1st Quarter 2018 • 33(1)
1 CHOICES 1st Quarter 2018 • 33(1)
Health Insurance and National Farm
Policy
Shoshanah Inwood, Alana Knudson, Florence A. Becot, Bonnie Braun, Stephan J. Goetz, Jane M.
Kolodinsky, Scott Loveridge, Katlyn Morris, Jason Parker, Bob Parsons, Rachel Welborn , and Don E.
Albrecht
JEL Classifications: Q14, Q15, Q18, I13
Keywords: Farm Bill, Health Insurance, Rural Development, Young Farmers
In the midst of national healthcare debates, there has been little discussion of how health, healthcare costs and
access, and health insurance fit into national agriculture policy efforts to build a more vibrant and resilient farm
economy. Yet Inwood (2015) found that 65% of commercial farmers identified the cost of health insurance as the
most serious threat to their farm, more significant than the cost of land, inputs, market conditions, or
development pressure. In order to grow the next generation of farmers and increase rural prosperity, there is a
need to understand how healthcare costs, access, and insurance affect both agriculture and rural development.
Responding to the shrinking and aging farm population, Congress has broadened approaches to stimulating growth
and innovation in the food and agriculture sector through recent Farm Bills by including added funding for new and
beginning farmer and rancher programs. Along with increasing access to markets, capital, and land, many
programs focus on building human capital in the farm sector through training and education. These rural and
workforce development programs have not, however, considered how health insurance influences these initiatives
or the role of health insurance as a salient tool for supporting rural economic development.
In 2011 and 2015, the USDA included questions about health insurance on the Agriculture Resource Management
Survey (ARMS). The ARMS data track overall numbers of farmers insured and their source of coverage. Yet, outside
of Ahearn, El-Osta, and Mishra (2013) and Ahearn, Williamson, and Black (2015), there has been little discussion or
analysis of how health, health insurance, or access to healthcare affect farm management decision-making and
rural development. The authors of this paper are members of the national USDA-NIFA-funded project Health
Insurance Rural Economic Development and Agriculture (HIREDnAg). The goal of this national research and
Extension project is to understand how health insurance affects economic development and quality of life in the
agriculture sector. We present new research findings examining health insurance access and use in the farm
population and connections between health insurance and risk management, farm viability, and farmland access.
We also discuss implications of this research on efforts to grow the next generation of farmers and ranchers and
on rural economic development.
Approach and Methods
The research presented here is based on data from farmers and ranchers (hereafter farmers) collected in 10 case
study states across the United States, including: California, Kentucky, Massachusetts, Michigan, Mississippi,
Nebraska, Pennsylvania, Utah, Vermont, and Washington. Study states are located in each USDA region of the
country (Northeast, North Central, South, West). State flexibility in implementing 2010 federal health insurance
reforms introduced through the Patient Protection and Affordable Care Act (ACA) created discrete policy
environments. States had the option to expand Medicaid and to establish state or federal health insurance
exchanges, also known as marketplaces. Within each region, we paired states based on whether or not they chose
to expand Medicaid (Figure 1).
2 CHOICES 1st Quarter 2018 • 33(1)
Using a mixed-methods
approach, we conducted
in-depth interviews with
up to 10 families in each
case study state in 2015–
2016 and surveyed
randomly sampled
producer households in
these states in 2017,
yielding 1,062 responses.
Mixed-methods research
that includes both
qualitative and
quantitative methods
offers better
crosschecking and
triangulation of data
(Guba and Lincoln, 1981)
and ensures the reliability
and validity of analysis
(Janesick, 1994). Survey
and interview questions
focused on healthcare and
health insurance access, off-farm work, farm finances and
economics, and farm labor. To ensure that our sample was
representative of the national farm population, we weighted
the sample on reported sales data to match sales proportions
reported in the 2012 Census of Agriculture for the national
farm population (Table 1). We present both the quantitative
and qualitative data and include quotes that reflect common
themes expressed by farmers in both the interviews and
written survey comments.
