Health Economics and Policy, Labor and Human Capital,

Ahearn, Mary Clare

Mishra, Ashok K.

English

Research Papers in Economics

  
4th Quarter 2009 | 24(4)  
ACCESS OF FARM HOUSEHOLDS TO HEALTH CARE  
Mary Ahearn and Ashok Mishra 
Access to health care involves adequate availability of medical professionals and related services and the 
ability to afford those services, through health insurance plans and/or to cover out-of-pocket expenses. 
Measuring adequacy of care available and the ability of the farm population to pay for care for the 5.5 million 
persons in family farm households is confounded by a variety of factors that point to the uniquenesses and 
differences among farm families, as well as the limitations of current data systems. Regarding the adequacy 
of care, health status of farm people, riskiness of the farming environment, and the physical distances to 
health professional services and facilities all come into play. Besides household income, the ability to pay for 
care is largely influenced by access to reasonably priced insurance plans, such as employer-sponsored 
plans. Health care reform promises to directly address the issue of access to affordable health insurance 
coverage that here-to-fore has not been widely available to self-employed individuals and their households. 
However, it is much less clear how health care reform will affect the location of health professionals and 
facilities in rural areas where farm households are more likely to reside. 
Incomplete Farmer Health Status Data 
Unlike for the general population or the rural population, objective and comprehensive information on the 
mortality and health status of the relatively small farm population is not available. Therefore, there is no 
simple summary conclusion to draw about the health status of the farm population, as is possible when 
discussing health status of the rural population. Partial information on health outcomes of farmers is available 
from small area epidemiological studies that are not representative of all farmers (e.g., cancer effects of 
alternative pesticides on high-risk farmer groups). Nationally comprehensive, yet partial, indications of the 
health status and mortality of farmers are available through occupational fatalities data and self-reported 
health status of farm operators whose principal occupation is farming—less than half of all principal farm 
operators. Information is also available on factors that contribute to health outcomes of farm operators with a 
major occupation of farming, such as personal behavior (e.g., smoking and diet). 
But, it is clear that farming has had and continues to have more fatal on-the-job injuries than most other 
occupations. While the overall occupational fatality rate of workers in the United States in 2008 was 3.6 per 
100,000 workers, the rate for those with farming or ranching as a major occupation was more than ten times 
higher—39.5 per 100,000 (U.S. Department of Labor, 2009). Furthermore, whereas fatal injuries per 100,000 
workers generally declined for all U.S. workers from 1992 to 2008, the fatality rate for farmers and ranchers 
almost doubled during this same period. Leading causes of farm fatalities from workplace injuries and 
accidents are transportation incidents including tractor rollovers, contact with objects or equipment, and 
assaults including animal attacks. More than 100 farmers in the United States die annually from tractor 
overturns. Contributing to the risks are the long hours worked during planting and harvesting periods by 
farmers, their family members, and hired workers. The fatal injury rate for those in crop production has 
averaged more than twice that for those in animal production. While these national data are for farm 
operators, we also know that they have implications for others who live on U.S. farms since farming is one of 
the few industries in which the families—who often share the work and live on the premises—are also at risk 
for injuries, illness, and death. In the Keokuk County, Iowa Health Study, youth reported the average age for 
driving tractors of 11, for driving self-propelled combines of age 13, and for applying or handling fertilizer of 
age 12. This occurs, despite the legal prohibition of hazardous work for children under the age of 16 (Park, et al. 2003). 
In contrast to higher farmer fatality rates, a recent ERS report found generally favorable health-related 
personal behaviors and disease incidence self-reported by individuals with farming as their major occupation 
in a national survey. In particular, the incidence of farmer smoking was significantly less than that of other 
workers (Jones, et al. 2009). The incidence of cancer, asthma, and emphysema are often the focus of 
epidemiological studies of small farmer groups because some farming practices, such as the use of farm 
chemicals, are often hypothesized to result in negative health outcomes. And, yet, this study reported that 
relative to nonfarm workers, farmers reported significantly lower—not higher—incidence rates of asthma and 
emphysema and no difference in the incidence of cancer. Seemingly confounding results are reported 
elsewhere in the literature for asthma. For example, a small Iowa population study found farm children were 
less likely to have asthma than other children in the county, unless they were living on farms that raised hogs 
and added antibiotics to feed (Merchant, et al. 2005). On the other hand, a study of dairy farmers in New 
York showed that farmers have an elevated risk for asthma (Jenkins, et al. 2005). The Iowa study also found 
that men had lower rates of asthma than women, even though the men were more likely to be farming and 
have greater exposure to hazardous conditions, such as grain dust and agricultural chemicals (Merchant, et 
al. 2002). 
In a national sample, farmers reported significantly lower incidence rates of cardiovascular diseases than 
nonfarmers, perhaps as a result of their physically active lifestyle (Jones, et al. 2009). This is consistent with 
a study of New York dairy farmers for 1999 which found that farming had a protective effect for hypertension 
and other cardiac conditions (Jenkins, et al. 2005). 
The need for health care and health status can be mediated by higher socioeconomic status. Farm operator 
households are more likely to be of higher socioeconomic status than all nonmetro households: a larger 
share has household heads that graduated from college and median household income and wealth are 
higher. But the need for care also generally increases with age and farm persons have an older age profile 
than the general U.S. population. In short, what partial information is available on the health status—and, 
hence, health care needs—of the farm population simply does not lend itself to a clear conclusion about how 
the farm population compares to the general U.S. population. 
Farm People Travel Greater Distances to Health Care  
Convenient access to health care is more likely to be a challenge for persons residing in sparsely populated 
areas, whether farm or nonfarm, as a result of the greater distances to doctors’ offices and major medical 
facilities. The geographical distribution of the households of farm principal operators is quite different from 
that of all U.S. households, which are predominantly located in metro counties (83%), with one-third in 
principal cities of metro countries. In contrast, farm operator households are predominantly (60%) located in 
rural areas, and among rural households, farm households are more likely to be in the lower density, more 
remote rural areas. Farm households located in metro areas are concentrated in smaller metro areas while 
nonfarm households are more likely to be in large metro areas. 
