How Medicaid Work Rules Are Failing

Since June, Arkansas has required some enrollees to document that they work or engage in other work activities (e.g., job training or volunteer work) for at least 80 hours per month, unless they report that they qualify for limited exemptions. Before Arkansas began implementing its new policy, it was predicted to lead to large coverage losses, including among beneficiaries who are eligible but get tripped up by red tape, and would not meaningfully increase employment.

Here’s what happened:

As of December 1, nearly 17,000 Arkansas Medicaid beneficiaries have lost coverage due to the new requirements. This amounts to nearly 22 percent of all beneficiaries so far subject to the new policy, even higher than the 15 percent coverage loss Kentucky projected would result from its waiver by the fifth year and the 6 to 17 percent coverage loss that Kaiser Family Foundation researchers forecasted could result from implementing work requirements nationwide. The harm to beneficiaries will likely continue to grow next year, as Arkansas begins extending the policy to beneficiaries aged 19 to 29. (It currently applies to those above 29 but below 50.)

Among those subject to the work requirement, 13 percent failed to meet them for November. The main reason even more Arkansans haven’t lost coverage seems to be that most beneficiaries didn’t have to report any new information to comply with the work requirement: state data already showed they were working or qualified for exemptions. Among those who needed to report, few succeeded — around 80 percent of those who had to report exemptions or work hours failed to do so last month.

The number losing coverage exceeds the supposed target population: beneficiaries not working and not eligible for exemptions. Studies estimate that around 4 percent of those subject to the work requirement are not working and do not qualify for exemptions. Yet each month, 13 to 29 percent of those subject to the requirement have failed to report sufficient hours, many of them not reporting any hours.

News accounts corroborate that eligible people are losing coverage. For example, one working beneficiary with a chronic condition described losing his Medicaid coverage and then being unable to afford medications, in turn losing his job due to his deteriorating health. Another is rationing her medication after being unable to navigate the reporting requirement and losing coverage, despite working 25 to 35 hours each week — which equates to well over the monthly minimum.

Arkansas’ web portal has created problems, but challenges for beneficiaries go well beyond that. Many have rightly criticized Arkansas’ decision to restrict reporting to an online portal. More than 20 percent of Arkansas beneficiaries lack internet access, and another 20 percent have no broadband access. In addition, Arkansas’ web portal is unavailable from 9 pm to 7 am each day, is not mobile friendly, is not accessible for those with certain disabilities and requires a complex login procedure.

Arkansas officials have announced they will add a phone reporting option, but that will not eliminate the hurdles the policy creates for eligible beneficiaries. These include:

Complex rules creating significant confusion among beneficiaries. Some beneficiaries apparently believed they could maintain their coverage by reporting work hours just once, not realizing they needed to report every month. Also, clients can only count up to 40 hours of job search each month, but several beneficiaries reported over 80 hours of job search for November. These beneficiaries likely thought they were complying as they diligently looked for work and reported their hours but were not actually within the confines of the rigid policy.

Lack of staff support. The state hasn’t hired additional staff to answer questions or make accommodations for individuals with disabilities. By not investing in staff and other resources to support enrollees who should be exempt or need help complying with the requirements, Arkansas is creating a bureaucratic maze that is causing many eligible enrollees to lose coverage.

Insufficient and ineffective outreach. Some beneficiaries never learned about the new rules in the first place. The state conducted much of its outreach through social media and online videos that failed to reach much of a population that lacks access to computers or the internet. And although the state along with health plans, providers and advocates conducted outreach to educate beneficiaries about the new work requirement, they failed to reach many enrollees due to inaccurte phone numbers in case file.

The data so far appear inconsistent with any meaningful gains in employment as a result of the policy. While many beneficiaries have met the requirement by working, nearly all of those were people who were automatically deemed compliant because they were already working before the new rules took effect or because they complied with work requirements under SNAP (formerly food stamps), which were also already in place. Only 371 beneficiaries met the requirement by reporting work hours for November.