MONANGO, N.D. - Val Wagner sits at her kitchen table. A space heater hums gently. A wall clock announces the new hour with a tractor engine's recorded roar. Outside, on a raw, windy winter morning, her husband, Mark, feeds cattle on the family farm. Their four sons, ages 14 to 7, are at school in Ellendale, the oldest two competing in a science fair.
Quietly, without rancor or resentment, Val Wagner talks about her cancer and the other medical issues confronting her family - and the challenge the Wagners face with health insurance.
"It's been difficult at times. The cost just keeps going up, and the plans keep changing," she said. "But we also feel fortunate we've able to maintain our coverage. And we know so many other people in agriculture are struggling with health insurance, too."
The Wagners definitely aren't alone.
Traditionally, weather and commodity prices have been the big worries for farmers and ranchers. Now, the big keep-us-awake-at-night concern for many is health insurance.
"It's the thing I keep hearing most often: health insurance has become such a big worry for so many of us," said Theresia Gillie, a Hallock, Minn., farmer and president of her state Soybean Growers Association.
Farmers and farm group officials say they're squeezed financially, especially in the current period of low farm profitability that leaves them little money with which to pay escalating health insurance costs. In the past five years alone, monthly premiums have doubled and annual deductibles have tripled or quadrupled, many farmers report.
What's more, some health insurers are pulling out of rural areas or even entire states, reducing potential options for farmers and farm families. And the insurers that remain often revamp their existing plans, forcing farmers to make tough, complicated choices about a replacement.
Val Wagner knows all about that.
She and Mark have supplied their own medical insurance since they were married 16 years ago. Val is 39, Mark 45.
"Up until five years ago, we had the same plan. We never had an issue with it. Our premiums would increase, but it was the coverage we needed. Then we found our plan was being discontinued," she said.
'We've stuck with the company, but they keep bouncing us from plan to plan," she said. "We find our coverage is dropped, so we have to find a new plan. We have to read through pages and pages of information to make sure our coverage, especially for our youngest son, will continue."
Eli Wagner, 7, has a metabolic condition that severely limits his protein consumption.
In December, the Wagners' coverage was dropped for the third time in five years. They were able to transition to another plan with the same company, Blue Cross Blue Shield of North Dakota, "but we needed to find another plan that gets us close to where we're comfortable with," Val Wagner said.
The most recent switch is just part of "the whole, never-ending cycle of trying to understand it (health insurance) and keep on top of it," she said.
But she stresses she's not complaining.
"I feel bad for those families that don't have a plan to turn to," she said.
Not only farmers
Three caveats to the farmers-are-struggling-with-health-insurance picture:
• Affordability is a longstanding concern among farmers, insurance officials say. Pat Bellmore, chief marketing officer of Blue Cross Blue Shield of North Dakota, said, "When I began as a young representative out in the field 32 years ago, I was getting concerns back then when family premiums were hitting $100 (monthly) and people were talking about it no longer being affordable."
• Farmers and ranchers are hardly the only ones struggling with health insurance concerns. Forty-three percent of Americans with health insurance have trouble paying their deductible, according to a survey released this spring by the Henry J. Kaiser Family Foundation, a nonprofit organization that focuses on health care issues.
• Some in agriculture stress there's been one huge improvement in recent years: The Affordable Care Act, also known as Obamacare, has helped farmers and others who had been without health insurance.
Val Wagner said her family has checked into getting coverage under the Affordable Care Act, but decided to stick with their family plan coverage from Blue Cross Blue Shield of North Dakota.
"It (the ACA) was so cumbersome, trying to decipher it all," Wagner said. "Some people have had really good luck with that. But it just wasn't something we feel comfortable with."
Gillie and others in ag say they're happy for people who have secured insurance through the Affordable Care Act. They also say health insurance is a bigger concern now than ever before.
Gillie said that her own family paid $600 a month, with a $3,800 deductible, for health insurance five years ago.
"Now it's $1,400 a month premium with a $13,000 deductible," she said.
Increases of that size are common in farm families, she said.
"This is a lot of money. It's people's mortgage payment. It takes away our ability to buy a new vehicle or make improvements to our homes. It's less money for our rural communities," Gillie said. "If that's not crippling, I don't know what is."
A 2015 study by the U.S. Department of Agriculture provides the most current information on farmers and their health insurance coverage. It finds two areas in which farm household's health insurance differs notably from that of the overall U.S. households.
• 10.7 percent of U.S. farm households had no form of health insurance, compared with 9.1 percent of the general population.
• 55.6 percent of farm households obtain their health insurance through an employer, compared with 55.7 percent of the general population. Put differently, farm households are slightly more likely than their general population to secure their own insurance.
Even so, as USDA notes, the majority of farm households with health insurance receive it through an employer.
It may surprise people outside agriculture that so many farm households rely on off-farm jobs for health insurance. But everyone involved in modern ag understands that important decisions - whether to enter or leave farming, whether a spouse takes an off-farm job, whether a part-time farmer gives up an off-farm job to farm full time - often are driven by health insurance. As health insurance costs escalate, health-care considerations become even more important.
Wagner - whose family now pays $1,500 monthly in health insurance premiums with an $11,000 annual deductible - said she "can understand why people get jobs that pay insurance. It's a significant part of your budget."
She works "as often as I have time" as a certified paralegal in Ellendale and also as vice chair of the American Farm Bureau Federation's promotion/education committee, a post in which "I help people share stories about ag," she said. Neither position offers health insurance coverage.
"I've thought about getting a job that provides medical insurance. I've made the phone call, I've done the legwork," she said. "But two things (stopped her): I want to be present in my boys' lives and also, working full time, changes the ability to help out on the farm."
The Wagners operate what could be described as a fairly typical diversified North Dakota family farm. They raise corn, soybeans, wheat and alfalfa, and operate a 179-head cow-calf operation. One the day of a recent visit, calving had just begun. There were three new calves, two of them twins.
Mark and Val, who grew up in nearby Forbes, have four sons: Ian, 14; Scott, 13. Evan, 10, and Eli.
"Looking back, I really wanted to have a little girl. But having these four boys, I realize this was what was meant to be," she said. "It's fun watching them grew up. I can't imagine living anywhere else."
In the week before following the visit, her sons played in a combined 11 basketball games. On the day of the visit, the two oldest Wagner sons were involved in a science fair and were being "judged as we speak," she said.
Scott advanced to the regional science fair, she reported later.
The Wagners have struggled for years with Eli's health problems.
By the time he was 18 months old, he had gone to 21 different specialists.
"We finally found a team of specialists at Mayo Clinic who was able to figure it out," Val Wagner said.
Eli "was the saggy-baggy elephant. He looked like a very thin, old man in a baby's body," Wagner said. " Without the (medical) care, I'm almost positive I'd be a mother of three, not a mother of four."
Today, Eli is allowed only 28 grams of protein per day. That's the equivalent of two slices of bread, a small glass of milk and a slice of cheese.
But, "He's doing amazing. He plays football with his brothers, plays with toy tractors. Everything appears to be normal," she said.
Last year, however, the Wagners came up against a new medical challenge: Val was diagnosed with thyroid cancer.
"It was not expected. I got that phone call," she said. "It was a gut check; I have these four young boys and I want to see them grow up."
"They say thyroid cancer is the 'good cancer' to get. I struggle with saying any cancer is a good cancer. But I'm grateful for the technology we have now, and being able to find it so quickly," she said. "I was lucky."
Her thyroid was removed Aug. 11, and she began radiation therapy in October.
The surgery paralyzed her vocal chords and she lost her voice for three months. Later, gel was injected behind her vocal chords so she could speak; the procedure wasn't expected to be a permanent solution. Eventually, the problem worked out on its own.
She will be rechecked in April and hopes she'll be told, "You're cancer-free."
'Can't not have it'
Val's first surgery alone cost about $35,000.
"How would you ever get out from under that (without medical insurance)?" she said. "I can see how people can get bankrupt so quickly."
Though "it can be difficult to think about these premiums, and what you're paying, going without (insurance) is not an option," she said. "We have to make sure our business will continue. All it takes is one catastrophic event, one event, and it can bankrupt our farm."
"It's expensive. But you can't not have it," said Mark Wagner, on a short break from feeding cows.
The Wagners have found ways, such as driving older vehicles, to come up with money to pay for their coverage, they say.
"We've been able to navigate that road. We've been able to figure out what's best for our family, but be as budget-friendly as possible when we could," Val Wagner said.
No 'silver bullet' yet
Like just about everyone else involved in ag, Wagner is looking for realistic ways to improve health insurance and farmers' access to it.
"I'm one of those people who feel, rather than start from scratch, let's fix with what's wrong with the current system. Especially things like pre-existing conditions and lifetime maximums. I never really thought about it until I had a child who had those concerns," she said. "I'm hopeful that within the next five years, we have some kind of better answer."
For now, "We all need to make affordable health care part of the conversation,' she said. "Not just about affording it, but doing what's best for your family."
The conversation is neither easy nor pleasant, given escalating costs and uncertainty about what the future will bring, she said.
"People are really leery about looking forward. But health care and health insurance are so important. We've just got to think and talk about it," Wagner said.