Compared to the general U.S. population, farm operator households generally have to travel greater 
distances to receive health care, especially specialized care. Based on the Department of Health and Human 
Services’ Health Professional Shortage Areas, as shown in Figure 1, 17% of the farm population resides in 
shortage areas for primary care access, compared to less than 4% of the U.S. population (Jones, et al. 
2009). Farmers are more likely to reside in shortage areas for dental and mental health care, too, than the 
general population. Nearly half of all farmers reside in areas designated as mental health shortage areas.  
Health Insurance Coverage and Health Expenses of Farm People 
There are 2.1 million farms in the United States. Most of these farms, 97%, are classified as family farms 
operated by a self-employed farmer. Obtaining health insurance coverage can be a challenge for self-
employed persons, farm or nonfarm, since the major source of health insurance in the United States remains 
employer-sponsored insurance. In 2008, 75% of insured persons under 65 years of age in 2008 were 
enrolled in employer-sponsored insurance programs (Denavas-Walt, Proctor, and Smith, 2009). Government 
insurance plans are available to those 65 or older and those with specialized needs, such as the disabled or 
those with very low income. Otherwise, those without access to employer-sponsored insurance plans must 
rely on individual health insurance plans. The terms and expense of health insurance plans vary widely, but 
generally individual plans have higher premiums and greater out-of-pocket expenses due to greater 
exclusions, deductibles, and co-pays. 
Data on health insurance coverage of the U.S. population has been available for decades. However, 
because of their small numbers, data on persons in farm operator households have only been available since 
2006 on USDA’s Agricultural Resource Management Survey. For the most current year available, 2008, 
15.4% of the U.S. population had no form of health insurance; for members of farm operator households, the 
comparable figure was 17.7% (U.S. Department of Agriculture, 2009). But in the prior two years, persons on 
farm households were more likely than the general public to have health insurance. The higher rate of 
decline in insurance coverage for farm persons from 2007-08, compared to the U.S. population, points to 
their greater vulnerability to being uninsured. In some cases, farm households lost employer-sponsored 
health insurance along with off-farm job opportunities, and in other cases, farm households were less able to 
purchase the more expensive individual plans directly from an insurance company as their household 
incomes declined. 
Although farm operators are largely self-employed, the majority of farm households have an operator or 
spouse employed off the farm. Consequently, as with the general population, the most common source of 
health insurance for members of farm households is employment-based. In fact, farmers are almost as likely 
as the general U.S. population to receive their health insurance through an outside employer. Farmers are 
more likely than the general population to directly purchase their health insurance from an insurance 
company, and less likely to receive health insurance from a government-sponsored program, such as Medicare or Medicaid. 
In 2008, about half of farm household members had health insurance coverage from an employment-based 
plan. For households where both the principal operator and spouse worked off-farm, nearly three-quarters of 
household members were covered by employment-based plans. In households where neither the principal 
operator nor the spouse worked at an off-farm job or business, only 18.6% of household members were 
covered by employment-based plans. Members in these households had significantly more coverage under 
private-direct purchase plans and government-provided plans, such as Medicare. The reliance on 
government plans for those who do not work off the farm is consistent with the higher share of these 
operators who reported being 65 years old or more. 
One major reason that a farmer or rancher would work solely on the farm and not have access to employer-
sponsored insurance through an off-farm job is the intensive time commitment for some commodity 
specializations. An obvious example of this is in dairy production. Farming is the major occupation for 95% of 
those that specialize in dairy production—significantly more than the 43% across specialties. Compared to 
the 60% of all farm persons who receive insurance from employer-sponsored plans, only 30% of persons in 
dairy households do. In 2008, 47.5% of persons in dairy households did not have any health insurance 
coverage. In 2007, the comparable share was 34.7%. This increase is reflective of the deteriorating financial 
conditions for dairy producers from 2007 to 2008 when average dairy family farm income from farming 
declined by 6.2%, with further declines expected for 2009. 
Having health insurance and the source of health insurance are major determinants of the household 
expenses for health care. More than 10% of farm households had only direct-purchase insurance in 2008, 
the most expensive type of plan on average. These farm households had the highest health expenses of all 
farm households, nearly $8,000 per household and accounting for one-fifth of their total household cash 
expenses in 2008. 
Implications of Reform 
Although comprehensive information does not exist on health status of farm persons, that is not the case for 
information on their access to health care. As often self-employed and residents of remote rural areas, most 
farmers currently face a double challenge in obtaining access to care. We can say with relative certainty that 
farm operator households have less access to care as measured, first, by availability of local medical 
resources. Secondly, they have less access due to their higher health care expenditures for insurance 
premiums and out-of-pocket expenses, although they also have greater average incomes. 
Current versions of the health care reform bills that extend insurance coverage to individuals that are not 
currently offered group plans through employers could increase access of farm households to insurance 
coverage. In addition, given the known risks of their farm occupation, farmers who currently face obstacles in 
obtaining coverage as insurance companies seek to minimize their exposure to enrollees in high-risk 
occupations are likely to have those obstacles removed. Although specific plan benefits are not clearly 
defined under the reform bills, plans available through an insurance exchange could include plans that offer 
co-pays and deductibles that are much lower than those currently offered by the current individual plans. 
Due to low population densities and small patient volumes in rural areas, geographical access to care—
particularly for farm households living in smaller and more remote counties—will likely continue to be a 
challenge after the next round of health care reform. Rural areas are already experiencing less access to 
physicians, for both primary care and specialists. Provisions that provide incentives for medical personnel to 
locate in underserved areas, for example, medical school loan forgiveness programs, will aid in improving 
access to care. However, there is a great deal of uncertainty about how providers and insurance companies 
will adjust to the incentives provided by changes incorporated in new legislation. Of special concern will be 
adjustments that come in the form of movement of health care resources away from rural areas as discussed 
in other articles in this issue, if providers recognize greater incentives to locate in metro areas.  
  