Health Insurance Access and Use
Partly because of off-farm work, farmers have historically had
overall high rates of health insurance (Ahearn, Williamson,
and Black, 2015). Findings from the USDA’s 2015 Agricultural
Resource Management Survey (ARMS) found that farmers are
just slightly more likely to be uninsured than the general
population (10.7% vs. 9.1%); dairy farmers are the most likely
to be uninsured because they are most likely to farm full time
and therefore less likely to have off-farm employment
(Prager, 2016). Similar to the ARMS data, the majority of
farmers in our survey sample (92%) reported that they and
their families had health insurance in 2016. The way farm
families are insured, however, is complex and varies by their
age and life stage, health, values, and the structure of the
enterprise.
In the survey sample, 32% of farmers reported two or more
health insurance plans within the same family. For example,
one Nebraska farm family of four had insurance plans from three different sources: employer-based insurance for
one adult, marketplace-purchased insurance for the other adult, and Medicaid (Children’s Health Insurance
Figure 1. Map of Case Study States
Table 1. Farmer and Rancher Demographics
3 CHOICES 1st Quarter 2018 • 33(1)
Program, CHIP) for both children. Half (50%) of the farm families had health insurance through an off-farm
employer, 38% had a public health insurance plan (Medicaid, Medicare, or CHIP), and 29% purchased a private
policy. Smaller percentages of farmers purchased a plan through a farm organization (3.7%), were on their parents’
plan (3.6%), or enrolled in
a healthcare sharing
ministry (1.1%) (Table 2).
Health insurance options
vary with age and income
of individual family
members and can change
during life events and
transitions, such as leaving
a parent’s insurance,
change in marital status, or
changes in off-farm
employment. For example,
a Utah rancher shared, “I had good health insurance through my wife’s employer. I lost it when we got divorced.”
Among older farmers, it is common for one family member to be on Medicare while their younger spouse, not yet
eligible for Medicare, has an employer-offered plan or a state or federal health insurance marketplace plan. Older
farmers frequently reported delaying healthcare until they were eligible for Medicare at age 65. As a farmer from
Michigan explained, “Once we hit 65 everything was taken care of.” While changes in health insurance due to life
course changes are not unique to farm families, farming is a physical occupation, and physical health is a
prerequisite for the business to operate. Farming ranks among the most dangerous occupations in the United
States (CDC, 2013), and the injury rate for agricultural workers is 40% higher than the rate for all workers (BLS
2011), reinforcing the need to understand how health, access to healthcare, and the farm business are connected.
Fourteen percent of farmers reported they had transitioned from employer-based insurance options into the
marketplace or enrolled in a public health insurance plan in the last five years. A provision of the ACA uses income
and not assets to determine Medicaid and Marketplace subsidy eligibility (Andrews, 2013). This provision
decouples the family from the assets of the enterprise and addresses the “land rich, cash poor” conundrum
farmers often face. A Vermont dairy farm family was surprised to find they were eligible for expanded Medicaid;
they explained that “we met with the assistor who looked at our [net] income, and we qualified… [I]t was the first
time we had health insurance.”
About one out of five farmers (19%) of farmers shared that marketplace health insurance options available after
2010 allowed them to sign up for health insurance for the first time. For example, a ranch family with five children
explained how ACA health insurance legislation changed their access to healthcare. Their three oldest children had
never gone to the doctor because they had no health insurance. After the ACA implementation, the two younger
children had preventative well-child visits and the family had access to a wider range of health services.
In 2016, 8% of our sample had no health insurance. These farmers shared that marketplace plans were
unaffordable to them for two reasons. Some reported the premiums were unaffordable, while for others the cost
of using the plan was too high due to high deductibles and out-of-pocket costs. These farmers still reported
prioritizing their health by being cautious with their bodies, going for chiropractic care, bartering for healthcare, or
using food as medicine.
