Introduction
Farmworkers are essential to the U.S.’s ability to supply the country with a constant food supply. These individuals work in physically demanding environments, which may result in cases of heat stroke, pesticide exposure, chemical exposure, dermatitis, respiratory conditions, traumatic injuries, dental concerns, cancers, poor child health and other poverty related health problems. The need for healthcare access is high; approximately 93% of crop farmworkers needed healthcare services between 2009 and 2012. Moreover, 33% of those who needed services were unable to access services, representing a major service gap for farmworker populations (NAWS, 2012).
Legal status is one of the many barriers that affect farmworker access to healthcare. Moreover, it illustrates an important link between access and politics. Access is heavily dependent on the legal status of farmworkers, and approximately 50% of farmworkers are undocumented (NAWS 2012). Historic policies such as the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, a welfare reform policy that aimed to reduce dependency on welfare included a provision that excluded all immigrants from receiving benefits for five years after arriving in the United States. This and other restrictive policy attempts have a direct effect on immigrant populations’ access to healthcare. The aforementioned policies stem from conservative ideologies, while liberal ideologies tend towards redistributive policies (Navarro et al. 2006; Campante 2011). This is illustrated by the states that have expanded Medicaid coverage through the 2010 Affordable Care Act, where more liberal states expanded coverage than conservative states and provided increased access to healthcare services for underserved populations. Due to the differences in political ideologies across states there exists concern about the ability of individuals to access healthcare in non-expanded states. Moreover, as the Affordable Care Act does nothing to assist the undocumented population, approximately 50% of the farmworker population, access to healthcare for farmworkers will continue to remain low.   
As mentioned previously, there are numerous barriers that affect the ability of farmworkers to access care. These factors include, but are not limited to: legal status, language, education, cost, cultural barriers, lack of insurance, generational barriers, migratory nature of work, lack of understanding of healthcare system, and personal transportation. However, these factors may vary by geographic location. This paper may serve to provide additional support for findings from previous scholars.
Going forward, I first discuss the characteristics of farmworkers; second, I provide a theoretical link between political ideology and healthcare access; I then explore how ideology impacts access to care for farmworker populations, and finally, I discuss the findings and implications of the barriers that affect healthcare access. My results indicate that both regional political ideology and regional percent Hispanic are significant indicators of predicted healthcare access.

