The Farming Population and Health Insurance: Educational Needs and Approaches of Extension Professionals

Introduction

Few occupational groups in the United States face greater risk to their health than farmers and farm workers as farming ranks among the most dangerous occupations in the United States (Centers for Disease Control and Prevention, 2013). Farming families who are uninsured or underinsured can accrue crushing medical debt, which can increase financial risk, lead to farm foreclosure, and reduce overall quality of life. Farmers, especially those farming full time, have had historically high rates of being uninsured and underinsured. Although health insurance policy changes over time, the need for the farming population to understand health, health care, and health insurance is constant.

Scholars have argued that Extension is well poised to respond to health insurance needs (Braun, 2012;Inwood, Braun, Knudson, Parker, & Parsons, 2015); however, there has been no research examining how Extension is approaching health insurance outreach and education for the farm population or what support tools and resources Extension needs for doing so. To fill this research gap, we used an exploratory research format to understand the role Extension can play in the dissemination of health insurance information to farmers. Specifically, we sought to answer the following research questions:

1. What health insurance needs has Extension identified as important to agricultural communities?
2. How is Extension currently approaching health insurance outreach and education?
3. What specific tools and resources does Extension need to respond to these needs?

We provide a brief overview of current Extension health insurance education programming, followed by the results from our series of national focus group discussions with Extension professionals. We conclude with recommendations and strategies for health insurance programming targeting farmers.

Background

Farmers must navigate the health insurance landscape from two perspectives: as individuals/family members and as employers (Inwood, 2015). As a result, health insurance policy can affect farmers through both individual and employer requirements. Federal and state health insurance policies require individuals, families, and employers to make decisions within a complex, market-based environment in which consumers are expected to be "informed shoppers" (Consumers Union, 2011).

Recognizing both the complexity of health insurance and the role Extension can play in health insurance education, University of Maryland Extension developed a general-audience health insurance literacy curriculum called Smart Choice Health Insurance (Bartholomae, Russell, Braun, & McCoy, 2016; Brown et al., 2016). Riportella and O'Neill (2015) produced a complement to Smart Choice called You and Health Insurance: Making a Smart Choice for Farm Families. Inwood et al. (2015) called for Extension to further tailor health insurance outreach efforts to target farmers and farm workers. As trusted members of and advisors in the community, Extension educators have both credibility as information providers and access to hard-to-reach populations through well-established outreach channels (Franz & Townson, 2008; Henning, Buchholz, Steele, & Ramaswamy, 2014; McDowell, 2003).

However, there is currently little understanding of Extension professionals" approaches to health insurance programming for farmers. A clearer understanding of the issues and problems Extension professionals encounter can lead to the development of tools and resources that will increase the efficacy of outreach efforts and help promote social and economic development of the agricultural sector.

Methods

We collected qualitative and quantitative data through a series of national online focus group sessions run through Adobe Connect in March 2015 and October 2015. Krueger and Casey (2000) define focus group research as a planned series of discussions allowing researchers to identify issues, emotions, contradictions, tensions, and other nuances that can be missed through other research methods. The small size of focus groups and interaction of participants allow researchers to explore the breadth of experience and knowledge about a particular issue (Lundy Allen, Grudens-Schuck, & Larson, 2004). Although our results are not generalizable, they are transferable to Extension professionals who work in the spheres of agriculture and health.

An online focus group methodology allows for polling and immediate discussion of tabulated frequencies (Loveridge, Nawyn, & Szmecko, 2013). In our study, focus group members answered 16 closed-ended poll questions and seven in-depth discussion questions, responding to questions orally through a phone connection. Participants reported on existing Extension programming, problematic issues they had observed, health insurance literacy, opportunities to bolster Extension programming, and desired future resources. We transcribed recordings from the discussions verbatim and analyzed the transcriptions qualitatively for patterns and themes in HyperRESEARCH using a grounded theory approach (Charmaz, 2006). We analyzed quantitative data from the poll questions by using Excel. Herein, we report the findings most salient to our research questions.

