In June, Arkansas became the first state to implement a work requirement in its Medicaid program. The initial group subject to the policy were Medicaid expansion recipients aged 30-49 who had no children under 18 in the home, did not have a disability, and who did not meet other exemption criteria, including fulfilling the SNAP work requirement. On a monthly basis, recipients must work, volunteer, go to school, search for work, or attend health education classes for a combined total of 80 hours, and report the hours to the Arkansas Department of Human Services (DHS) through an online portal. Recipients who do not report hours any three months out of the year lose Medicaid health coverage until the following calendar year.

September 5 is the reporting deadline for the third month of the policy, making today the first time that recipients can lose Medicaid coverage as a result of the work requirement. There are 5,426 people who missed the first two reporting deadlines, which is over half of the group of 30-49 year olds subject to the policy beginning in June who had not been identified by the state as being exempt (Note 1). If these enrollees do not log August hours or an exemption into the portal by September 5, they will lose Medicaid coverage until January 2019 (Note 2).

Making Medicaid health coverage contingent on completing work-related activities is highly contentious. The Obama Administration rejected states’ requests for Medicaid work requirements because, they argued, policies that can undermine access “do not support the objectives of the Medicaid program.” In March 2017, the Trump administration sent a letter to state governors asserting its support for policies that use Medicaid “to increase employment and community engagement,” and in early 2018 the administration approved four states’ Medicaid work requirement proposals in 1115 waiver requests (Arkansas, Indiana, Kentucky, and New Hampshire).

In late June, two days before Kentucky’s work requirement was to go into effect, U.S. District Judge James Boasberg halted its implementation writing, “…the Secretary never adequately considered whether Kentucky HEALTH would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid.” A similar lawsuit challenging the legality of Arkansas’ policy, described by Governor Asa Hutchison as designed to help Medicaid recipients “move out of poverty and up the economic ladder,” has recently been filed.

Interviews With Medicaid Recipients

Little is known to date about how those impacted by the new Medicaid work requirement feel about the policy. To explore Medicaid recipients’ attitudes about Arkansas’ work requirement and their early experiences with the policy, in mid-August I conducted in-depth interviews with 18 adult Medicaid recipients in northeast Arkansas.  The interviews were conducted in three counties, one of which is urban (Craighead County) and the other two of which (Greene and Randolph Counties) are rural.  All three have higher percentages of white, non-Hispanic individuals than the state as a whole, and all three supported President Trump in the 2016 election at higher rates than the state overall. Half of those interviewed met the age criteria to be subject to the work requirement.

While this group is far too small to provide generalizable results, the interviews do illustrate how the state's policy is interacting with the day-to-day lives of Medicaid recipients to produce serious potential consequences that have little to do with policy's stated objectives. What I found was a profound lack of awareness about the policy. A number of people were at risk for losing their Medicaid health coverage because of complex life circumstances, not because of a conscious decision related to the work requirement.

Respondents expressed mixed feelings about the idea of a Medicaid work requirement, generally believing that able-bodied people should be working, but wondering how the policy could accommodate those with serious health issues or without transportation. There was substantial concern about having an online portal as the mechanism for submitting monthly work hours.

Lack Of Awareness

Two thirds of the Medicaid recipients (12/18) I interviewed had not heard anything about the new work requirement. “First time I’ve ever heard anything [about it],” a 31-year old man, who had started a vocational training program the day we spoke, said. “You’d think it’d be on the news or something. I ain’t seen it on the news, and I watch Channel 8 news every night.” Others echoed his surprise: “I’ve never even heard of it” and “I can’t believe I ain’t heard something about it on the news.”

Of the six people who had heard about it, one was very knowledgeable, in fact familiar with the statistics on how many had missed the initial two reporting deadlines. Two others had heard only a little about it from family or friends (“I’ve heard a little bit about it, not a lot”), and three had learned of the policy from their letter from DHS.

At Risk Of Losing Coverage

Of the nine people who, based on their age, should have received a DHS letter letting them know they were subject to the work requirement, four said they had received a letter. Two said the letters indicated they were exempt because they already met the SNAP work requirement.

The other two were at risk for losing Medicaid coverage. One, a 47-year old woman, said she had received her letter about three months earlier; she believed, incorrectly, that she had three months to report her hours. When I asked her if reporting her hours was an obstacle, she said she was struggling with very stressful life issues, including a mentally ill sister, and as a result the work requirement had not received much of her attention. The other person, a 40-year-old woman, described being overwhelmed by receiving the letter: “Basically… I’m like, okay, I’ve got this letter. I file it and I don’t know what to do with it...”

The other five who should have received a work requirement letter were either not sure if the letter arrived or thought it had not. When asked about receiving a DHS letter, a 42-year-old woman said, “I don’t know, I’m going to have to check and make sure [I didn’t receive the letter], because I need my Medicaid card for my sugar pill and my blood pressure pills.” A 46-year-old man, who had recently completed an inpatient drug treatment program, kicking a multi-decade drug addiction, wasn’t sure either. “I may have [received the letter]…I’m horrible about opening mail….I probably throw’d it away.” While the three others did not believe they received the letter, they were all exempt by either working and/or having children in the home, but likely needed to report their hours and exemptions in the portal to maintain Medicaid coverage.