The Contemporary Gatherers
The historic “gatherer” was a member of a group of people who subsisted through foraging in the wild. As humans have evolved over time, our foraging has become increasingly organized and routine.  Today’s contemporary gatherers are farmworkers. Farmworkers consist of individuals who dedicate their lives to general farming practices in the form of field crop workers, nursery workers, livestock workers, farmworker supervisors, and hired farm managers (USDA, 2014). However, this study utilizes the NAWS dataset, which does not include non-crop farmworkers; excluding livestock workers.2  According to the 2012 Current Population Survey, the vast majority of farm laborers and supervisors are of Hispanic origin, however, the majority of farm managers are non-Hispanic Whites (USDA, 2014). The largest group of workers are undocumented workers from Mexico, while the second largest group of workers are U.S. citizens, followed by legal permanent residents (NAWS, 2013).     
An analysis of the NAWS data was performed to examine farmworkers. It is important to note that NAWS sampling methods provide results that are representative of the entire U.S. farmworker population. The data suggest 74% of U.S. crop farmworkers are male; 77% are non-migrant; 49% are citizens or green card holders; 50% are undocumented; 50% have elementary or middle school education; 75% speak Spanish as their dominant language; 59% have personal transportation; 69% do not have health insurance; and 95% earn between $10,705 and $14,356 annually.  Moreover, it is essential to understand the need for healthcare services in conjunction with ability to access services. There exists a disparity between the need for services by farmworker populations and the ability of farmworkers to access the needed services. Approximately, 32.9% of farmworkers have need of healthcare services, but have been unable to access such services; compared to 60.3% of farmworkers who have needed services and had the ability to access them. Notably, less than 7% of the farmworker populations have not needed healthcare services.
The NAWS farmworker population is comprised of both migrant and seasonal farmworkers (MSFW) and year-round, non-migrant farmworkers. There are significantly more non-migrant year-round farmworkers than MSFW’s in the sample; 5,220 versus 1,521, respectively. It is important to understand the difference between the two populations as circumstances may be exacerbated for migrant farmworkers due to the nature of their mobility compared to their non-migrant counterparts. The Department of Labor (DOL, 2013) defines a seasonal farmworker as, “a person who during the preceding 12 months worked at least an aggregate of 25 or more days or parts of days in which some work was performed in farm work, earned at least half of his/her earned income from farm work, and was not employed in farm work year round by the same employer.” An individual who qualifies as a migrant farmworker must meet all the requirements of a seasonal worker and the distance that the worker travels to work must be far enough away from their permanent residence that the worker cannot return home on the same day. The migration may be between farms, counties, or states, depending on the situation of each individual worker.  Migrant farmworker populations face barriers that are exacerbated due to their mobility.
Farmworker needs and access is further categorized into non-migrant versus migrant farmworker to examine whether or not there exists a difference in ability to access healthcare. There is a pronounced difference in ability to access services by migrant farmworkers in comparison to their non-migrant counterparts. Results suggest that 28.4% of non-migrant farmworkers compared to 48.5% of migrants have needed healthcare access, but have been unable to obtain services. This illustrates the disparity in healthcare access due to the migratory status of a worker.
Farmworkers are core components of the nation’s agricultural industry, yet these workers have become marginalized and forgotten rather than shown gratitude. Farmworkers are subject to various physical and mental dangers associated with their work, extreme poverty, and living and working arrangements that hinder their access to health coverage and care. In terms of physical health, farmworkers and their children are exposed to toxic chemicals, such as organophosphate pesticides which have been linked to neurodevelopment complications, chemical exposure, infectious diseases, dermatitis, heat stress, respiratory conditions, traumatic injuries, reproductive health concerns, poor dental hygiene, cancers, overall poor child health, and other poverty related illnesses. Mental health, cultural assimilation, job uncertainty, geographic isolation, substandard housing conditions, distance from family, boredom, and health and safety concerns contribute to poor mental health among farmworkers.
NAWS (2013) data illustrate that between the years 2009 and 2012, 68.7% of the general farmworker population and 31.3% of migrant farmworker populations were uninsured. Based on findings from previous scholars, a variety of traditional socioeconomic factors, such as gender, migratory and legal status, education, transportation, insurance coverage, cost, and communication with hospital staff are barriers to healthcare access for farmworker populations. However, previous literature does not account for the effect of geopolitical factors on healthcare access. To further our understanding of when and how vulnerable populations access healthcare, I account for the effect of geopolitical factors on access.

Group Dominance and the Suppression of Subordinate Groups
Group threat theory holds that, “Attitudes of dominant group members towards a subordinate group are influenced by fears among dominants that they will be put at systematic disadvantage to subordinates” (Wilson, 2001). Thus, dominant groups who fear losing their position in the hierarchy will intentionally seek to prevent subordinate groups from gaining power. The level of threat tends to increase with growing numbers of members in the subordinate group.  Previous scholars have used group threat theory to explore American perceptions of “threatening” groups relative to the policy preferences of dominant groups.  Wilson (2001) finds that “American perceptions of threats to their economic and cultural interests may exert appreciable influences on their policy preferences.”  There exist natural tendencies for one’s own group to exhibit favoritism towards members within the group, however, groups will not show aggression, bias, or retaliatory behavior towards outside groups unless the outside group poses a threat to some degree.  
Other scholars have combined group threat theory with conflict theory to show how groups generate conflict through clashes over scarce resources, values, and power. Not only is the struggle to gain resources, values, and power, but also there exists a desire to prevent the opposing group from making menial gains (Bobo 1988). Similarly, Branton et al. (2011) used group threat theory to analyze the effects of perceived threats and views of nationalism among Whites in relation to Hispanic-targeted immigration policy, which resulted in increased anti-Hispanic immigration policy after periods of heightened perceived threat.
While group threat theory has its supporters, there are opponents to the theory. Group threat theory is heavily criticized for its inability to take into account the effects of subordinate group size and the level of perceived threat by the dominant group.

