Almost 17,000 Arkansans have now lost their health insurance due to the state's experimental work requirement for certain low-income adult Medicaid beneficiaries, according to a monthly report released by the state Department of Human Services on Monday.
The state terminated coverage for another 4,655 beneficiaries due to noncompliance with the work rule in early December, adding to the 12,277 who were cut off and locked out of Medicaid from September to November. Those people were enrollees in the Arkansas Works program, the state's approach to Medicaid expansion. Arkansas Works provides low-income adults with marketplace insurance plans through private carriers such as Blue Cross or Ambetter, but their premiums and other cost-sharing are paid by Medicaid.
However, those who lost coverage due to the work requirement in 2018 — including those who just lost it in December — may regain their insurance as soon as Jan. 1. The work rule says that Medicaid beneficiaries who don't report 80 hours of monthly "work activities" to DHS for any three months out of a given calendar year are locked out of the Arkansas Works program for the rest of that year.
The three-month threshold resets in 2019. That means anyone may reapply for coverage in the new year, a DHS spokesperson confirmed by email on Monday, as long as they meet income-eligibility criteria.
In 2018, the work requirement applied only to Arkansas Works beneficiaries ages 30-49. Beginning in January, it will expand to include those ages 19-29 as well. (People 50 and older are not subject to the requirement.)
Governor Hutchinson, who has championed the work requirement, issued a statement on Monday afternoon through a spokesman. The program appears to be "accomplishing its intent," the governor said by email. "Since June 1, more than 4,100 Arkansas Works beneficiaries have moved into work, which is the primary goal of this initiative. ... As for those who did not comply and, as a result, lost coverage, they will have an opportunity to re-enroll in January.”
The most recent DHS numbers show enrollment in Arkansas Works has now dropped below the number of adults in the state's "traditional" Medicaid program, which includes groups such as elderly or disabled people. As of Dec. 1, there were 234,385 enrolled in Arkansas Works. In January, there were 285,564 — a drop of more than 50,000. (The traditional adult Medicaid population was 240,092 on Dec. 1.)
Only a portion of that enrollment decrease can be directly attributed to the work rule. DHS data indicate the agency closed thousands of cases in December for other reasons, such as "failed to return information" or "unable to locate client." Some of those beneficiaries likely found insurance coverage elsewhere, such as through a new job. But other factors may also be at play: Previous reporting by the Arkansas Nonprofit News Network suggested Arkansas takes an especially aggressive approach to terminating coverage due to paperwork and compliance issues, such as not responding to a DHS request for information quickly enough.
Asked about the enrollment figures, Hutchinson praised the efforts of DHS Director Cindy Gillespie to implement "data-matching procedures for all Arkansas Works beneficiaries in order to maintain the integrity of the rolls. This has been key as we work to ensure that those who qualify for the program remain and those who do not are rolled off." He also noted Arkansas's low unemployment rate. "[S]ince 2015, more than 65,000 Arkansans have moved out of poverty. These statistics support my belief that many of these individuals have moved into work and up the economic ladder," the governor said by email.
The work requirement was created by Hutchinson and enabled by a waiver to federal law granted by Trump administration officials in March. Since it was first rolled out in June, the policy has attracted a growing chorus of critics, including the federal Medicaid and CHIP Payment and Access Commission, or MACPAC. The nonpartisan legislative agency has urged a "pause" on disenrollments in Arkansas, citing the low response rate from those beneficiaries who are required to report their hours each month. The fact that at least 9 out of 10 beneficiaries don't report any hours at all may indicate the state's reporting and outreach process is flawed, MACPAC has said.
Hutchinson has pushed back against such arguments. The work rule provides ample exemptions to those who need them, he's said, and the majority of Arkansas Works recipients are exempt from reporting, for various reasons. The governor maintains that those who have not met the requirement have found insurance elsewhere, moved out of state or have simply chosen not to comply.
However, DHS announced changes to its process for reporting work hours just last week. As of Dec. 19, it will begin operating a "help line" that will allow Arkansas Works beneficiaries to report their hours by phone. Previously, DHS required beneficiaries to use a website to report their hours, though the agency did allow third parties such as insurance agents (dubbed "registered reporters") to relay the information from beneficiaries to the state website. It also announced plans to begin buying paid advertising to inform beneficiaries about the policy.
The state's creation of another alternative to the online reporting process may be a response to critics who pointed out Arkansas's relatively low rate of internet connectivity — especially among low-income households — and problems with the website. The state's portal is taken online for 10 hours every night, from 9 p.m. to 7 a.m. The DHS phone line will also be offline during those hours.
Bruno Showers, a senior policy analyst with Arkansas Advocates for Children and Families, said the changes announced by DHS last week are "a good first step, but it’s kind of a baby step." Most beneficiaries, he said, are used to applying for public assistance in-person at their county office. (DHS offices provide access to computer terminals for beneficiaries to report work hours but do not have caseworkers dedicated to the task of reporting hours.)
As for increased advertising and outreach from DHS, Showers said, "it's good they’re doing it now, but they should have been doing it from the beginning." He expressed concern the state may not budget enough money for outreach; DHS is still developing the budget for its paid advertising effort. "If it’s just a token amount, that’s not going to do much at all. ... There are a lot of details to be filled in," Showers said.
As in previous months, Monday's DHS report shows that few of those required to report their hours are doing so. There were about 65,000 people subject to the requirement in November. Of those, about 54,000 didn't have to report anything to the state. (Out of that number, most were deemed to be in compliance because DHS already had income information on file that indicated the beneficiary worked more than 80 hours monthly.) Another 900 reported an exemption to DHS. About 1,400 satisfied the reporting requirement. About 8,400 did not satisfy the requirement (and of those, 4,655 were in their third month of noncompliance).
Arkansas is the only state that has so far implemented a work requirement in its Medicaid program. A rule in Kentucky was blocked by a federal judge earlier this year before it could get off the ground, and plaintiffs in Arkansas have challenged Arkansas's policy on similar grounds. A ruling in the Arkansas case could come in early 2019.
Both the Kentucky and Arkansas litigation is far from being resolved, however. Trump administration Medicaid officials said in November that they had addressed the judge's previous concerns about Kentucky's rule, which cleared the way for its possible implementation unless the court intervenes again.
Arkansas Works and Medicaid expansion programs in other states were created by the Affordable Care Act, or Obamacare. On Friday, in a separate lawsuit, a federal judge in Texas ruled that the ACA was unconstitutional in its entirety. Most legal experts believe the decision is unlikely to stand.
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.