If knowledge of the health of migrant and seasonal farmworkers and their dependents is limited, an understanding of their health care utilization and the access barriers they actually experience is even more general and inferential. Ninety percent of all migrant families have family incomes below the federal poverty level, and the per-capita income in communities heavily populated by migrant families is half the U.S. average (National Migrant Resource Program, Inc., undated). In 1985, the average migrant farmworker earned only $3,295 per year from farm labor; his or her total income from all sources was only $6,194. (Rust, 1990).

Despite their poverty and the virtual absence of private insurance, migrants and seasonal farmworkers experience more barriers to obtaining Medicaid than other low-income groups. A survey of migrant health centers, conducted by the National Association of Community Health Centers in the spring of 1991, documented the remaining barriers, from the providers' perspective, after the Medicaid expansions mandated by Congress in 1989 and 1990 (National Association of Community Health Centers, 1991). Additional barriers to receiving Medicaid benefits would surely emerge if migrants and seasonal farmworkers were queried directly. The survey's most important findings include (1) the difficulty migrants have in establishing state residency and completing the application process before they must move on (these difficulties have persisted despite 1979 Health Care Financing Administration [HCFA] regulations that attempt to ease residency requirements for migrants); (2) the problems migrants experience in retaining coverage and satisfying periodic redeterminations once they receive benefits; (3) the barriers created by documentation and application procedures (because of the time and level of paperwork involved); and (4) the language and cultural barriers inherent in the application process, including the unavailability of forms and translators for non-English-speaking migrants. Forty-three percent of respondents reported mobility-related problems, 43 percent reported language barriers, and 77 percent reported documentation problems. These problems were almost equally present for pregnant women and children—notwithstanding the elimination of categorical eligibility limitations and the liberalization of financial eligibility requirements, which should mean that nearly all pregnant women and children in migrant families would be able to meet Medicaid eligibility standards. Other problems noted by the migrant health centers in this survey included the migrant's inability to comply with face-to-face interview requirements; states' continuing to require permanent residence, despite HCFA guidelines to the contrary; states' denial of benefits to lawful residents because of misapplication of federal alienage standards; and the failure to have hours and locations that are accessible to migrants. These difficulties in obtaining Medicaid benefits were reported by migrant health centers that are presumably highly motivated to help migrants; consequently, the difficulties faced by migrants who



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