Arkansas is the first state to test it, and thousands
have been kicked off the program.
Sept.
24, 2018
The
Trump administration argues that imposing work requirements for Medicaid is an
incentive that can help lift people out of poverty. But a test program
in Arkansas shows how hard it is merely to inform people about new incentives,
let alone get them to act.
In the
first month that it was possible for people to lose coverage for failing to
comply, more than 4,300 people were kicked out of the
program for the rest of the year. Thousands more are on track to lose health
benefits in the coming months. You lose coverage if you fail to report three
times, and the program, in effect for three months, is slowly phasing in more
people.
Arkansas
is the first state to test a work requirement, a policy that the administration has encouraged, and that several other
states are hoping to copy. The demonstration project is testing whether a work
requirement can help encourage more low-income people to work, volunteer or go
to school and improve their financial prospects.
The
early results suggest that the incentives may not work the way officials had
hoped. Arkansas officials, trying to minimize coverage losses, effectively
exempted two-thirds of the eligible people from having to report work hours.
Of the
remaining third — about 20,000 people — 16,000 didn’t
report qualifying activities to the state. Only 1,200 people, about 2
percent of those eligible for the requirement, told the state they had done
enough of the required activities in August, according to state figures.
Seema
Verma, the administrator of the Centers for Medicare and Medicaid Services,
which approved the project, offered an enthusiastic assessment of the results
so far. “I’m excited by the partnerships that Arkansas has fostered to connect
Medicaid beneficiaries to work and educational opportunities,” she wrote on Twitter. (Her office declined to offer any
further statements on the Arkansas experience.)
Advocates
for the poor, and the state officials in charge of the program, said the low
compliance numbers suggested that many eligible people probably didn’t know the
program existed. State officials said they worked hard to get the word out —
mailing letters, sending emails, placing phone calls, briefing medical
providers, putting posts on social media sites and distributing fliers where
Medicaid patients might find them.
“I was
literally taking fliers to the urgent care clinic when I was taking my kids to
get tested for strep,” said Amy Webb, the chief communications and community
engagement officer for the Arkansas Department of Human Services. “If there’s
something we are not doing to reach people, if someone will tell us how to do
that, we will do it.”
But it
seems that not everyone opened or read their mail. Ray Hanley, the president of
the Arkansas Foundation for Medical Care, which ran a call center for the
state, told my colleague Robert Pear that many people never answered their phones. The state said the open
rate on emails was between 20 and 30 percent.
It’s
harder to measure how many people opened paper mail, but the state noted in its
recent report that it knows that thousands of people in the program either move
away from their recorded address or fail to answer other mail from the state.
Housing instability and moves are more common among
low-income Americans.
Jessica
Greene, a professor of health policy at Baruch College in New York, visited
three Arkansas counties last month and interviewed 18 Medicaid beneficiaries.
Twelve of them were unaware of the work requirement, according to an article she
published on the website of the journal Health Affairs.
That
may not be entirely surprising. “I ignore mailings and calls from my health
insurer — I get them all the time,” said Eliot Fishman, a senior director of
health policy at Families USA, a consumer advocacy group.
Mr.
Fishman oversaw Medicaid demonstration projects in the Obama administration. He
said he learned that it was challenging to use health insurance as a vehicle to
shape behavior, because most people don’t read the fine print of their health
benefits.
Under
Mr. Fishman’s watch, Indiana tested a program to get beneficiaries to
take more responsibility for their health. Medicaid patients who made small
monthly payments in special accounts, got a checkup or did other activities
could earn more generous benefits. Ms. Verma, then a consultant, helped the
state devise that program. In an evaluation, it turned out that only a minority
of eligible people understood that the accounts existed.
Joan
Alker, the executive director of the Georgetown Center for Children and
Families, who opposes work requirements for Medicaid, said the state could have
done more to get the word out — if it had been willing to spend more.
The
Obama administration spent millions on advertising and in-person help when it
rolled out Obamacare’s coverage expansion in 2014. Even then, it took several
years before the uninsured rate among poor Americans stopped dropping. “You
cannot have an incentive strategy that is allegedly designed to change people’s
behavior if people are not aware of it,” she said.
The
challenge goes beyond getting the message out. The state requires those
eligible for the work requirement to report their work hours every month, and
only online. Arkansas has one of the lowest rates of internet penetration in
the country; estimates from the Urban Institute suggest that more than a
quarter of eligible families are not online.
Advocates
for the poor describe the state’s website as
confusing to navigate, especially for people with limited computer skills and
overall literacy. (Click on the site yourself and see if you can figure out
how to report work hours.) The state has tried workarounds — like offering
computer terminals in county offices, and training volunteers to help people
log their hours.
But
evidence from a range of social programs — including Medicaid — has repeatedly demonstrated that administrative
hurdles can cause eligible people to lose benefits.
As the
program is expanded to more people, awareness and compliance may spread over
time. But the early results could mean the end of the program before we know
for sure. A lawsuit challenging the work requirement will be reviewed soon by a
federal judge who already knocked down a similar work rule in Kentucky. In that
case, the judge, James Boasberg, said Kentucky had been insufficiently
concerned about the people who might lose coverage because of the
requirement. In Kentucky, those losses were theoretical. In Arkansas, they’re
already real.
Margot
Sanger-Katz is a domestic correspondent and writes about health care for The
Upshot. She was previously a reporter at National Journal and The Concord
Monitor and an editor at Legal Affairs and the Yale Alumni Magazine. @sangerkatz • Facebook
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