Healthcare Access for Farmworker Populations: Traditional SES Factors and Non-traditional Ideological Linkages
As this paper examines the effects of ideology on healthcare access, it is important to first identify barriers that inhibit access to healthcare for both general farmworker populations and MSFW populations; and then to explore the potential relationship between ideology and healthcare access.

Healthcare Barriers for the Vulnerable Populations
Research surrounding the barriers that limit farmworkers’ ability to access healthcare services is extremely limited. Most research is related to immigrant families, Hispanic populations, Medicaid users, and rural access issues; populations sharing similar characteristics and circumstances to farmworker populations. These similarities allow previous studies related to healthcare access of vulnerable populations to inform this analysis.
Previous studies have found that there exist a multitude of factors that influence the ability of an individual to access healthcare services. One common cause of reduced healthcare access is lack of insurance. Hispanic populations have the highest uninsured rates of all ethnic groups in the U.S., where an even larger disparity exists between Hispanic populations who are citizens and undocumented workers. NAWS (2013) data illustrate the overwhelming majority of respondents were Hispanic and undocumented, which exacerbates the low levels of farmworker insurance rates.  Closely tied to the ability of an individual to purchase health insurance is household income, the U.S. Census Bureau (2014) reported that Hispanic populations have consistently lower household incomes compared to White and Asian ethnic groups. 
Barriers to healthcare access can overlap making it increasingly difficult to gain access to healthcare services. It has been found that Medicaid clients are faced with a range of barriers, including lack of knowledge of the application process and eligibility questions, language barriers, legal status concerns, income, general inconvenience, pending decisions, mobility, technological difficulties, and misinformation from Medicaid staff. Moreover, rural Hispanic immigrants in the Midwest place additional emphasis on the impact of language barriers, specifically the lack of available translation services limits their ability to access healthcare services. 
Closely tied to the issue of language barriers is the legal immigration status of an individual. Barriers to healthcare access are increased for individuals who have resided in the U.S. for shorter periods of time, meaning first-generation immigrants would have a significantly harder time than fourth-generation immigrants. These findings are associated with the ability of an individual to assimilate to the U.S. culture, which for many MSFW’s can be particularly challenging due to seasonal employment and isolated living conditions. 

Healthcare Access for MSFW Populations
Literature related to healthcare access for farmworker populations is limited. There exists vastly more literature related to health care access of MSFW populations than general farmworker populations, which may stem from the tendency to characterize non-migrant farmworker populations as part of the general Hispanic population. Therefore, this paper seeks to make a contribution to the study of farmworker healthcare access.
Lack of insurance coverage is a known barrier to healthcare access, specifically Medicaid, that is complicated by the legal status of a farmworker family. Most MSFW’s are not eligible for Medicaid due to their undocumented status; however, U.S. born children are indeed eligible for services. Due to enrollment issues such as language barriers, difficulties understanding the application process, financial eligibility issues, and frequent movement between states, many eligible MSFW’s and their families are unable to receive coverage through Medicaid.  Additional problems arise because the quantity and physical location of federally funded health centers are insufficient to serve the MSFW population. 
In addition to legal status, there are factors that affect the delivery of healthcare services to MSFW’s . These factors include differences in both language and culture from the dominant population, low levels of education, financial strain, frequent migration, poor transportation, lack of insurance and documentation, and the accessibility of local healthcare centers. Cultural differences are another factor that influences access, as these differences are associated with embarrassment and shame to ask for more information related to their healthcare or how to access services. Further, MSFW’s tend to have low levels of education and language comprehension, which have large negative effects on one’s ability to find, enroll, and participate in healthcare programs. 