As a cost-saving strategy, coupled with personal convictions, a small percentage of farmers (1.1%) reported
enrolling in healthcare sharing ministries or faith-based healthcare plans as alternatives to buying health
insurance. These plans do not cover preventive health services, but serve as a risk management strategy by
providing catastrophic coverage. As such, some farmers reported delaying preventative care for themselves and
their families that was not covered. The plans potentially inhibit access to care until a health issue becomes acute
and expensive to treat. Some farmers shared how they continued to rely on public healthcare access through
Table 2. Farmers’ Source of Health Insurance Coverage
4 CHOICES 1st Quarter 2018 • 33(1)
programs like subsidized vaccinations. A Michigan farm family with a large grain operation and enrolled in a faith-
based plan reported relying on the local county vaccine program for their children, while a Michigan fruit grower
shared, “I have a Christian Managed Health Care Account. I need a shingles vaccine. They don’t cover it. I’ll wait
two years till I’m 65 and then Medicare will cover it.”
Connection between Health, Health Insurance, and Risk Management
Farming is an inherently risky and dangerous occupation, and many farmers view health insurance as part of their
risk management strategy. Three out of four famers surveyed (74%) reported that health insurance is an important
or very important risk management strategy. As one farmer from Kentucky shared, “You have to have insurance.
We have a risky job.” Another farmer from Mississippi said, “Show me a farmer who is not injured.” Nonfatal
injuries and work-related illnesses can result in lost work time and permanent impairment that reduce farm
productivity and profitability.
The health and well-being of all farm family members directly impact the farm enterprise. The farm enterprise and
farm family are often treated as separate, but the two are intertwined. Two out of five farmers (40%) reported
that they or a family member had health problems affecting their ability to farm. In addition, 50% reported they
would have no one to run the farm in the case of a major illness or injury. These findings demonstrate the way in
which health creates constraints on the farm operation with direct implications for enterprise growth and
development. Current farm risk management programming predominantly focuses on production and marketing
related risks and currently places little emphasis on health risk outside of farm safety. These findings reinforce the
need for more active integration of health into business and risk management planning.
Health Insurance, Farm Viability, and Farm Land Access
The finances of farm operations and farm families are often co-mingled, and healthcare costs can influence the
trajectory of the farming enterprise. Greater than two-thirds (64%) of farmers reported that they were not
confident they could pay the costs of a major illness or injury such as a heart attack, cancer, or loss of limb without
going into debt. Moreover, 53% reported they were concerned they would have to sell up to the entirety of their
farm assets to address health-related costs such as long-term care, nursing home care, or in-home health
assistance.
Nationally, farmers have an average age of 58.3 years, and an aging population is more prone to health conditions
that require costly care. Two-thirds (64%) of farmers in the survey sample reported having a pre-existing health
condition. Taken together, these results indicate that to cover healthcare needs, older farmers may need to farm
longer to augment their incomes or sell land to the highest bidder, which may result in nonfarm development and
exacerbate the land-access bottleneck for young and beginning farmers. This further disrupts efforts to attract
young farm families, as aging farmers persist in their occupations past the window of opportunity for their children
and other young farmers to succeed them.
Growing the Next Generation of Farmers
The Farm Bill supports new and beginning farmers through strategic investments in production, marketing, access
to capital and land, and succession planning but does not address health insurance. The Young Farmer Coalition
cites health insurance as one of the top three issues affecting the trajectory and success of young and beginning
farmers (Shute, 2011). Examining macro-level data, Ahearn, Williamson, and Black (2015) and Bubela (2016)
expected farmers would have little incentive to purchase a health insurance plan in the marketplace because of
the burden of high costs on a young and beginning farmer’s operation. We found, however, that access to
affordable health insurance through marketplace subsidies and Medicaid expansion has benefitted young farmers,
especially in Medicaid expansion states.
