Medicaid Work Requirement Weighs Most Heavily on Arkansas’s Homeless, Advocates Say
In the last four months of 2018, Arkansas cut off health insurance for almost 17,000 low-income adults who did not meet the terms of the state’s Medicaid work requirement, the first such policy in the nation.
Republican Governor Asa Hutchinson, the architect of the work rule, has said the requirement is “common sense” given Arkansas’s low unemployment rate. Those who have lost coverage due to noncompliance likely found insurance elsewhere or moved out of state, the governor said in September.
“Or it could be that they simply don’t want to be part of the workforce. They’re able-bodied, but … they don’t desire to do it,” he added.
But critics say the rule does little to incentivize employment and much to harm poor Arkansans. A 2018 report from the Kaiser Family Foundation found that about 6 in 10 adults on Medicaid (excluding those on federal disability) were already working full-time or part-time. Most of the rest said they were too sick or disabled to work, were caring for a family member or were in school or retired.
Local service providers say the rule is particularly hard on those experiencing homelessness. Losing access to health care may make it more difficult for such beneficiaries to hold down a job, they argue, because their stability depends on having their complex medical and mental health needs met.
“I have seen that having [health] coverage available to people enables them to work. It is a baseline for being able to work,” said Paul Atkins, a homeless advocate in Little Rock. Atkins is associate pastor at Canvass Community Church, a hub for homeless outreach in the capital city. He’s also a licensed insurance agent who has helped over a hundred people sign up for Arkansas Works, the state’s name for Medicaid expansion.
The state isn’t investing any new money in re-entry programs or other job supports in conjunction with the work requirement, Atkins noted.
“There’s no carrots involved. It’s just a stick,” he said. “If people are not working, especially in this economy, there are other reasons beyond unwillingness. … If you want people to work, help them to work. Don’t take away their health insurance.”
Bernadette Reynolds, a co-pastor at Mercy Community Church of Little Rock and a board member of the Arkansas Homeless Coalition, said many of those living on the street have chronic conditions that require regular medication.
“People who don’t have insurance, that have diabetes, that have blood pressure issues — those are the ones I’m really concerned about,” she said. “They can’t get in to see a doctor when they’re sick, so they’re doing the emergency rooms. Well, what’s that doing? It’s putting stress on the ERs.”
Individuals with mental health issues or intellectual disabilities often can’t keep up with the state’s mandate, Reynolds said. “You’ve got to understand, a lot of our population have mental handicaps, so they can’t always keep appointments,” she said.
Reynolds knows firsthand what it’s like to grapple with health problems while being homeless. “I’ve been there,” she said. “I’m still trying to pay [medical] bills from when I was homeless, and I’ve been in a house for four and a half years. … There were several times — five times in one year — when I’d end up in the hospital. … I’d go off my [blood pressure] medication because I had no way to get it, then two weeks later I’m in the hospital, near stroke.”
An Arkansas Works beneficiary herself, she testified to the peace of mind that came with getting insured. (Because she’s over age 50, she’s not subject to the work requirement.)
“I can take care of myself,” Reynolds said. “I can get my annual bloodwork done, so I know if I need more cholesterol medicine or if I can come off of medication. I can get my mammograms done. I can get my women’s annual exam done. … I don’t make a lot of money doing what I do, but my medications are taken care of.”
A change of course on Medicaid expansion
Until recently, advocates of the Affordable Care Act considered Arkansas to be one of the law’s great success stories. The state saw its adult uninsured rate cut in half from 2013 to 2016 — the second-largest per capita decrease in the nation — as a result of the ACA’s Medicaid expansion. Arkansas took an unusual public-private approach to expansion, obtaining a waiver from the Obama administration that allowed it to use Medicaid dollars to pay for private marketplace insurance plans for low-income beneficiaries.
Hutchinson inherited the program from his Democratic predecessor when he won the governorship in 2014. To the consternation of some Republicans calling for an end to “Obamacare” in Arkansas, the new governor decided to keep Medicaid expansion intact.
However, Hutchinson also sought to put his own conservative stamp on the program. He rebranded it “Arkansas Works” and sought a new waiver from federal officials that would allow the state to implement a work requirement. The Obama administration refused to allow Arkansas and other states to pursue work requirements for Medicaid — but when the Trump administration took the reins in Washington, Hutchinson found a willing partner in Seema Verma, the head of the federal Centers for Medicare and Medicaid Services.
In March, Hutchinson and Verma announced CMS had approved Arkansas’s requested waiver. “This is not about punishing anyone,” the governor said at the time. “It’s about giving people an opportunity to work. … It’s to help them to move out of poverty and up the economic ladder.”
Though CMS authorized work requirements in six other states in 2018, Arkansas was the only one to get its policy off the ground last year. A similar waiver in Kentucky was blocked by a federal judge in the District of Columbia last summer before it could go into effect. A lawsuit filed on behalf of nine Arkansas Works beneficiaries is now before the same judge, and a ruling could come as soon as mid-January. The lawsuit says the Trump administration overstepped its bounds in authorizing Arkansas’s work requirement, alleging the policy runs counter to the goals of the Medicaid program.