We recruited participants through the four U.S. Department of Agriculture Rural Regional Development Centers and Cooperative Extension electronic mailing lists. We used snowball sampling techniques to increase the size and scope of our focus groups. Snowball sampling is a nonprobability sampling technique in which participants refer others they think would be interested in and appropriate for the study (Tracy, 2013). Participants included 15 Extension professionals. The majority (60%) represented the agriculture and natural resources (ANR) program area, and a third (33%) represented the family and consumer science (FCS) program area. The sample was fairly evenly gender-balanced, comprising 60% women. Participants identified that they were either actively working on health insurance–related and health care–related issues or were participating to learn more about health insurance policy and how to integrate this topic into their programming.

Results and Discussion

Extension Issues

Overall, Extension professionals recognized the importance of appropriate health insurance plans to farmers' livelihoods. All participants responded that it was important or very important for a farmer to have a plan that fit the needs of his or her family and farm. However, participants also acknowledged that farmers are not equipped with the tools to select appropriate plans because, in their opinion, farmers lack health insurance literacy (Table 1). Health insurance literacy is an individual's capacity to find, select, and use appropriate health insurance plans (Consumers Union, 2011). By contrast, participants reported high personal health insurance literacy levels (Table 1).

Table 1.
Participant Estimates of Health Insurance Literacy

Health insurance literacy statement	Agree	Mixed	Disagree
Farmers and ranchers have health insurance literacy.	8%	46%	46%
I have health insurance literacy.	71%	7%	21%

Extension participants anticipated that low levels of health insurance literacy among farmers would lead this population to seek resources from Extension. Over half (54%) of the participants expected that farmers were turning to Extension with health insurance questions. Despite perceiving that farmers needed and wanted to talk about health insurance, participants reported having low levels of engagement with farmers on the issue. More than half (64%) reported that they infrequently talked with farmers about health insurance plans; only 7% frequently discussed the topic. Furthermore, nearly three quarters (71%) of participants reported feeling either neutral or ineffective at helping farmers choose health insurance plans (Table 2). Thus, there is a gap between the belief that farmers need assistance from Extension and the degrees to which Extension professionals engage in relevant conversations, feel effective in assisting farmers, and take the initiative to raise health insurance literacy levels.

Table 2.
Effectiveness in Helping Farmers
Find, Select, and Use Health Insurance Plans

Effectiveness level	Percentage
Effective	14%
Neutral	29%
Ineffective	71%

On the basis of the focus group discussions, we identified three main issues that led to the perception of ineffectiveness among the participants: (a) difficulty understanding federal and state health insurance policy as it applies to farmers, (b) different experiences, and (c) lack of reliable resources. Health insurance options and requirements vary on the basis of state and farm structure. Trying to decipher broad requirements is confusing due to the complexity of health insurance laws, regulations, and terminology.

One participant summed up his confusion related to understanding farmers' responsibilities as employers by stating that he needed "just kind of a fine-tuning on the employer piece . . . when are you considered an employer versus a contractor? Where is that line? When are you responsible [for health insurance]?" This participant had considerable confusion about when farmers were required to provide health insurance options to employees and interns due to differences in federal and state employer requirements.

Differences in federal and state policy implementation and perceptions of public opinion can create confusion about how best to help farmers. Whereas some participants felt encouraged and supported to work on health insurance education, others did not. One ANR participant noted that political contentiousness around health policy changes can create challenges for Extension professionals and affect their ability to provide factual, objective information. According to the participant, "The first year that we were doing health insurance education . . . the restrictions on what could be said and couldn't be said were very defined. And pretty much we were told not to leave the scripts. And so it gets in the way of writing articles for the popular press and just doing some sort of frontline information spreading about what's possible and where the risks are."

These experiences of uncertainty and ineffectiveness reflect the varied state policy environments within which Extension conducts programming. Often, study participants reported viewing state-specific differences as barriers to comprehending and disseminating accurate information about health insurance options and requirements.

Participants noted that Extension's ability to act as a resource is further constrained by the fundamental disconnection between the experiences of Extension agents and their constituents. Extension professionals emphasized that as public employees with state health benefits, they do not have to make as many health insurance choices as their constituents. One noted, "Personally, all I do is check box X on line Y and say I have full-year health insurance, and I'm done. But the people in this country who probably have the least health literacy are the ones that are dealing with the 8962 forms and the 1095a forms, and so I think as Extension educators, we've got to get into that process, even though we don't use it personally."

