Earlier this year, Arkansas became the first state to implement a policy that—with some exemptions, including for people age 50 and older—requires adult Medicaid enrollees to work 80 hours every month at the state’s minimum wage. The policy has serious implementation problems, and is quickly ncreasing the number of uninsured in the state.
In Compliance or Not—That is the Question
Much of the issue stems around exemptions, compliance, and reporting requirements. In addition to working 80 hours every month, enrollees can meet work requirements by participating in some other approved activity—like job training, going to school, or volunteering in the community. Among those exempt from the requirement altogether are people who care for an incapacitated person. But regardless of status—that is, whether people are active workers, participating in qualifying activities, or exempt individuals—all must report their activities (or exempt status) to the state every month. Those who fail to report for three consecutive months are locked out of the Medicaid program for the remainder of the year.
The policy is already taking a toll on people. Since implementation, over 12,000 people have lost their Medicaid coverage—and along with it, they likely lost access to critical medicines, needed mental health services, and preventive care—after the state determined they had not reported the required activities or exemptions. By 2019, the requirement could result in loss of coverage for up to 50,000 adult Medicaid beneficiaries.
But are all such individuals really out of compliance? The problem is, it’s hard to tell—because it’s difficult for people to prove compliance. The only way people can prove compliance is by logging in their activities or exempt status through the state’s online portal. Yet this could be a highly difficult task to perform in a state where nearly 30 percent of households lacked broadband internet service in 2016. While one might assume people could access the reporting website using their mobile phones, this avenue, too, is problematic: the state’s online portal has been professionally rated as not mobile friendly.
Even though the state makes computers available at two public locations in every county, barriers remain: insufficient numbers of computers, unreliable or sluggish internet connections, inability to navigate a web-based site, difficulty establishing an account on the web portal, low literacy levels, lack of transportation, language barriers, and the possible unavailability of evening hours at the county sites. Other barriers include lack of awareness of the reporting requirement or how to report.
The Arkansas Policy is Reversing a Good Trend
The value of health coverage cannot be overstated. A significant body of research demonstrates that Medicaid expansions under the ACA led to improvements in access to care, health outcomes, self-reported health status, and financial security for low-income adults. They have also led to lower uncompensated care costs for hospitals and clinics. Since Arkansas expanded its Medicaid program under the Affordable Care Act, its uninsurance rate declined over 10 percentage points—from 24 percent in 2013 to 14 percent in 2015--one of the top 10 largest drops in uninsurance rates in the country.
Now, Arkansas’ work requirement is reversing those significant gains in health insurance coverage for low-income uninsured adults, and likely, the health improvements that come with it. Policies and processes that impede the Affordable Care Act-related progress are certain to have negative impacts on the health of Arkansas residents, possibly even creating the ripple effect of impacting their ability to engage in gainful employment due to unaddressed health problems. In turn, providers will likely see their uncompensated care costs rise, and the state will likely end up ponying up part of the tab.
Challenging the Arkansas Policy
This isn’t the end of the story. On August 12, 2018, three organizations filed a lawsuit on behalf of three Arkansas plaintiffs to stop the continuation of the state’s work requirement. The case is before the same judge who ruled against Kentucky’s work requirement earlier this year. In that case, the judge determined that the work requirement was not likely to promote Medicaid objectives—to provide access to health insurance coverage for low-income, qualifying individuals.
In addition to the lawsuit, the Medicaid and CHIP Payment and Access Commission (MACPAC)—a non-partisan agency that makes recommendations to the federal government and states on Medicaid issues—recently sent a letter to the U.S. Secretary of Health and Human Services urging him to stop Arkansas from disenrolling people subject to the work requirement until the state implements specified changes. Such changes include improving efforts to inform and educate consumers about both the work requirement itself and how to report work-related activities. MACPAC also asked the Secretary to begin collecting data needed to support robust evaluation of the policy’s impacts.
It remains to be seen whether Arkansas’ work requirement will withstand legal scrutiny, and whether HHS will follow MEDPAC’s recommendations. In the meantime, it is critical to continue to monitor the implementation of the policy and the number of Arkansans losing coverage. After all, their health hangs in the balance.
Lynda Flowers is a senior strategic policy advisor at the AARP Public Policy Institute. Her areas of expertise include Medicaid, social determinants of health (including social isolation), oral health, and health prevention/promotion.
Jean Accius is senior vice president for AARP Thought Leadership and International Affairs. His areas of expertise include aging, caregiving and long-term care policy.