Linking Ideology and Healthcare Access
In this study I propose that the threat perceived by a region’s dominant ideological group will affect farmworker access to healthcare. This supposition was derived from group threat theory, which states that dominant groups attempt to keep subordinate groups at systematic disadvantages to ensure their own personal success, specifically towards subordinate groups that pose a threat to the dominant group.  Maslow’s hierarchy of needs posits the basic needs that must be met before an individual can reach self-esteem and self-actualization, the stages where individuals have self-confidence and are able to critically assess situations. Healthcare is a basic need for individuals without which their abilities to reach higher levels of Maslow’s pyramid are limited. Dominant groups that prevent access to healthcare for subordinate groups are preventing them from meeting their basic needs, and preventing them from gaining power.
 Navarro et al. (2006) found “an empirical link between politics and policy by showing that political parties with egalitarian ideologies tend to implement redistributive policies.” Today, the Republican Party is relatively anti-redistribution and Democrats relatively pro-distribution (Campante, 2011). Redistributive politics aimed at reducing inequality have tangible effects on the health of impoverished populations (Szreter & Woolcock, 2004). Thus, areas that are predominantly liberal, and Democratic, that favor distributive policies may have increased healthcare access compared to areas that are predominantly conservative, Republican, that do not favor redistributive politics.
 In terms of the link between party dominance and perceived threat, Hawley (2011) finds that lifelong Republicans are more likely than Democrats to support immigration restrictions when the concentration of Hispanics in their community is high, resulting from the perceived threat of the immigrant population. Immigration restrictions are not confined to the number of permitted immigrant entries in a year. They include policies related to public assistance and healthcare access. Thus, illustrating the link between dominant-group-determined policy decisions and the size of the subordinate group.
Group threat theory has advantages as it acknowledges that threats to dominant groups such as fear of job loss, competition, loss of power due the relative size of the subordinate group, and/or lower economic growth may lead dominant groups to take action to prevent subordinate groups from rising in status.Thus illustrating the potential for dominant groups to prevent subordinate groups from accessing basic necessities, such as healthcare services, which ultimately can prevent a subordinate group from rising in power. To further explore how group threat theory explains variations in healthcare access, I use a series of political indicators, regional unemployment rate, and regional percent Hispanic to quantitatively analyze the effects of regional ideology, unemployment rate, and percent Hispanic on healthcare access while using the previously established barriers as control variables.      

Explaining Farmworker Healthcare Access
My expectations related to healthcare access by geopolitical factors are based on group threat theory. The theory suggests that perceived feelings of intergroup threat may lead to actions from the dominant group that may negatively affect the subordinate group or simply prevent the group from prospering. It is suggested that since farmworker populations in the U.S. are predominantly of Hispanic origin, these individuals are treated similarly to the general Hispanic population, which is negatively perceived by the dominant American group. There exists extreme discontent between Hispanic immigrant populations and the dominant American population, where the dominant group fears economic losses due to increased competition for jobs, consistent with Wilson’s (2001) findings. However, there exists a slight difference in the level of perceived threat by the dominant group, which calls for the separation of the dominant American group into two dominant subgroups, conservatives and liberals. While both perceive a threat by the farmworker population there are differences in the level of perceived threat and, thus, level of effort placed to help or hinder the population.  In this case, the dominant party may affect the basic needs of individuals, and their ability to access healthcare. As mentioned previously, Maslow’s hierarchy of needs illustrates the hierarchy of needs where basic needs must be met before an individual can self-actualize or gain power. The action of a dominant group affecting the ability of a subordinate group to access healthcare would be a way of preventing the subordinate group from rising in power. Therefore, I expect to observe the following:
H1: Benefits to disadvantaged populations are increased in regions comprised of majority liberal leadership and lower in regions of majority conservative leadership.
As mentioned previously, economic competition is a key factor in the perception of threat by a dominant group (Wilson, 2001). Part of economic competition refers to job competition where dominant groups may perceive subordinate groups “taking” jobs away from the dominant group as a threat. Therefore, we would expect to see differences in the perceived level of threat based upon the unemployment level of the region; where regions with higher unemployment would perceive the subordinate groups as greater threats than areas with low unemployment. Based on this logic, I expect to observe the following:
H2: Benefits to disadvantaged populations are reduced in regions of higher unemployment compared to regions with low unemployment.
Group threat theory relies on the assumption that the relative size of the subordinate group affects the level of perceived threat by the dominant group. In the case of farmworkers, the majority is of Hispanic origin. The Pew Research Center (Passel el al. 2011) found that between 2000 and 2010 the Hispanic population in the U.S. grew by 43% and accounted for 56% of the nation’s population growth over that same time period. The Hispanic population growth was significantly larger than the population growth of White Americans. Thus, I would expect to see differences in the level of perceived threat based on the relative size of the Hispanic population in various geographic regions. I expect to observe the following:
H3: Benefits to disadvantaged populations are reduced in areas with higher concentrations of Hispanic populations.