Indeed, farmers have many more decisions to make regarding health insurance than Extension professionals do. Yet our findings suggest that Extension workers rely on their personal health insurance decision-making processes to educate farmers rather than tailor messages specifically to the unique experiences and needs of farmers. When discrepancies in health insurance needs become apparent, Extension workers may find that their perceived high personal health insurance literacy is not sufficient to help their agricultural audiences.

Participants reported addressing their own lack of knowledge by turning to others for information or making referrals to outside experts. Because of the lack of agriculturally specific health insurance knowledge within Extension, 67% of participants reported that they turned to others in Extension when they had questions about health insurance. Participants also said that they often referred health insurance questions to the "experts." The majority of participants (65%) indicated that they refer constituents to service providers explicitly set up to assist with health insurance issues. One noted, "It is an important decision, and I don't want to steer them wrong. I keep it very basic and repeat about 10 times, 'You need to talk to an expert. You need to get advice from somebody who really knows this.'"

However, despite the propensity of referrals to experts, only 23% of participants thought farmers were actually seeking information from health insurance service providers. They acknowledged that even the established experts can be inadequate resources, suggesting that "[farmers'] attorneys, CPAs and . . . insurance people don't even understand the full complexities of the laws and policies from the [farmers'] perspective." Although health insurance service providers are trained on health insurance issues, participants reported that they feared referring farmers to health insurance service providers who may have little understanding of the unique needs of farmers.

Moving Forward: Helping Extension Professionals Address Health Insurance

Currently, FCS educators lead the majority of Extension programming related to health and health insurance, with little crossover to ANR or community development (CD) programming. ANR Extension professionals are well-informed about the details of agricultural livelihoods and could potentially be a great resource when it comes to health insurance information. Participants identified two ways in which Extension could improve its ability to assist farmers: (a) Span the boundaries between the agriculture and health insurance sectors, and (b) increase professional development and knowledge of applicable resources for Extension professionals.

Spanning the Boundaries Between the Agriculture and Health Insurance Sectors

Extension can engage in boundary-spanning activities to bridge the low-to-no communication gap between the agriculture and health insurance sectors. Participants noted a lack of frequent or effective communication among Extension professionals, health insurance service providers, and health insurance brokers or agents. Table 3 illustrates participant frequencies of working with state health insurance resources. Nearly half (47%) of the participants indicated that they had never talked about health insurance with state health insurance personnel, further compounding the lack of agriculturally specific health care knowledge within Extension.

Table 3.
Frequencies of Working with State Health Insurance Resources

Frequency level	Percentage
Frequently	7%
Neither frequently nor infrequently	20%
Infrequently	27%
Never	47%

Participants addressed this communication gap when they noted the unique opportunity for Extension to facilitate conversations between the agriculture and health insurance sectors. Individuals such as health insurance service providers can deliver specialized health insurance information; however, accessing these resources can be costly in terms of time and energy.

One participant suggested that Extension's interfacing with such resources to create learning opportunities would provide farmers with the opportunity to ask questions and listen to one another and to "realize they're not alone in their inability to navigate or to get an answer to something." This participant imagined that by bringing a health insurance expert to the community, into a supportive space, Extension would be encouraging farmers to participate with and learn from a well-informed health resource.

Additionally, Extension's established credibility may encourage greater farmer participation in programming. One participant indicated that his relationship with farmers was vital in getting them to attend health insurance–specific workshops by stating, "Before I started dealing with the insurance side of things, a lot of people already knew who I was, so . . . when I [did] a program, it didn't really matter what the topic was—they'd show up."

Extension represents a trusted resource that is already embedded in agricultural communities. Health insurance experts can glean audiences and credibility by relying on this preestablished trust in Extension.

Increasing Professional Development and Knowledge of Applicable Resources for Extension Professionals

In addition to boundary spanning, participants identified a need for Extension as an organization to provide its personnel with relevant training across program areas. Participants noted that there has been a lack of professional development related to health insurance within Extension in general. About half (53%) of participants had attended one or two health insurance training sessions, the majority of which were in FCS; 27% reported that they had never attended a training session. Participants identified health insurance access as an important issue; however, many of them did not have experience with health insurance issues or know about existing Extension resources.