Policy Not Sparking Work-Related Changes

Of the nine participants who were likely subject to the policy, only two were not meeting the 80 hour work-related activity requirement and did not seem to qualify for an exemption. Both told me that were actively seeking work, and that the work requirement had not at all impacted their job seeking. In addition, those I interviewed between the ages of 19-29, who will be subject to the policy in 2019, either worked, went to school, and/or had children under 18 years old in the home. No one I spoke with reported that the policy had or would spark them to change their work-related activities.

Online Portal Challenging For Many

Participants described a very wide range of computer and online skills and access. Approximately a third said that reporting hours on the online portal would not be possible for them: “I can’t do that. I don’t have a phone. I don’t have a computer.” Another third thought they could figure it out: “It wouldn’t be an issue, but it has been a while since I used one [a computer].” And a third had access and were highly confident of their skills: “I’m very, very computer literate.”

Regardless of their skills, everyone thought that requiring hours to be reported online was an unnecessary obstacle that made the work requirement very difficult for many recipients. Several, who were confident of their own skills, mentioned family members who would struggle. “Half my family probably doesn’t have a smart phone….A lot of people here don’t have internet still,” a 19-year old woman explained. Her 47-year-old mother-in-law had struggled using the portal: “She had to do it online or something, and she didn’t like it at all.”

Mixed Attitudes About Linking Medicaid And Work-Related Activities

Almost all the participants believed that people who could work should be working. “I believe if you are able to work and you want the extra help that Medicaid gives, then you should work,” said a 28-year old woman who was currently working and has young children. But several expressed concern about those who had mental or physical conditions that would prevent them from meeting the requirement. One man raised questions about people who were “borderline” who were not officially considered disabled but still had serious health conditions. A 42-year-old woman, who works with people with disabilities said, “I think it’ll do more harm than good…. What they supposed to do, just get cut off Medicaid because they can’t meet those requirements?”

Others raised concerns about transportation needed to get to work and volunteering. “Some people don’t have vehicles, and sometimes it’s not necessarily their fault. Sometimes something happens and they lose their money... It’s not fair,” said a 21-year old recipient who is a college student. When I asked a woman who was looking for work whether she had tried to get help from the Department of Workforce Services, she said that she couldn’t get there because it was 30 miles away and there is no public transportation.

Not Going To Lift People Out Of Poverty

Participants were very skeptical about the Governor’s claim that the work requirement policy would help them out of poverty, as many were already working and still struggling financially. Several raised the issue of the low minimum wage in Arkansas ($8.50 per hour) and suggested that raising the minimum wage would be a more effective way to help low-income workers. Others suggested that what was needed to help people move up the economic ladder was training: “If you got training that helped you get better pay. I think that would help.” One participant argued that the policy was not about getting people to work at all, but about reducing the number of Medicaid recipients: “It seems like a ploy for the state to save money. That’s all it is. It’s nothing about trying to get people back to work…”

Summing Up

The low level of awareness of the Arkansas Medicaid work requirement among the Medicaid recipients I interviewed helps to explain why fewer than half of the first group required to report hours or an exemption on the online portal have done so in the first two months of the policy. Clearly, there has not been adequate communication about the policy to those who are being impacted by it. The state is relying principally on the letter they send to recipients to spark change in recipients’ work-related activities and to report hours or exemptions using an online portal (Note 3). Given that the state is aware that many recipients do not open their mail (the program flyer says in bold text, “Be sure to read mail from DHS as soon as you get it.”), a much broader educational effort is needed to inform recipients about the policy.

The process for reporting hours and exemptions using an online portal poses a substantial barrier to the more vulnerable Medicaid recipients who have neither technology like phones, computers, and email accounts, nor experience using the technology. DHS Director Cindy Gillespie has argued the online portal will help prepare people for the work world: “We need to help them get an email (address) and learn how to deal in that world, or they will never be successful.” Yet, no training is provided and no one I spoke with was aware of the registered reporter option, where recipients can designate someone to report their hours.

Of the people I interviewed who were at risk of losing Medicaid coverage as a result of the work requirement, most were at risk because they lacked awareness of the policy or were overwhelmed by it, rather than because they were not meeting the 80 hours a month of work-related activities or the terms of an exemption. If this is true more broadly, the state will be ending people’s health coverage for the wrong reasons, adding credence to those who argue this policy is about reducing the rolls, rather than supporting people to get employment.

A 38-year-old woman who recently had to quit her job to get her niece, who she mothers, a birth certificate and other paperwork to start school argued that the policy does not take into account the complex lives of low-income people. “You are saying this should be possible, but you don’t know my circumstances. You haven’t been here,” she explained.

Author's Note

I would like to thank the people who I interviewed for their openness in sharing their thoughts and experiences with me.  I would also like to thank 1st Choice Healthcare, Helping Neighbors Food Pantry, and Mission Outreach of NEA for welcoming me into their organizations to conduct the interviews.

Note 1

The policy was rolled out to one quarter of recipients aged 30-49 each month from June through September. The program will begin for those aged 19-29 in January, and those 50 years old and older are not subject to the work requirement.

Note 2

If the recipients did not report hours or an exemption by the last day in August they lost coverage on the 1^st of September, but it will be reinstated if they report by September 5.

Note 3

DHS has developed a website with videos, flyers, and other information about the policy. There is, however, no link to the website from the main Medicaid beneficiary website, and no one I interviewed said they had used it.