Charles Gresham held various jobs in the food industry and construction, but was routinely let go because he would have seizures on the job. Due to his health, the thirty-seven-year-old resident of Harrison, Arkansas, needed work with a flexible schedule, which is almost impossible to find in the low-wage labor market.
Arkansas’s Medicaid expansion program helped Gresham get the care he needed. But then he started receiving confusing and complex letters from the Arkansas Department of Human Services, telling him he needed to report work hours in order to keep his benefits. As a result, according to a lawsuit filed last November, he began to have “more anxiety attacks than normal” as he worried that his medical coverage would be discontinued, with potentially fatal consequences.
Another plaintiff in the lawsuit, twenty-six-year-old Russell Cook of Little Rock, worked seasonally as a landscaper. But, due in part to an extended rainy season, the job fell short of providing the requisite eighty hours per month under the state’s new Medicaid work requirement. “The loss of health insurance could be catastrophic for Mr. Cook, as he is presently living on the streets, where deteriorating health can have especially severe consequences,” the lawsuit states.
A third plaintiff, forty-two-year-old Treda Robinson of Searcy, Arkansas, has anemia that causes “fatigue, weakness, and heavy menstrual bleeding,” according to the lawsuit. She began receiving Medicaid in 2014 but had to quit her job for medical reasons in 2015. Her condition required serious surgery, most notably having a massive tumor removed, putting her Medicaid in doubt. Though her documented disabilities should satisfy the requirement, Robinson was told that her ill health did not exempt her. If she was noncompliant for three months, she would be removed from Medicaid entirely.
The lawsuit, with a total of nine named plaintiffs, accuses the Trump Administration of “bypass[ing] the legislative process and act[ing] unilaterally to fundamentally transform Medicaid, the cornerstone of the social safety net.” Arkansas began requiring work for health care in June 2018, threatening Medicaid for thousands. The plaintiffs were represented by Legal Aid of Arkansas, the Southern Poverty Law Center, and the National Health Law Program.
In March of this year, the plaintiffs succeeded; a federal judge struck down the requirement and it was immediately halted. That means the work requirement is gone, at least for now. But during the nine months that it was policy, more than 18,000 low-income people lost their health insurance. Most have not gotten it back.
Many of these individuals are entitled to reinstatement, but don’t know how to make this happen. Perhaps they have no idea how they lost their health coverage. Perhaps they’ve decided that the stress of reapplying just isn’t worth it, and they’ll go to the emergency room when a health problem escalates. Nonprofits that could help them have no idea who they are.
Advocates for people in need say the experience of these Arkansas should be a warning sign to other states that, with a green light from the Trump Administration, are planning to institute new work requirements for Medicaid recipients. Republicans in these states see these rules as a way to cut costs and promote “self-sufficiency.” But critics see them as politically motivated efforts to milk resentment against people who receive any form of government assistance other than handouts to the rich.
President Donald Trump’s Department of Health and Human Services announced in January 2018 that it would allow work requirements for Medicaid. All states needed to do was submit a waiver request to be approved by the department. The next day, the department approved a work requirement project in Kentucky. Since then, it has also authorized plans for Arkansas, New Hampshire, Arizona, Indiana, Michigan, Ohio, Wisconsin, and Utah. (The rules in Kentucky and New Hampshire, like those in Arkansas, were struck down by a federal judge.)
Work requirements—which can be found in public assistance programs from the Supplemental Nutrition Assistance Program (SNAP, commonly called food stamps) to cash welfare—stem from the assumption that people living in poverty are struggling not due to, say, socioeconomic forces beyond their control, but because of their own individual choices. Proponents of work requirements spout platitudes like “the best way out of poverty is a job,” presuming that people who receive benefits like Medicaid are not working.
Most adults who receive Medicaid are already working, often low-wage jobs in which workers’ schedules are inconsistent and health benefits are rare.
Work requirements, therefore, might more accurately be called “paperwork requirements,” according to Elizabeth Lower-Basch, director of income and work supports at the Center for Law and Social Policy. “The vast majority of the people who lost benefits” due to work requirements, she says, “should have been exempt or were in fact working and just didn’t know that they needed to report their hours, or couldn’t figure out how to navigate the [reporting] system.”
Lower-Basch adds that because Medicaid provides the medical care necessary to keep people healthy and vital, it’s not a replacement for work—it supports work.
The results of Medicaid expansion bear this out. Across the country, Medicaid expansion has made people healthier. In the thirty-six states plus the District of Columbia that have expanded coverage to low-income adults, people have been better able to access preventative care for chronic illnesses (which disproportionately affect low-income people), avoid emergency room visits, and afford their medications.
After Arkansas expanded Medicaid in 2014, the uninsured rate fell by more than half, from 22.5 percent in 2013 to 10.2 percent in 2016, one of the largest drops in the nation. For poor people in rural areas, the reduction was even starker. According to a report by the Georgetown University Health Policy Institute Center for Children and Families and the University of North Carolina’s North Carolina Rural Health Project, 45 percent of low-income adults in rural areas of Arkansas did not have insurance in 2009. By 2016, only 22 percent did not.
“There’s a large population of people that had never had insurance before, that has insurance [now],” says Loretta Alexander, health policy director at Arkansas Advocates for Children and Families. “We’re talking about people at the bottom of the economic scale that now can actually go to the doctor when they need to go to the doctor.”