Those subject to the requirement must show the state they’ve completed at least 80 hours of “work activities” each month, which may include school, volunteering, job training or a limited number of job search hours. The rule applies only to a relatively small subset of people. Children, federal disability recipients and anyone older than 50 are among those excluded. In 2018, the requirement applied just to Medicaid expansion beneficiaries ages 30-49; it began applying to 19- to 29-year-olds on Jan. 1.
As of Dec. 1, Arkansas’s total Medicaid population was 880,028, but just 64,743 were subject to the work requirement. And even among those, the majority of beneficiaries were deemed automatically exempt from having to report their hours for various reasons, such as having a dependent child in the home or being identified as “medically frail.” In November, only about 10,768 were required to actually report information to the state Department of Human Services.
Yet 4 in 5 didn’t do so: That month, 8,426 beneficiaries didn’t satisfy the requirement. Only 1,428 people in the entire state met the reporting requirement in November (and two-thirds of those did so by meeting a separate, pre-existing work requirement in SNAP, the food stamp program.)
If a beneficiary fails to meet the requirement for any three months out of a calendar year, he or she is kicked off the program and locked out of re-enrolling in Arkansas Works for the rest of that year.
Advocates say much of the problem lies with the state’s reporting process and low levels of public awareness of the policy. A Kaiser report on Arkansas’s work requirement published last month found that “monthly reporting of work or exemption status is confusing and a challenge for most enrollees,” based on a series of focus groups with 31 beneficiaries.
Until recently, beneficiaries were required to report their hours via a DHS website that is taken offline for 10 hours every night. The website requires the user to have an active email address in order to set up an account, along with a unique identification number that is sent by mail from DHS. In December, in response to criticism, DHS announced it was establishing a helpline that will allow beneficiaries to report their hours by phone instead of online. The agency also committed to investing in an outreach and advertising campaign.
Crucial paperwork ‘gets rained on’
Reynolds said people living on the street are too focused on meeting their day-to-day needs for food and shelter to keep up with the reporting requirement. “They forget that they have to report by a certain time, because, you know, life does get in the way. And not everybody is high enough functioning to remember, ‘Once a month I’ve got to get to the library or take time off of work,’ “ she said.
“They can’t keep up with paperwork, because it gets rained on,” she added. “And all the time, people are stealing other people’s bags. … People lose their IDs, insurance cards, all their important papers, birth certificates. We’re forever in a cycle of trying to replace things so people can do what they need to do to survive.”
The state grants exemptions to people for many reasons, but homelessness isn’t one of them. Marci Manley, a DHS spokesperson, said by email that’s because the agency crafted the details of the Medicaid work rule to mirror exemptions in the pre-existing SNAP work requirement.
“Those exemptions were meant to recognize long-term or longer-term life situations,” Manley wrote. ”However, everyone agreed that there also needed to be a way for beneficiaries to report other situations that might be shorter-term life events, which resulted in the Good Cause Exemption for Arkansas Works enrollees. We know that, unfortunately, people do face issues like homelessness, domestic violence, sudden hospitalization, natural disasters, and other catastrophic events.”
To request a good cause exemption, a beneficiary or his or her representative must email DHS with a description of the “extenuating circumstances” in question. That request must then be processed and independently verified by agency staff. Homelessness is one circumstance that could qualify a person for a good cause exemption, according to an internal DHS desk guide. However, the document adds, “designated staff members have the discretion to grant a Good Cause Exemption for any circumstance which would reasonably prohibit the individual from completing or reporting work requirement activities.”
DHS granted the catchall exemption to 471 beneficiaries from June to December, Manley said. It’s not clear how many of those people were homeless.
Kevin De Liban, an attorney for Legal Aid of Arkansas, is one of the lawyers working on the suit to stop the work requirement. Though Legal Aid has used the good cause exemption to help some clients get their coverage reinstated, he said the process is flawed.
“Any program that depends on a good cause exemption or some sort of exceptions process to work isn’t a program that’s designed well,” De Liban said. “You want something that works for everybody.”
Many people experiencing homelessness may also qualify for another exemption, such as being considered “medically frail” based on an assessment of health conditions. Manley said DHS has worked with the Arkansas Homeless Coalition and others to help service providers understand how to help clients request an exemption.
The state’s complex rules often do not square with the reality of people’s lives, Reynolds said.
“Not everybody who is mentally ill has gone to see someone to get diagnosed,” she said. “We have mentally ill people out there who do not draw [disability] checks, who aren’t on ‘medically frail’ Medicaid.”
“To me, it’s ludicrous, because it’s just causing more work for everybody involved, which is state money … that could be going to other things. It makes me very angry,” Reynolds said.
Governor Hutchinson, however, continues to defend the policy as a “proper balance of values.”
“I fought hard to maintain Arkansas Works, despite odds against it, despite enormous criticism,” the governor said in September, when the first round of coverage losses were announced. “Compassion and common sense says this is a good program for those that are trying to move up the economic ladder and to better themselves. It’s also about providing assistance to those who need it. And it is also about the value of work and responsibility.”
Benjamin Hardy is a contributor to the Arkansas Times and the Arkansas Nonprofit News Network. His reporting on Arkansas’s Medicaid work requirement was made possible in part by a 2018 fellowship sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund.