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Monterey County Medical-Legal Partnership

Friday, February 14, 2020   (0 Comments)
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Monterey County Medical-Legal Partnership

Providing free legal services to clinic patients


Written by Aaron Voit, Medical-Legal Partnership Managing Attorney, California Rural Legal Assistance


Aaron Voit will be presenting at the Western Forum for Migrant and Community Health in Sacramento on February 20th.


When is the appropriate time to disable a pregnant worker?  That is a question that has long been in the minds of providers at the Monterey County Health Department’s nine Federally Qualified Health Clinics, which serve many farmworkers and families in California’s Salinas Valley—known as the Salad Bowl of the World.  The Salinas Valley is also home to CHAMACOS, a UC Berkeley longitudinal study of mothers and children which has linked prenatal pesticide exposure to pervasive developmental disorder and poorer mental development at age 2, poorer attention and hyperactive behaviors at age 5, and lower IQ at age 7.  Increasing awareness about the reproductive hazards of farmwork prompted difficult conversations between providers and pregnant farmworker patients like Vanessa, a strawberry picker who regularly saw tractors and helicopters applying pesticides close by, and sometimes smelled a chemical aroma when she was working.  

Even though 100% of the pregnant farmworkers in the CHAMACOS study were found to have pesticides in their urine, pregnant farmworkers across California typically work well into their second or even third trimester.  For low-wage workers often living paycheck to paycheck, many can’t afford to stop working during their pregnancy because they need money for rent, food, medications, clothing, school supplies, the list goes on.  Believe it or not, most states don’t offer any financial support to help pregnant workers make ends meet when they can no longer work due to their pregnancy.  

However, a growing number of states now offer a state disability insurance program, where workers pay into a fund that they can then draw from if they become unable to work due to a qualifying health condition, like pregnancy.  California’s State Disability Insurance program (SDI) can provide up to 52 weeks of partial wage replacement (60-70% of normal wages).  Workers can only receive benefits if they have paid into the system. Undocumented workers are eligible for SDI, and it is not one of the benefits that could negatively impact someone’s immigration prospects under the new Public Charge Rule.  Medical providers are the gatekeepers to these programs because they must certify to the state that it is no longer medically advisable for their patient to continue working.


Photo Credit: David Bacon


Pregnant workers in California, especially those in low-wage, high-risk occupations like farmwork, rely on the State Disability Insurance program (SDI) so that they don’t have to choose between their family’s health and financial stability.  Unfortunately, pregnant farmworkers haven’t been able to access SDI early in pregnancy, when the developing brain is most vulnerable to teratogens like pesticides.  That is in part because EDD, the state agency that administers SDI, offered no guidance to providers about when they could certify their patient for benefits prior to four weeks before the estimated due date.  For providers serving pregnant farmworker patients like Vanessa, many believed they were not allowed to disable their patient early in pregnancy and others were not aware of research like CHAMACOS on the reproductive hazards of farmwork.  It is commonplace that pregnant farmworkers are told they cannot be certified for disability until the fifth or even seventh month of pregnancy.   


Photo Credit: David Bacon


For help understanding the ins and outs of California’s SDI program, Monterey County Health Department FQHC providers turned to the attorneys at their clinic. Since 2017, a Medical-Legal Partnership (MLP) between the Monterey County Health Department and California Rural Legal Assistance, Inc. (CRLA) brings free legal services to hundreds of patients every year.  Doctors and other staff identify patients with health-harming legal needs, and CRLA attorneys meet those patients on-site at their clinic, working in partnership with their healthcare team to provide legal services that can improve social determinants of health like income, housing, education, workplace safety, and physical environment.  In a given week, the MLP may help get bed bugs and mold out of patients’ homes, make sure disabled workers get the reasonable accommodations and medical leave they need, increase school-based services for special needs students, and connect victims of intimate partner violence to immigration services.

In the effort to improve health outcomes for pregnant farmworkers and their children, that work began in early 2018 by increasing conversations between patients and providers about the hazards of farmwork, and connecting with research like CHAMACOS which bears out patients’ lived experiences.  Patients and providers then educated CRLA attorneys about the social determinant of health (income) that prevented many pregnant farmworker patients from following the medical guidance to stop working in the fields earlier in pregnancy.  Drawing on decades of work with farmworker communities statewide, CRLA attorneys saw how the SDI system was failing pregnant farmworkers who couldn't get the replacement income they needed to stop working in fields sprayed with teratogenic pesticides.


Photo Credit: David Bacon

Together, the MLP team analyzed the legal definition of disability under California’s SDI program, and determined that providers could in fact ceritfy their pregnant patient for SDI as soon as it was not medically advisable for them to continue working.  In early 2019, several courageous doctors decided to be the first in the state to certify their pregnant farmworker patient as early in pregnancy as the positive pregnancy test.  EDD, the state agency that administers SDI, initially denied several patients’ claims because they weren’t familiar with the occupational hazards that pregnant farmworkers face.



Photo Credit: David Bacon

Alongside the California Work and Family Coalition and the Center for WorkLife Law, CRLA attorneys represented those patients to appeal their denial of SDI benefits.  In July 2019, EDD officially cleared the way for pregnant farmworkers to receive SDI benefits as early in pregnancy as is medically advisable, and added language to website FAQs reflecting the same.  The FAQ language is the first practical guidance for California’s physicians about the possibility of disabling their pregnant patients before four weeks prior to the estimated delivery date.  As of December 2019, EDD's new stance and updated website language finally extend SDI benefits to some of California’s hardest working and most marginalized moms!  This new standard would not have been possible without EDD’s receptiveness and commitment to their constituents.  

When is the appropriate time to disable a pregnant worker? The answer depends, first and foremost, on when the pregnant patient would like to stop working. It now also depends on what state you’re in.  In California, , EDD’s FAQs for Providers affirm that providers of pregnant patients whose “job requirements (e.g. lifting, continuous standing, regular chemical exposure, etc.) pose a risk to the pregnant patient or fetus” can certify them for SDI as soon as “it is not medically advisable for your patient to perform her regular or customary work.”  This is a huge shift in the way that pregnant women in all high-risk occupations can access the benefits they need for a safe and successful pregnancy.  The challenge is now to spread this work so that pregnant workers in all high-risk occupations in California and beyond no longer need to choose between a healthy pregnancy and financial stability for their families.






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