and work 7 days a week, 12 to 16 hours per day. They work in bad weather, often in horrific working conditions, and work when they are sick or injured. Farmers are proud, self-reliant, independent people with a strong work ethic. However, these great qualities may prevent farmers from leaving the farm to attend a medical or mental health appointment.  There are realistic problems associated with leaving the farm in the middle of the day to attend a medical or mental health appointment. Dairy cows do not respond well to change and are on a milking schedule. Farms are losing money and farmers are hyper focused upon cutting costs, saving time and conserving resources. Their first priority will be to save the farm at all costs, often at the expense of their physical and mental health.  

Unfortunately, there can also be stigma associated with depression and mental illness.  Perception is reality for the rural farmer and there is a great concern about confidentiality, especially concerning mental health issues and services. A medical waiting room is far less threatening than the waiting room in a mental health clinic.  

There are ways in which medical and mental health providers can support the rural farming communities with accessibility, availability and cost of medical and mental health services. Hospitals should have ACA navigators assigned to assist individuals with purchasing appropriate health care coverage on the network. Bassett Hospital, located in Cooperstown, New York, has done an excellent job in the establishment of small satellite medical clinics in rural areas focusing upon examination, diagnosis, treatment, minor procedures, and referral. A farmer may be more inclined to seek medical treatment if they do not have to drive long distances. 

However, it would be beneficial if the clinics offered evening hours for appointments, and the clinics should consider a sliding fee scale for the uninsured poor. Hospitals should also revisit their policy concerning financial assistance being based upon gross income rather than adjusted gross income for the self-employed. Concerning mental health services, hospitals should have clinical social workers rotate to the various rural clinics for counseling sessions. This would eliminate the embarrassment, stigma, and confidentiality concerns associated with the waiting room of an outpatient mental health clinic. There is no stigma associated with medical appointments and no one would know if the individual was waiting for a medical appointment or mental health counseling.

What are your biggest fears in this moment? What opportunities do you see?

This response represents my personal views and not necessarily those of NYCAMH or NYCAMH employees.

During the 2016 campaign, Donald Trump promised great things for the American farmer.  Yet his seemingly ill-advised trade war and the subsequent retaliatory tariffs have resulted in making American farm commodities less attractive on the world market, have resulted in lost foreign markets, decreased exports, and reduced farm profits.  Trump’s trade war hurt American farmers and rural communities. Many farms already at the mercy of uncertain weather, variable markets and high inputs, have been driven to the edge of the void by Trump’s policies. My biggest fear, as with anything with this administration, is what’s next?

As far as opportunities, there have been numerous news articles about the farm milk price. Many politicians, including Senators Chuck Schumer and Kirsten Gillibrand, have voiced concern about the price that farmers receive for their milk. The 2020 election might be motivation for some politicians to actually attempt to solve the problem rather than just use it as a talking point, but farmers and consumers will have to hold their political feet to the fire. Farmers, farm organizations, and consumers must keep the pressure on their elected officials to take action to guarantee dairy farmers a fair price for their milk. Consumers should support their rural community and local farmers and growers. Consumers should know where their food comes from and purchase locally grown agricultural products.      

Is there a specific policy or action that your organization is driving or would endorse?

I directed this question to Julie Sorenson, PhD., NYCAMH’s Director. Julie says:

“The Northeast Center does not have a specific policy that we would endorse beyond the provision of funding to expand agricultural workers and farm owners access to high-quality, culturally competent, mental health support. A good example would include federal funding for the Farm Ranch and Stress Assistance Network which was introduced in the 2019 Farm Bill or funding for various state-based mental health and financial counseling services, such as NYCAM’s Farm Partners Program, NY FarmNet or VT FarmFirst. These services can work to ameliorate, to some degree, the consistent financial stressors that farm owners and workers are dealing with on a daily basis. However, these resources cannot completely address the more deeply rooted structural issues that have made U.S. farming an extremely difficult and financially risky enterprise. These issues relate to product pricing which for certain commodities are outside the farmers control and are not even remotely tethered to the cost of production, access to an affordable, trained and consistently available pool of labor, and assistance with meeting regulatory compliance demands. Addressing these issues would require developing a functional immigration policy that offers streamlined access to both seasonal or year-round workers (as in the case of dairy farms), more communication across government agencies so that there is consistency in agricultural regulatory compliance, as well as regular assessments of regulatory burden and product pricing that is based on the cost of doing business. Lastly, access to healthcare is an absolutely vital component of ensuring the welfare of food producers, whose work is based on their ability to engage in physically demanding work. Although the discussion of the Affordable Care Act has been politically divisive, a federal policy that addresses the rising costs of healthcare and health insurance and improves access to these resources would greatly improve the lives of our nation’s producers.” 

What do you want the larger agricultural community to know about the healthcare needs of farmworkers, farmers, and/or foodchain workers?

It does a terrible injustice to farmers to describe “farming” as an occupation. Farming is a time honored way of life and work is intertwined with daily family living. There was a time in this land when you could drive down any state or county highway and pass countless small dairy farms with cows grazing in the fields.  Now you pass barns with collapsed roofs and overgrown fields. Many dairy farms went back generations but now some small family farms are facing extinction as the result of the current milk price. Farmers have no control over the price they receive for their milk, and cannot increase the price of their milk when inputs such as fuel, seed corn, and fertilizer increase. With farmers, something has to give and usually it is their health care coverage. The Affordable Care Act took some financial pressure off of the small farmer, and for many it was the first time they were able to afford family health care coverage.  Any rollback of the ACA will adversely affect the farmer’s ability to purchase healthcare.

New York Center for Agricultural Medicine and Health aims to enhance agricultural and rural health by preventing and treating occupational injury and illness through research, outreach, education, and clinical consultation services by a professional interdisciplinary staff that includes epidemiologists, biostatisticians, social workers, information specialists, occupational health nurses, educators, physicians, bilingual safety specialists and support staff.  

Patrick O’Hara, LMSW, is a Clinical Case Manager for New York Center for Agricultural Medicine and Health (NYCAMH) within the Bassett Healthcare Network. He provides free and confidential counseling and case management services for anyone in production agriculture, and works primarily with disabled farmers. He has a B.S. from Cornell University and a Masters Degree in Social Work from Nelson A. Rockefeller College of Public Affairs and Policy.