Among young farmers, 18 to 34, over 11% report purchasing a policy from the health insurance marketplace, and
almost half (41%) enrolled in a public health insurance program (Medicaid, TRICARE, or CHIP). Young and beginning
farmers who purchased health insurance plans in the marketplace were able to take advantage of the available
5 CHOICES 1st Quarter 2018 • 33(1)
income-based subsidies, as one young farmer from Massachusetts explained, “It is cheaper for me to purchase a
Silver plan in the marketplace than to go without health insurance and pay the penalty. And I really like having
health insurance.” A young diversified farming couple in Vermont explained, “This insurance [Medicaid] means I
can keep farming, it reduces the risk of farming for me and I don’t worry as much about being in a really risky
occupation hard on my body.” Marketplace and expanded Medicaid have provided more health insurance options
for young farmers in the early phase of their business cycle. By removing the need for a full-time off-farm job with
benefits, farmers reported being able to invest more time and money into growing their operation.
Affordable and accessible health insurance options were especially significant for families who prioritized health
insurance coverage for their children. Farm families shared the conflicting insurance options they face: 1) Famers
can insure their families through an off-farm job, which takes time and energy away from the enterprise, or 2)
depending on income, children may qualify for state-run CHIP health insurance; however, parents may remain
uninsured or underinsured. Some farm families reported deferring job opportunities that would offer extra income
and cash flow because the added earnings would increase their income above the threshold eligibility for public
health insurance, but income levels would still be relatively low, making marketplace health insurance options
unaffordable. This suggests that policies and programs aiming to build a young vibrant farm population can be
strengthened by accounting for how health insurance factors into young and beginning farmer’s business plans
and family needs.
Jobs and Rural Development
In this sample, the majority (72%) of farmers 18–64 years old reported having full-time, part-time, or temporary
off-farm work for additional income and access to health insurance. Understanding the relationships among types
of jobs (e.g., salary, hourly), employers (e.g., public, private, nonprofit), and benefit packages that are supporting
farm families is critical to understanding their effect on the farm business and rural economic development. While
off-farm work provides an important source of income, cash flow, and health insurance, it also takes time and
energy away from the farm enterprise and family and is an added source of tension and distraction. One
multigeneration rancher commuting to a full-time off-farm job 45 minutes away articulated this challenge faced by
many farmers:
We really would love it if we didn’t have to worry about me having a full-time job for insurance so that we
could just farm and ranch. We would be okay on the farm without my full-time job, but you have to have it
for the insurance. …you’d get more done so you’re not doing everything in the dark at 11 o’clock at night.
I’m a believer that my family would have been a little better off if I was just working part time.
The stress of off-farm work is compounded by lack of high-paying employers offering health insurance and benefits
in rural areas and shapes how farmers balance farm priorities with off-farm employment demands. In our
interviews, farmers consistently pointed out the stress of commuting long distances to work, farming, and family
obligations and the additional stress of performing well at their job to ensure they would not be fired or let go and
lose their benefits.
As noted earlier, even farm families with employer-based insurance reported that individual family members are
insured through different plans. In this survey, 46% of farmers were insured through public-sector jobs (health,
education, government) compared to 36% in the private sector, and 20% in the nonprofit sector. In rural areas,
public-sector jobs tend to offer the highest wages and most generous benefits. Changes in public- and private-
sector employment options and benefits affect the financial stability and social well-being of farm families with
impacts felt throughout rural communities.
Another challenge some farmers noted is the lack of physical access to healthcare resulting from rural hospital
closures. Several farmers reported the consolidation of rural healthcare facilities, resulting in longer distances to
travel for services. Employers prefer to locate in communities with high-quality healthcare services leaving rural
communities without strong healthcare systems at a disadvantage in attracting new businesses offering quality
jobs (Pender, Marré, and Reeder, 2012). Rural development programs embedded in the Farm Bill need to account
for these emerging trends when creating programs and developing incentives for rural economic development.