Participants were asked to identify the types of training and resources they would find useful. We provided them a list from which to select as many options as were applicable. The top three requests were for assistance in identifying preexisting educational materials, identifying key stakeholders in decision making, and assessing farmer health insurance literacy (Table 4).

Table 4.
Training, Education, and Resource Needs

Area in which assistance is needed	Percentage of respondents
Identifying a variety of preexisting educational materials	86%
Identifying key stakeholders in decision making	79%
Assessing health insurance literacy	71%
Developing appropriate verbal communication skills	64%
Identifying health insurance professionals for referrals	57%
Developing new educational materials	43%
Note. Respondents could choose multiple responses.

Moving Forward: Programming for Farmers

Although Extension has yet to develop a comprehensive health insurance literacy program for farmers, participants described more narrowly focused but successful programming efforts already aimed at this target audience. Three strategies—identifying key decision makers, embedding health insurance issues in broader programming, and disseminating health insurance information through multiple channels—provide a foundation for building formal training programs to teach Extension professionals how to work with farmers on health insurance issues.

1. Identify key decision makers. Participants emphasized having had success in identifying key decision makers in health insurance decision making. For example, FCS participants reported having successfully targeted women, who are often the ones "worried about and thinking about these [health insurance] kinds of concerns," by incorporating health insurance programming into Annie's Project, a program that seeks to strengthen women's roles in farm enterprises. One participant reaffirmed, "[Women] make a lot of decisions on the insurance. . . . we found that to be an effective group to get information out [to]."
2. Embed health insurance issues into broader programming. Participants reported embedding health insurance and health care issues into programming that is related to whole retirement planning, estate planning, financial business management, and succession planning. One participant explained that by incorporating health insurance issues into programs that "aren't necessarily directly insurance-related but might be labor-related or [that address] some general crop updates . . . [has] helped bring up awareness." Numerous participants stressed the interconnectedness of health insurance with issues such as succession planning and quality of life. They viewed their role as one of connecting the dots from health insurance to other issues to secure long-term farm viability. One mentioned that farmers often are "not planning for the transition of [their] land because they are afraid they're going to need it to pay for health care costs in the future."
3. Disseminate health insurance information through multiple channels. From a program execution standpoint, respondents reported three main mediums for talking about health insurance issues: printed educational materials (80%), online educational materials (53.3%), and informational materials provided in a traditional classroom setting (53.3%). Participants emphasized the need for in-person programming; they attributed this need to low levels of technological literacy and higher average ages among farm and ranch populations. One respondent noted, "It's very important to consider the age of the farmer/rancher. If they're older, they may not be as comfortable using websites. They may need [a] more paper/pencil [approach], [or] to sit down and talk with somebody."

This sentiment suggests greater potential success with health insurance outreach characterized by face-to-face interactions. Additionally, face-to-face interactions are important due to the relative isolation of farmers and the complexity of farm business structures. As one participant noted, "The more rural the location, the more difficult it is for farm businesses to access professionals other than through the Internet . . . which isn't always convenient [for] or well accepted [by] the more senior members of the ag community." Participants indicated that a combination of face-to-face and online programming is most appropriate for agricultural populations.

Conclusion

As health insurance policy evolves, the ability of farmers to access health insurance information and navigate options will become increasingly critical to assuring successful farm enterprises. Extension professionals have an opportunity to innovate by taking a key role in deciphering the health insurance landscape and connecting the agriculture and health insurance sectors. We found that Extension professionals are actively asking for professional development and educational resources to address health insurance literacy in the agriculture sector. Innovation occurs when individuals and groups recognize they have needs (Rogers, 2003) but lack the capacity to respond knowledgeably (McCoy, 2016). The next steps are to offer opportunities for professional development and to generate research-based educational materials. Our study can be used as a baseline from which to develop and conduct additional quantitative research with larger sample sizes and across a wider range of Extension professionals. Extension investments in professional development and health insurance education are vital for ensuring continued rural development efforts and solidifying Extension's role as a crucial health insurance community resource.

Author Note

Author change in affiliation: Shoshanah Inwood is an assistant professor at The Ohio State University, Wooster, Ohio, and may be reached at Inwood.2@osu.edu

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