For More Information 
Denavas-Walt, C., Proctor, B., and Smith, J. (2009). Income, poverty and health insurance coverage in the 
US: 2008. Washington, D.C.: U.S. Dept. of Commerce. Bureau of the Census. P60-236 (Rv). 
Jenkins, P., Earle-Richardson, G., Bell, E., May, J., Green, A. (2005). Chronic disease risk in Central New 
York dairy farmers: results from a large health survey 1989-1999. American Journal of Industrial Medicine 47 
(1), pp. 20-26. 
Jones, C., Parker, T., Ahearn, M., Mishra, A., and Variyam, J. (2009) Health status and healthcare access of 
farm and rural populations, EIB-57. Washington, D.C.: U.S. Department of Agriculture, Economic Research 
Service. 
Merchant, J., Naleway, A., Svendsen, E., Stromquist, A., Kelly, K., Taylor, C., Thorne, P., Reynolds, S., 
Burmeister, L., Sanderson, W., Chrischilles, E. (2005). Asthma and farm exposures in a cohort of rural Iowa 
children. Environmental Health Perspectives 113 (3), pp. 350-356. 
Merchant, J., Stromquist, A., Kelly, K., Zwerling, C., Reynolds, S., and Burmeister, L. (2002). Chronic disease 
and injury in an agricultural county: the Keokuk County Rural Health Cohort Study. The Journal of Rural 
Health, 18 (4), pp. 521-535. 
Park, H., Reynolds, S., Kelly, K., Stromquist, A. Burmeister, L., Zwerling, C. and Merchant, J. (2003). 
Characterization of agricultural tasks performed by youth in the Keokuk County Rural Health Study. Applied 
Occupational and Environmental Hygiene, 18(6), pp. 418-429. 
U.S. Department of Agriculture, Economic Research Service. (2009). Farm household economics and well-
being briefing room. Available online: http://www.ers.usda.gov/Briefing/WellBeing/ 
U.S. Department of Labor, Bureau of Labor Statistics. (2009). National census of fatal occupational injuries. 
Available online: http://www.bls.gov/iif/oshcfoi1.htm/. 
Mary Ahearn (mahearn@ers.usda.gov) is a Senior Economist, Economic Research Service, USDA and Ashok Mishra (amishra@agcenter.lsu.edu) is an Associate Professor, Department of Agricultural Economics 
and Agribusiness, Louisiana State University AgCenter. 
The views expressed in this article are the views of the authors and not necessarily the views of the 
institutions of the authors.  
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Access of Farm Households to Health Care

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