Editor's Note: This is the second in four-part series looking at Arkansas' work requirements for Medicaid. Part three will appear in Friday's edition.
Over the past three months, the state Department of Human Services has removed thousands of people from Arkansas Works — the state's Medicaid-funded insurance program for low-income adults — for not reporting at least 80 hours of “work activity” under a new rule.
The rule, which began for the first subset of beneficiaries in June, applies to able-bodied adults under age 50. (In 2018, the requirement applied only to those ages 30-49, but it will begin including 19- to 29-year-olds in 2019.) Those who don't comply for any three months in a calendar year are kicked off Arkansas Works and locked out until the new year begins. Arkansas is the first state to implement a work requirement as part of a Medicaid program.
Most people on Arkansas Works were likely working long before the state's requirement came along. An analysis released last December by the Kaiser Family Foundation, a national health policy research nonprofit, found that about 60 percent of working-age, able-bodied adults on Medicaid worked full time or part time. Most of those in the remaining 40 percent said they were in school, retired, taking care of a family member or too ill or disabled to work — situations that would likely make someone eligible for an exemption under Arkansas's rules.
But DHS numbers show that among people required to report work activities last month, only about one in nine complied.
In October, the work requirement applied to 69,041 people, according to the most recent DHS report. The vast majority, 55,388, did not have to report anything, either because they received an exemption or because the department had income information on file that made the agency assume they were working enough hours. (The fact that many workers are automatically deemed exempt from reporting may add to confusion about who exactly is required to report.)
Just 1,525, or about 2 percent of the total, satisfied the rule by actually logging on to DHS website and reporting 80 hours of work activities. That left 12,128 people who didn't meet the reporting requirement that month. Of those, 3,815 had reached their third month of noncompliance and had their cases closed.
National health policy advocates have expressed alarm over such figures. On Nov. 8, the Medicaid and CHIP Payment and Access Commission (MACPAC), a nonpartisan federal advisory panel, sent a letter to Medicaid officials in the Trump administration calling for a "pause in disenrollments" in Arkansas. The fact that so few people were reporting work hours suggested the policy "may not be structured in a way that provides individuals an opportunity to succeed, with high stakes for beneficiaries who fail," commission chair Penny Thompson wrote.
One way to interpret the low reporting rate is that many beneficiaries aren't motivated to keep their insurance. Another is that many people simply aren't sure what they're supposed to do.
Robert Smith, 48, got a letter in late October telling him he'd be cut off on the first of the month. "They said I hadn't completed my 80 hours. I didn't even know I was supposed to complete 80 hours," he said in a recent interview.
Smith, who lives in Benton, said he's now only able to work intermittently because of chronic back problems and a torn rotator cuff. He currently works part time hauling trash, despite the pain in his back and shoulder. "It's pretty tough. You just gotta bear it and do what you gotta do," he said.
Smith has also been diagnosed with abnormally low testosterone levels, he said, and for the past 17 years has received regular injections of the hormone from a doctor. Arkansas Works covered those injections. The insurance wasn't perfect — it didn't cover his X-rays after a recent fall, he said — but he's not happy about losing it over a requirement he only just heard about.
"I didn't even know nothing about it until it was too late. And, I mean, how are you supposed to work if your back's messed up? Do I have to go and volunteer 80 hours somewhere? I don't understand what they're wanting," Smith said.
To policymakers who might ask why he was only holding down a part-time cash job, Smith said he'd point out to them that he worked hard for decades.
"You know, my kids are raised. I don't owe nobody, nobody owes me nothing, so I took the last year and a half off just for me," Smith said. "Because I've been killing myself all my life." Still, he said, "I have no problem taking a job that I'm capable of doing without tearing my shoulder or messing my back up more."
In its Nov. 8 letter, the federal commission criticized Arkansas's insistence that beneficiaries use the web portal to report hours, considering the state has one of the lowest levels of internet connectivity in the nation. (Census data compiled by the Urban Institute, a D.C.-based think tank, show about 18 percent of households lacked home internet access in 2016, including no access through a cell phone.) Yet DHS has made many of its educational resources available only online or through social media, the letter noted.
DHS Director Cindy Gillespie has said the web portal is a means of pushing beneficiaries to gain computer literacy skills. "We need to help them get an email (address) and learn how to deal in that world, or they will never be successful," she said in March. However, DHS has devoted no additional resources to teaching beneficiaries those skills. Gillespie also acknowledged at the time that online-only reporting would help the agency save money. "If you implement it in the old-fashioned way of, 'Come into our county office,' we would have to hire so many people," she said.
DHS insists it's doing everything it can to keep people informed. It contracts with the Arkansas Foundation for Medical Care to operate a call center. It regularly sends mail to beneficiaries informing them of their status (perhaps to excess — many complain of receiving a torrent of redundant and often contradictory letters from DHS). It has established a "registered reporter" process, which allows third parties to relay information from beneficiaries who have trouble reporting through the web portal.
Most registered reporters are insurance brokers, agents or others affiliated with the private insurance world. Insurance carriers have an incentive to keep Arkansas Works beneficiaries enrolled because of Arkansas's unique public-private approach to Medicaid expansion, in which the government pays for the cost of private insurance for most beneficiaries. The plans are provided by the state's three health insurance marketplace carriers: Arkansas Blue Cross Blue Shield, Ambetter of Arkansas and QualChoice. (Smith was enrolled in a Blue Cross plan.) In other words, when beneficiaries get kicked off Arkansas Works, the companies stand to lose money.
Max Greenwood, a spokeswoman for Arkansas Blue Cross Blue Shield, the state's largest carrier, wrote in an email that the carrier has designated "close to 200" employees as registered reporters. "We have made close to 10,000 telephone calls, sent approximately 115,000 letters, approximately 10,000 texts and about 27,000 emails in hopes of reaching impacted members," she added. Blue Cross has also reached out to providers and pharmacists to offer their patients assistance with reporting.
Still, Blue Cross has seen 6,857 members disenrolled due to the work requirement as of Nov. 15, Greenwood said. She said it's "fair to say that there is still a significant number [of beneficiaries] that are unaware they are subject to the requirement."
A spokesperson for Ambetter, the second-largest carrier in the state, said by email it had also "implemented a robust outreach plan for both members and providers." Ambetter has had 4,259 members disenrolled because of the work requirement as of Nov. 13. The spokesperson added that "members report that internet access, computer literacy and lack of transportation are their greatest challenges to meeting the work requirement."
It's unclear how effective these outreach efforts have been. The Medicaid commission letter noted that DHS was unable to provide data on how many beneficiaries had been helped by registered reporters.
This reporting is made possible in part by a yearlong fellowship sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund. It is published here courtesy of the Arkansas Nonprofit News Network, an independent, nonpartisan project dedicated to producing journalism that matters to Arkansans. Find out more at arknews.org.