Reporting on Arkansas Medicaid work requirements – and their fallout Date: 01/18/19
By Benjamin Hardy
I spent most of 2018 mining a fairly narrow vein of health policy: Arkansas’s first-of-its-kind work requirement for certain Medicaid expansion beneficiaries. I wrote three big stories about the work rule and related topics, along with many smaller ones. My initial plan for the year was to survey Arkansas’s Medicaid program more broadly, not just the work requirement. But I soon found that this particular policy and the human stories it generated were so complex — and so poorly understood — that it became my main health care beat.
My first big story came out in June, when the requirement took effect for the first group of beneficiaries – people aged 30 to 49. I focused on the policy itself, partly because there were so many important details to report (and also, frankly, because I didn’t have success finding compelling human stories at that time). Much of my reporting consisted of digesting the voluminous documentation surrounding the state’s 1115 demonstration waiver from federal CMS. I also spoke to state legislators, insurance carriers, the state Department of Human Services (DHS) and multiple health policy advocates in Arkansas and D.C.
Work requirements are inherently complicated, I discovered, because people’s working lives are complex. And because such rules seek to delineate under what circumstances it’s permissible for someone not to be working, they entail a confounding array of exemptions, inconsistencies and quirks. For example, the vast number of workers in the informal economy (people who mow lawns or clean houses for cash, say) are considered to be working zero hours, since such labor isn’t verifiable by state employment data. Also, because Arkansas uses monthly earnings as a proxy to measure work hours, my reporting showed that the work rule actually requires those people who make a high hourly wage to work fewer hours per month than those who make minimum wage. Arkansas DHS says beneficiaries need at least 80 hours each month of “work activities,” which actually means $680 per month of earned income. (What else counts as a “work activity” is convoluted. Volunteer work is permissible. So is searching for a job, but only up to 39 hours per month. One hour of “vocational training” counts for 2.5 work activity hours, but an hour of “unpaid job training” counts for one work activity hour.)
My second major story, which was published in August, was unexpected. It came about because I noticed the state’s monthly Medicaid enrollment was shrinking significantly even before the work requirement began removing people from the rolls. Our governor, Asa Hutchinson, said the ongoing reduction was due to an improving economy and efforts at DHS to “scrub” the rolls of ineligible people.
After asking questions of the state and talking to advocates and beneficiaries, I found that many people were being disenrolled for what seemed like minor compliance issues. Not responding to a letter from DHS within a 10-day window apparently results in termination. So does an unreported address change. To find beneficiaries who lost coverage, I turned to social media. I published a note on the Arkansas Times Facebook page and eventually found two women (both of whom work, incidentally) who had been unexpectedly thrown off Medicaid, one because of a change of address and the other because of a paperwork error.
The third story came out in November, by which point the work requirement had stripped coverage from over 12,000 people. (The total rose to 17,000 in December.) I again had trouble finding human narratives. By this point, though, I was acquainted with the difficulties and began searching weeks in advance of my deadline. I contacted homeless advocates, community health centers and clinics, independent insurance agents, several nonprofit agencies, a legal aid group and others.
However, of the three people I included in the piece, two again contacted me because of a Facebook post soliciting stories (this time boosted by a little advertising money). The other was pure luck. A friend of mine struck up a conversation with a woman, Nannette Ruelle, who works at the restaurant next to his office. Ruelle had lost her health coverage because of the requirement and was now going without much-needed medication. (She’d been working 25-35 hours a week for most of the past year – more than enough to meet the Medicaid rules – but, like many people, she was confused about how to report her hours.) My friend knew I was looking for stories like Nannette’s and put me in touch with her.
I also wrote a number of smaller stories I feel were valuable, including coverage of Arkansas’s unusual online-only reporting requirement (which was recently rolled back somewhat), the state’s lack of an evaluation plan for its experimental rule and the monthly drumbeat of coverage losses once the policy began locking people out of Medicaid.
Benjamin Hardy is a reporter at the Arkansas Nonprofit News Network, and he reported in depth on Arkansas’ work requirements – and the related onerous reporting requirements – as an AHCJ Health Care Performance Reporting Fellow.