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Open Access Publications from the University of California

Health insurance coverage among farmworkers in California before and after the introduction of the Affordable Care Act (ACA): A mixed methods study



Background: Previous studies have found that although health insurance coverage expanded for farmworkers after the introduction of the Patient Protection and Affordable Care Act (ACA), coverage levels were lower than the general population. California recently introduced policies to expand coverage for previously excluded undocumented workers. This study examines the impact of the ACA on insurance coverage for farmworkers and identifies barriers to further expansion.

Methods: A mixed methods approach was utilized. Weighted statistical analyses were conducted on the National Agriculture Worker Survey (NAWS) data for 2011-12, 2015-16 and 2017-18 to study health insurance coverage before and after the introduction of the ACA. Qualitative interviews were conducted with growers, healthcare providers and community-based organizations to examine ACA related changes in health insurance for farmworkers.

Results: The ACA led to doubling of health insurance coverage for farmworkers in California (32.0%: 2011-12 to 64.8%: 2017-18), with higher rates for documented (43.0%: 2011-12: to 77.7%: 2017-18) than undocumented workers (2011-12: 26.0% to 2017-18: 46.8%), which were lower than rates for non-agricultural workers (73%). Barriers to obtaining coverage include the high cost of insurance for growers, high deductibles and copays for farmworkers and distrust of government agencies.

Conclusions: While the ACA led to significant improvements in health insurance coverage for farmworkers in CA, significant barriers remain for farmworkers seeking to obtain insurance and for growers seeking to provide coverage.

Policy Implications: States should consider funding a farmworker specific Medicaid program to provide health insurance coverage and care coordination across counties and states.

Cover page of Exploring Advocacy Coalitions involved in California's Sugar-Sweetened Beverage Tax Debate

Exploring Advocacy Coalitions involved in California's Sugar-Sweetened Beverage Tax Debate


Since 1982, California has attempted to pass a tax on sugar-sweetened beverages (SSB). To date, none have been successful. This study describes the advocacy groups and the strategies and policy arguments used by stakeholders to support or oppose statewide SSB tax legislation in California. The article uses the Advocacy Coalition Framework (ACF) to identify coalition groups and their members as well as examine the strategies and arguments used in California’s statewide SSB tax policy debates between 1999 and 2018. We use a mixed methods analysis with a predominantly qualitative approach to identify stakeholders involved in the SSB tax policymaking process and explore their policy arguments and advocacy strategies to advance their policy positions. Data consist of 11 California legislative bills (94 documents) and 138 newspaper articles. SSB tax policy debate did receive media attention. We identified two advocacy coalitions involved in the debate: a public health coalition and an industry coalition. The public health coalition focused on arguments about the health consequences and financial benefits of SSB taxes. The industry coalition responded with arguments that focused on how SSB taxes would harm the economy. Both coalitions used various strategies to advance desired outcomes. The public health coalition used advocacy strategies such as media and research evidence. The industry coalition used advocacy strategies such as preemption, alliances, and financial resources. Although SSB taxation has faced substantial challenges at the state level in California, advocacy coalitions can gain insight from policymaker’s experiences involved in previous legislation to inform future efforts to pass obesity prevention-related policies.

Cover page of Reducing Information Inequality: A Participatory Intervention in a Rural, Diverse Community

Reducing Information Inequality: A Participatory Intervention in a Rural, Diverse Community


Background: CDC-funded Partnerships to Improve Community Health (PICH) is a collaborative of over 40 community organizations working together to create a culture of health in Merced County. Underlying the policies, systems, and environmental approach that guided PICH projects is a comprehensive communication plan. As part of that plan, formative evaluation conducted at the start of the project found that residents and community organizations identified a weak information infrastructure as a major barrier to health: Residents struggle to find timely, relevant information that can help them improve their health, while stakeholders face challenges knowing how to reach diverse audiences with critical health-related information.

Aim: In this manuscript, I describe the process of conducting a participatory health communication intervention designed to address issues identified in communication infrastructure. The process includes adaptation of this method and intervention, developed in urban Los Angeles, to the rural context of Merced County.

Methods: Participatory health communication asset mapping (PHCAM), a method and intervention, was used to identify structures (safe, trusted spaces that serve distinct health communication needs: Informational, conversational, connection).

Development: A six-step process in which community leaders/residents identify & validate communication structures.

Implementation: Successful implementation of the map will be indicated from its use by (1) organizations (to disseminate information) and (2) residents (to obtain information). For the first, potential uses of the map were demonstrated at a convening with all partners, followed by one-on-one training and toolkit dissemination. To promote community knowledge/use, multiple resident convenings will be held at sites on the map.

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Understanding Smoking Preferences: Results from a Discrete Choice Experiment Amongst U.S. Adults


E-cigarette (vaping) use has increased dramatically in recent years. While switching to vaping might benefit cigarette smokers, there is a risk of increased use by nonsmokers. Adults (N=525) aged 18 to 88 years made choices between two alternatives that differed in policy-relevant characteristics. Nonsmokers preferred e-cigarettes over all other tobacco products (WTP $1.34). Nonsmokers showed a strong aversion to the addictiveness of the products and long-term health risks. Light and heavy smokers differed in their attitudes toward health risks, with heavy smokers being relatively unsensitive to long-term health risks compared to light smokers. Cost was a particularly important factor for nonsmokers. Marginal analysis suggests smokers were relatively unsensitive to price increases alone. Vaping is attractive for nonsmokers when they perceived health risks are low, suggesting that behavior change campaigns should focus on the health risks. Results also suggest that it may be difficult to get smokers to shift to vaping.

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Cover page of  Education and Life’s Simple 7: An evaluation of differential returns by sex, race, and childhood socioeconomic status

 Education and Life’s Simple 7: An evaluation of differential returns by sex, race, and childhood socioeconomic status


Few studies have examined whether the benefits of education for health differ across sociodemographic subgroups. We investigated whether educational attainment is associated with cardiovascular health, as measured by the Life’s Simple 7 (LS7) score, and whether the association differs by demographic characteristics. Data were obtained from the REasons for Geographic and Racial Differences in Stroke study (N=8,759 participants; mean age=63.8).

We used linear regression analyses with interactions by sex, race, childhood socioeconomic status (SES), and geography. Socially vulnerable groups (i.e., men from low childhood SES backgrounds, White people from low childhood SES backgrounds, Black people from low childhood SES backgrounds) benefitted less from each additional year of education than socially advantaged groups in predicting LS7 scores. However, we did not find evidence that differential returns extended to every group. Findings suggest that the inequalities present in the education system may further exacerbate the gap between advantaged and disadvantaged.

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