6 CHOICES 1st Quarter 2018 • 33(1)
Health Insurance, National Farm Policy, and the 2018 Farm Bill
Health insurance is a cross-sector risk for agriculture, interconnected with farm risk management, productivity,
health, retirement, need for off-farm income for farmers of all ages, and land access for young and beginning
farmers. In our survey, farmers expressed a preference for national health insurance policy to address specific
needs of the farm sector. Three-quarters of farmers (74%) believed that the USDA should represent their unique
needs in national health insurance policy discussions.
The 2018 Farm Bill presents a new opportunity to integrate health, access to healthcare, healthcare costs, and
health insurance into the Risk Management Agency (RMA) and Rural Development (RD) initiatives that work to
promote a vibrant and resilient farm sector. RMA programs traditionally focus on crop insurance as a way to
manage risk, but there is an opportunity to expand how risk is framed to include health, healthcare costs and
access, and health insurance. Moreover, there is an opportunity to account for age-specific health insurance needs
that change along the life course by accounting for the varying needs of young farm families with young children,
those who are middle-aged, and those over 65. The USDA has made substantial efforts to recruit a new generation
of farmers and ranchers. To ensure returns on this investment, it is critical to consider the interplay between
national farm policy and healthcare policy. RD initiatives could account not only for the number of jobs created in
rural areas but also the quality of those jobs, including the provision of health insurance benefits, to support
efforts to build a more vibrant and prosperous farm sector and rural economy. Including the ARMS health
insurance questions on the Census of Agriculture would allow researchers and policy-makers to track changes over
time and respond better to producer health policy and program needs.
For More Information
Ahearn, M.C., J.M. Williamson, and N. Black. 2015. “Implications of Health Care Reform for Farm Businesses and
Families.” Applied Economic Perspectives and Policy 37(2):260–286.
Ahearn, M.C., H.S. El-Osta, and A.J. Mishra. 2013. “Considerations in Work Choices of U.S. Farm Households: The
Role of Health Insurance.” Journal of Agricultural and Resource Economics 38(1):19–33.
Andrews, M. 2013. “Income, Not Assets, Will Determine Subsidies in Online Insurance Marketplaces.” Kaiser
Health News Network. Available online: http://khn.org/news/070213-michelle-andrews-answers-readers-
questions-on-assets-and-student-health-plans/
Bubela, H.J. 2016. "Off-Farm Income: Managing Risk in Young and Beginning Farmer Households." Choices 2016(3).
Bureau of Labor Statistics, United States Department of Labor. 2011. Number and rate of fatal occupational
injuries, by industry section. 2011. Available online: http://www.bls.gov/iif/oshwc/cfoi/cfch0010.pdf.
Center for Disease Control and Prevention (CDC). 2013. “Agricultural Safety.” Workplace Safety & Health Topics.
Available online: http://www.cdc.gov/niosh/topics/aginjury/.
Guba, E., and Y. Lincoln. 1981. Effective Evaluation. San Francisco, CA: Jossey-Bass.
Inwood, S. 2015. “Opportunities for Extension: Linking Health Insurance and Farm Viability.” Journal of Extension
53(3): 3FEA1.
Janesick, V.J. 1994. “The Dance of Qualitative Research Design.” In N. K. Denzin and Y. S. Lincoln, eds., Handbook of
Qualitative Research Design. Thousand Oaks, CA: Sage, pp. 209–219.
Pender, J., A. Marré, and R. Reeder. 2012. Rural Wealth Creation Concepts, Strategies, and Measures. Washington,
DC: U.S. Department of Agriculture, Economic Research Service, Economic Research Report 131, March.
7 CHOICES 1st Quarter 2018 • 33(1)
Prager, D. 2016. Health Insurance Coverage. Washington, DC: U.S. Department of Agriculture, Economic Research
Service. Available online: https://www.ers.usda.gov/topics/farm-economy/farm-household-well-being/health-
insurance-coverage/
Shute, L. 2011. “Building a Future with Farmers: Challenges Faced by Young, American Farmers and a National
Strategy to Help Them Succeed.” National Young Farmers Coalition. Available online:
http://www.youngfarmers.org/newsroom/building-a-future-with-farmers-october-2011/
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