Taking Care of the Family and the Farm - For Many Maine Farmers, Health Care is Out of Reach

Taking Care of the Family and the Farm - For Many Maine Farmers, Health Care is Out of Reach

May 29, 2024


Kristina Buckley

May is Mental Health Awareness Month – and ironically, with spring planting and calving season in full swing, it is also one of the busiest months for Maine farmers. We're sharing a piece from the 2023 maine farms journal that shows just how challenging it can be for farmers to access support for their mental and physical well-being.

The CDC underscores mental health challenges as being significantly higher within the agricultural community – and as several Maine farmers share in the piece below, the stressors and pressures farmers face to sustain their businesses can come at the expense of their own sustainability. With such physically and mentally demanding jobs, receiving adequate mental health support, being grounded and supported by community, and finding a sense of balance is key to a long and thriving life in agriculture.

If you’re a farmer, we know you’re already in the thick of things this month – and as the season continues to ramp up, we hope you are able to carve out moments in your routine to take care of your well-being. At the end of this week, we'll be sharing a variety of mental health resources and related podcast episodes for you in another post.

Taking Care of the Family and the Farm - For Many Maine Farmers, Health Care is Out of Reach

Article by Chelsea Conaboy. All images were captured for the journal by Yoon S Byun.

Alexis MacDonald can't trace the anxiety and depression she felt creeping up on her last spring to any one thing in particular. Rather, she says, it was was an accumulation of things, from the stress of running an organic dairy farm in an era of stagnant milk prices and rising costs, while raising two young children.

"Child care is exhausting," she tells me during a rare window of time when her 2-year-old daughter is napping and hers-year-old son sits in his father's lap in the cab of a tractor. "Farming is exhausting. Working with your spouse can be exhausting. And then, seasonal depression absolutely affects me."

MacDonald, who is 40 and started Bo Lait Farm in Washington with her husband, Co nor, in 2015, went looking for a therapist who could help. None who were nearby and seemed like a good fit accepted her insurance through the state's Medicaid program, MaineCare. She stopped looking, but the stress inherent in her life on the farm and the worry about the toll it all takes on her family's long-term health didn't go away.

Alexis and Conor MacDonald stand with their children, Bria, 2, and Rory, 5, at Bo Lait Farm in Washington, Maine. In addition to worrying about their finances they struggle with child care. MacDonald felt like she needed a therapist last year but couldn't find anyone who would accept her insurance so she stopped trying.

The barriers to essential health care in the United States are considerable. For many farmers, those barriers are stacked, one on top of the other, so high that the mental and physical health of farm families and farmworkers-the very people who provide the resources to keep so many others healthy-might be seen as a benchmark for all that needs to change.

Farmers "are a small portion of our population," says Florence Becot, a rural sociologist who studies the health needs of farm families at the Marshfield Clinic Research Institute in Wisconsin, "but they play this crucial role. If we don't have a healthy farm sector, what does that mean for our future?"

Most farmers live in rural communities, where access to preventive and specialty care, financial stability, and support for healthy behaviors is limited by geography and an economy dependent on seasonal work. Residents of Maine's most rural counties have higher rates of physical and mental distress than the more urban ones, considerably higher than national averages, and they experience more deaths from cancer, respiratory disease, suicide and accidental injury, according to an analysis published last year by the Maine Rural Health Research Center.

Across the United States, the suicide rate for farmers is about three and a half times higher than it is in the general population, according to the National Rural Health Association. The financial and physical strain of the job itself are major contributors to farmer mental health.

The job is dangerous, involving big animals and heavy equipment. It typically does not come with health insurance or sick leave. The work requires odd hours, luck with the weather and patience with prices that are often beyond a farmer's control.

For migrant and seasonal farm workers, the intensity of the work is compounded by a lack of health insurance for most, limited transportation and a health care system lacking in culturally competent care. Migrant farmworkers were declared essential workers during the COVID pandemic, yet policymakers continue to ignore the health needs of the workers themselves.

Then there's the culture-often the necessity of putting the farm above all.

Left Jenni Tilton-Flood at Flood Brothers Farm in Clinton, Maine. Flood says farm duties plus a health care system that wasn't built for rural people keeps people from taking care of themselves. Right A cow looks out from its stall at Flood Brothers Farm.

"We would never dream of missing a herd check for our animals," says Jenni Tilton­ Flood, part of the family that manages 3,400 cows at Flood Bros. Farm, the state's largest dairy. "The cows come first a lot of times."

Tilton-Flood can tell story after story about watching farmers in and around Clinton turn out when their peers have needed help, to run a farm while a family dealt with a serious illness or grieved a lost loved one. And there are other stories, like the one about her neighbor, who had a stroke and needed surgery but delayed the operation until after his crops were harvested. He let Tilton-Flood keep tabs on him but made her promise not to tell her family.

"We know to jump in when someone else needs help, but we also have this innate sense-and need-to not need help," she says.

The ramifications are especially acute when it comes to mental health. Tilton-Flood keeps a wall of photos near the milking parlor of people affiliated with the farm-the extended farm family-who have died, several from suicide, drug overdose or the health effects of substance use.