Data and Methodology
To evaluate factors affecting farmworker healthcare access, I estimated a model that utilized access to healthcare services within the last year as my dependent variable. Given the binary nature of the dependent variable, a logistic specification is used to evaluate geopolitical effects on farmworker healthcare access.  In order to assess the effect of political ideology on healthcare access the Shor and McCarty (2015) dataset was used. I aggregated the variable party median by legislative chamber and region using Federal Information Processing Standards (FIPS) codes to align regions with the predetermined NAWS regions. This process formed the ideology variable, which represents the average majority party median by chamber. This process was repeated for both unemployment rate and Hispanic population percentages to create regional variables that illustrated the effects of each variable on a regional scale. Consistent with the data section of this report, access is coded as zero for no healthcare access and one for healthcare access. The period of analysis ranged from 2009 to 2012, which is consistent with NAWS recommendations for using weighted data in regional longitudinal studies.

Results
The three key independent variables of interest in the study include: regional ideology, regional unemployment, and regional percent Hispanic. I find support for hypotheses 1 and 3, while hypothesis 2 is unsupported; suggesting that regional ideology and regional percentage of the population that is Hispanic affect farmworker healthcare access. More specifically, the probability of a farmworker accessing healthcare is reduced by 0.629 when comparing access in least conservative regions to most conservative regions, which suggests that conservative regions have less healthcare access than their liberal counterparts. Similarly, healthcare access is reduced by 0.579 in regions with higher concentrations of Hispanic populations compared to regions with lower Hispanic concentrations, suggesting that regions with higher concentrations of Hispanic populations have lower predicted rates of healthcare access. These results are illustrated by figure 1 and figure 2.

Figure 1: Probability of Accessing Care by Regional Ideology
Figure 2: Probability of Accessing Care by Regional Percent Hispanic

 

 

 

 

 

In addition to regional ideology and regional percent Hispanic, the model illustrates the significance of eight independent variables on farmworker healthcare access. The results indicate that the need for healthcare services is a significant factor in determining an individual’s access to healthcare services, where access is reduced by 0.646 between farmworkers who have needed healthcare services compared to those who have not needed services.
Figure 3: Probability of Accessing Care by Insurance Type

With regard to insurance coverage, the probability of access for farmworkers who have insurance coverage is increased by 0.646 compared to those who are uninsured, as illustrated in figure 3. Gender is indicative of an individual’s likelihood to access care. Female farmworkers are 0.538 times more likely to seek care than their male counterparts, as illustrated in figure 4. The probability of access for farmworkers who migrate for work is reduced by 0.198 compared to their non-migrant counterparts, as illustrated by figure 5.
Figure 4: Probability of Accessing Care by Gender

Figure 5: Probability of Accessing Care by Migratory

 

 

 

 

 

 