She and researchers studying rural health agree that, while farmers' reticence toward care is real, it stems in part from their experience interacting with a modern U.S. health care system that simply does not fit the life of farmers. Or of rural commu­nities as a whole, says John Gale, senior research associate at the Maine Rural Health Research Center at the University of Southern Maine.

In a broad sense, the cost of providing health care in a rural setting is generally higher per patient. The patient base is smaller and in many places declining, meaning fewer bills over which to spread the over­head of salaries and facility maintenance. Insurance payments to doctors and hospitals historically have not always accounted for those higher costs.

That's one thing, among a complicated mix of economic factors, driving health care consolidation over the past two decades, with independent doctors joining large practices and those practices, along with small hospitals, joining large urban hospital systems. In Maine and elsewhere, such consolidation has provided some rural hospitals the capital to stay open, but it also has led to a loss of local control, Gale says.

In some communities, it has meant cuts or reductions in services (obstetrical care has been especially hard hit). An analysis by KFF, a non­ profit and nonpartisan health policy organization, also found overall increases in health care costs from a drop in competition. The research on how it affects patient care is mixed, and there's also concern over the effect on providers.

The United States is short on doctors, partic­ularly in primary care and adult psychiatry, and the problem disproportionately affects rural communities, according to research by the U.S. Health Resources and Services Administration.

All of that means that even farmers with good insurance may face long drives and long wait­lists. But farmers are much less likely than the general population to have high-quality em­ployer-based insurance. If they do, it's typically because a family member works off-farm.

They are more likely to buy private health insurance through the state marketplace. Those plans generally have higher deductibles, which mean bigger out-of-pocket costs that may cause some to put off necessary tests and treatments.

When Becot, the rural sociologist, and colleague Shoshanah Inwood surveyed more than 900 farm households in 10 states, they found that a majority (55 percent) were not confident they could avoid going into debt if a major injury or illness occurred.

This wasn't a question of having insurance. Nearly all respondents did. But many also had high deductibles. One factor that increased medical economic vulnerability: children.

Child health is an important piece of addressing the well-being of farm families, Becot says. When she and her fellow researchers survey farmers about what resources they need in order to manage their mental health, many say access to child care. And when they survey farmers about what resources they need in order to raise children on the farm, many say affordable health insurance.

Becot argues that there is a clear eco­nomic reason for doing more to address the health and social needs of farm families.

Jenni Tilton-Flood talks about a wall of people who worked on the farm and died, including some from substance use or suicide, at Flood Brothers Farm

"Any challenge at the household level is going to impact the farm business," she says. Similarly, a more stable household can help a farm weather a crisis. That's because there is an exchange-in time and money and resources-between farm and family, she says. They are not separate.

Yet agricultural policy and farm programs in the United States typically treat them as if they are.

"They look at capital. They look at, do you have the right kind of tractors? Do you have the right kind of knowledge to farm? How can we make you a better business owner?" Becot says. "What this approach has failed to consider are the household level needs."

Every farmer I spoke with for this story can list off the times they've had to make the sometimes im­possible choice between taking care of the farm and taking care of their bodies or their family's health.

One vegetable farmer told me she limits the income she draws from the farm, afraid of losing the subsidy that helps her buy health insurance, but then she is reluctant to get care because she worries about being about to pay any surprise bills.

A dairy farmer told me how pregnancy com­plications required her to forgo a home birth and deliver instead at a Portland hospital 90 minutes away. She and her husband had planned to pay someone to milk the cows while she delivered, but they could only afford so much of that help and she ended up with a long induction. Her hus­band drove back and forth, each time asking the doctor how likely it was she would deliver in the six hours he'd be gone-a stress or for them all.

MacDonald experiences the tension between the physical demands of Bo Lait Farm and the physical demands of childrearing. She has tried, unsuc­cessfully, to find affordable child care nearby.

"There are definitely parts where it's like, this all feels like it makes sense and like this is how it should be, and we're all together," she says. "Then there are days where it's like, 'This is way harder than it needs to be, and I could feel way less stressed out if I just had three solid hours without the kids."

Conor MacDonald drives his tractor with his son Rory, 5, after fixing it, to bale hay on a field near Bo Lait Farm

At Grace Pond Farm, Rhiannon Hampson's family has health insurance through her role as state di­rector for the U.S. Department of Agriculture Rural Development program, but she has stories, too.

There was the time a doctor told her not to use the hand she'd injured while handling a rowdy heifer, and she knew immediately that wasn't an option. She iced it and wrapped it and returned to her chores. And when her husband, Gregg Stiner, recently drilled through his hand and needed a tetanus shot, the couple debated about whether to go to the nearby emergency room or the farther urgent care, worrying over the difference in the bill they'd get from each and how much time they'd lose off the farm.

But it may be the trade offs to come that Hampson worries about most: How will the hard labor of farm­ing and all that deferred rest affect them as they age?