A shift in healthcare access can be viewed in the transition between varying legal statuses of farmworkers, where the individuals with lowest levels of permanence/temporary status have reduced access by 0.383 compared to farmworkers with high levels of status, as illustrated by figure 6. Hence, farmworkers who are undocumented will have reduced access compared to their citizen counterparts. Education level is also indicative of access where individuals with lower levels of education have reduced probabilities of access (value of 0.168) compared to farmworkers with the higher levels of education. Cost of services is also a barrier to healthcare access and individuals who perceive the cost to be too high are 0.059 times less likely to access services compared to individuals who do not feel that the prices are too high. Therefore, as the price of services increases the probability of access is reduced among those for whom the costs are too high. Lastly, barriers of understanding are indicative of increased access where doctors who are able to understand patient concerns increase access levels by 0.332 compared to doctors who are unable to understand patient concerns. Hence, as the ability of medical and hospital staff to understand farmworker health concerns increases, the probability of access increases as well.

Figure 6: Probability of Accessing Care by Legal Status

 

 

 

 

 

 

In sum, these findings suggest that the ability of farmworkers to access healthcare services is a function of various factors, including regional ideology and regional percent Hispanic, where the more liberal region tends to provide improved access, and the higher the percentage of Hispanic persons in a region the less access they are able to obtain. Additional external variables that affect access to healthcare include insurance coverage, cost of services, and communication barriers between staff and clients. Moreover, the study illustrates the negative effects of background characteristics specific to individual farmworkers, such as gender, migratory and legal status, and education relative to their ability to access care. These results suggest that to improve healthcare access among farmworkers regional ideological differences and perceptions of Hispanic populations must be further assessed in addition to addressing issues associated with traditional socioeconomic factors that affect access.

Discussion and Conclusion: Improving Farmworker Healthcare Access
Returning to the fundamental question of this study, do geopolitical factors affect the ability of farmworkers to access healthcare? Yes, geopolitical factors do affect healthcare access. The results of this study suggest that at the regional level political ideology and regional percent Hispanic are significant factors in determining healthcare access. Regions that are predominantly liberal are associated with increased access compared to their conservative counterparts, while regions with high percentages of Hispanic populations are associated with lower levels of healthcare access. This study is the first of its kind to evaluate the impact of regional ideology and Hispanic presence on the farmworker population’s ability to access healthcare and contributes to the growing literature that links healthcare access to political ideology. This study finds that the size of the subordinate group does have a significant impact on the perceived threat by the dominant group.
I find that as the regional percentage of Hispanic increases the ability of farmworkers to access healthcare is reduced. These results illustrate the need for further study of regional ideology and the perceptions of Hispanic populations by dominant group members, specifically the differences in politics between liberal and conservative areas and their relation to Hispanic populations.  
In addition, the findings of this research are a significant addition to the existing research on farmworker healthcare access. As mentioned previously, research into farmworker healthcare is extremely limited, which points to the need for additional studies in this area of research. These results suggest that there are numerous ways to improve farmworkers’ ability to access healthcare through addressing socioeconomic factors such as insurance coverage, gender barriers, migratory and legal status, education, cost of services, and intercultural communication. Therefore, governments and key stakeholders seeking to improve farmworkers healthcare access should use these findings to support policy and program development.
The analysis of farmworker access presented in this study has two main limitations primarily stemming from the original data collection. The most important limitation in the data is the lack of availability of data at smaller geographic levels, such as state or local levels, as NAWS data are only available at the regional level. Due to these limitations, I urge other researchers to evaluate the effects of political ideology at both state and local levels on healthcare access for farmworker populations. Secondly, questions related specifically to issues regarding healthcare access were used only in the survey in 2009, while the majority of questions had been in place since 1993. If more data had been available, the study timespan could have been increased. I encourage other researchers to delve further into the link between healthcare access and political ideology at various geographic levels and to evaluate which policies have the greatest impact on farmworker healthcare access.
To conclude, this study is a valuable resource for both policymakers and scholars interested in the linkages between healthcare access and political ideology. The results suggest that politically liberal regions have greater access to healthcare services than conservative regions, which presents an opportunity for collaboration between liberal politicians and conservative politicians who may be interested in improving healthcare access for vulnerable populations.

---