In 2018, Hampson and Stiner moved the farm from Monmouth to 82 acres in Thomaston, in part to do more direct-to-market sales of their milk and poultry. One question has driven their planning as they've rebuilt the farm infrastruc­ture there: "What do we need to do to this thing in order to be operating it at 60 instead of 45?"

"That's the specter sitting in the corner of the room with you," she says, "the Ghost of Christmas future."

Dr. Mike Lambke is a family doctor with Skowhegan Family Medicine and, over the years, has watched too many patients and friends in agri­culture face a cascade of health issues as they age.

Sometimes it's because of long-ignored mental health concerns that lead to isolation, substance use and trouble managing the farm business. Sometimes it starts with a heart attack or a relatively minor injury. The acute problem is one thing, but if a farmer has been developing degenerative osteoarthritis, the reduction in activity required in recovery can cause symptoms to rapidly advance.

"Everything falls apart," he says. Farm operations may slow or stop. Equipment may be sold. And that turmoil in the farm business can have a big impact on the wellbeing of younger generations.

It's all connected, family and farm.

Alexis MacDonald gives her daughter, Bria, water at her home at Bo Lait Farm.

That's true for migrant workers in Maine, too, who generally have no health insurance, work for relatively low wages and support families back home.

If a farmworker goes to the emergency room or needs a hospital stay, they can end up with a bill for tens of thousands of dollars, and they may apply to the hospital's free care program to cover those costs, says Dr. Demetri Blanas, medical director of the Maine Mobile Health Program. But many farmworkers are found to be ineligible for such help. Their seasonal wages are used to calculate an annual income that may be much higher than they actually earn, and the family who depends on that income is not accounted for.

The Mobile Health Program tries to help patients avoid those bills. The program is federally funded and annually serves about 1,000 patients, primarily from Central America and Caribbean island nations.

Mobile medical units travel to the farms that employ migrant workers, during blueberry, wreath-making and apple seasons, and to dairy farms and seafood processing facilities year-round. They provide preventive care screenings and help patients manage chronic conditions, such as high blood pressure, diabetes and arthritis, often aggravated by stress, Blanas says. But there are farms and patients the program can't get to.

Blanas and his colleagues were disappointed when the Maine Senate this year voted down a bill to allow migrant workers to receive MaineCare. The change would have allowed the mobile health program to hire more staff and expand its reach, he says, and it would have given patients more stability and certainty when seeking care from other doctors and hospitals.

"It would have radically changed things for us and our patients," he says. "We rely on these workers to provide us with food, and it's just a matter of basic human rights."

Health policy in the United States is painfully slow to change. But there are potential bright spots.

The mental health and household level concerns of agricultural workers as a whole are getting more attention, Becot says. She pointed to the Women in Agriculture Act, co-sponsored by Congresswoman Chellie Pingree, that became law this summer. It creates a Women Farmers and Ranchers Liaison in the USDA and gives priority to rural development fund­ing aimed at increasing the availability and quality of child care in farming communities. Maine's brand new paid leave program can benefit farmers, too.

Nate Drummond carries a container of lettuce while harvesting vegetables at Six River Farm in Bowdoinham, Maine. Drummond runs an organic vegetable farm with his wife Gabrielle Gosselin, but cannot afford to provide healthcare for his farm employees. He also injured his hand last year, which, with insurance, cost roughly $7,000 out of pocket. Even while running a successful farm business, the margins are small, and unexpected costs like that can be difficult to cover.

The broad adoption of telehealth services during the pandemic may fill some gaps in rural health care, but it's not a cure-all and it's too soon to tell how much it will help, or whom.

The fact is, Gale says, "we haven't decided in this country-we think we have, but we really haven't-we haven't decided if health care is a right or a privilege."

So much is left to market forces that often lack logic.

Last year, Nate Drummond of Six River Farm was lifting a pallet from a pinched irrigation line when a tendon in his arm ruptured. He needed surgery, for which he covered about $7,000 in deductible before his marketplace plan kicked in.

Drummond says he would like better insurance for his family and to offer coverage to his employees. He and his wife, Gabrielle Gosselin, have looked at their options, but they are expensive and complicated to manage with a seasonal staff.

So, he says, it stings when he walks into an upscale brewery and sees people drinking $8 beers alongside a sign celebrating how the business offers coverage to all its employees. A good thing, certainly, but if the beer market can sustain health insurance for all, why can't the vegetable market?

"Vegetables are food, and food is a necessity," Drummond says, "and wages are connected to food prices."

If only, he says, there was a market for $10 tomatoes.

Left Noelle Koch, an employee at Six River Farm, harvests lettuce. Koch, an SMCC student in horticulture, has worked on the farm for two seasons; the first working as field crew, and the second working as a crop leader. Right Gabrielle Gosselin cuts flowers for the farm stand at Six River Farm.

Chelsea Conaboy is a health and science writer based in South Portland. Find more of her writing at chelseaconaboy.com and in her Substack newsletter, Between Us.

Yoon S. Byun is an award-winning photographer based in South Portland. You can find him on Instagram at @yoon.strewn. Together Chelsea and Yoon are the writer/photographer duo behind Strewn Wonder.

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