There are external benefits too. When signing up for Medicaid once it was expanded, many people also signed up their children. Expansion has also helped protect hospital access. Several hospitals in rural areas across the nation have closed, but in expansion states, Medicaid has funneled much-needed dollars into these institutions. Only one rural hospital has closed due to financial troubles in Arkansas since 2010—in May 2019.
Medicaid work requirements threaten all of this.
Arkansas launched its work requirement program in phases, beginning in June 2018, when Medicaid recipients ages thirty to forty-nine without children under the age of eighteen were required to report at least eighty hours of work, or “work activities” like job training, each month to keep their health care. In January, recipients ages nineteen to twenty-nine became subject to the rule. Failing to comply for three months would result in removal from the program.
The court struck down the work requirements at the end of March 2019. Just a few days later, approximately 6,400 more people would have been booted from the program, alongside the more than 18,000 people who had already lost their health care in 2018. As of yet, Arkansas is the only state that has implemented its work requirement and removed people from the program, but other state projects are set to unfold soon.
While most Medicaid recipients have jobs, bureaucracy and red tape make it extremely difficult to actually report work hours. Plus, many of these workers are in industries like food service or home health care, in which hours are unpredictable and workers may not meet the required minimum each month, try as they might. The consequences of poverty, like limited access to transportation and limited formal education, also make it difficult to meet stringent work tests.
Besides being simply ineffective, work requirements also posit that a person is only as good as their job, worth only what they can add to the economy—deserving of adequate health care only if they work for it.
Besides being simply ineffective, work requirements also posit that a person is only as good as their job.
Even so, conservative states attempted to tie work requirements to Medicaid during the Obama Administration, but the Obama-era Department of Health and Human Services refused to grant waivers for such projects, arguing that doing so would conflict with the objective of Medicaid: to provide health insurance to low-income people. In other programs, like cash welfare, work requirements do a poor job of actually promoting long-term employment.
But what work requirements are quite successful at is removing people from programs altogether. And that is precisely what some conservatives want.
“This work requirement not only provides Arkansans with an opportunity to gain employment and move up the economic ladder, but also allows the state to concentrate our limited resources on those who need it most,” Arkansas’s Republican Governor, Asa Hutchinson, said in a statement highlighting that 4,353 people were removed from Medicaid three months after the state’s work requirement went into effect.
This is a generous read of a punitive policy, suggesting that possibly being removed from a health program could be an opportunity.
Besides, the requirement certainly didn’t function like an opportunity. A study published in The New England Journal of Medicine in June 2019 found that 97 percent of people subject to Arkansas’s new work requirement would have satisfied it, were it not for multiple barriers created—whether intentionally or due to bureaucratic incompetence—by the state agency overseeing the program.
After more than fifty years of serving the community, Little Rock Community Mental Health Center in Little Rock, Arkansas, has announced that it will be closing its doors on September 23, as this issue goes to press. Lisa Teer, crisis director at the community clinic, wrote in an email to The Progressive that the clinic, which served about 2,500 patients mostly through public health programs, was “impacted significantly” by funding changes in Medicaid and Medicare—and the burden of the Medicaid work requirement.
“Our clients were not informed appropriately or didn’t have the ability to address the requirements in time to avoid service interruption,” and the result was chaos, Teer wrote. Many patients, some who were homeless and didn’t have access to resources like transportation, simply lost care. The clinic lost patients, and was forced to assist clients with getting their benefits reinstated—without, of course, being able to bill for that time.
Official efforts to assist people in reporting their work hours were ineffective and flawed. The state Department of Health Services sent letters explaining the work requirement, without knowing whether a Medicaid recipient had changed addresses or was homeless. Officials made phone calls and sent emails, but often did not connect.
Another problem was that reporting work hours or an exemption required a person to log onto a website that was available only between the hours of
“If the goal [was] to get people into employment that is sustainable and to get them out of poverty, this was a complete failure.”
7 a.m. and 9 p.m. This meant a person getting home after 9 p.m. couldn’t log on until the next day, if they could log on at all. Rural Internet access is notoriously unreliable—or nonexistent. Arkansas ranks as one of the worst states in the country for broadband access, with just three-quarters of the state population able to access the Internet. Such access is obviously cost-prohibitive for the poorest people—including those required to report work hours to keep Medicaid.
“You put these huge barriers in people’s way, between them and health, and they’re not going to be able to navigate [the process],” says Tomiko Townley, advocacy director at Arkansas Hunger Relief Alliance. “If the goal [was] to get people into employment that is sustainable and to get them out of poverty, this was a complete failure.”
According to a new report by Arkansas Advocates for Children and Families, employment rates actually fell after the rules were put in place, as people who lost their health care due to the work requirements had to give up their jobs.
And although all those who were kicked off the program in Arkansas are eligible to re-enroll, the vast majority have not.
“The state hasn’t done anything to help people reenroll,” says Kevin De Liban, staff attorney at Legal Aid of Arkansas. Re-enrollment, then, “is a matter of people learning [about it] when they go to the doctor or the pharmacy, or [if they] saw a Legal Aid flyer or something.”
By the end of February, according to the most recent report posted on a state website, just 1,910 of the more than 18,000 people kicked off the rolls had reapplied and regained Medicaid coverage. (Alex Azar, secretary of Trump’s Department of Health and Human Services (DHS), claimed without evidence that this “seems a fairly strong indication that the individuals who left the program were doing so because they got a job [in] this booming economy.”)
But that’s not all. According to enrollment figures provided by the Arkansas Department of Human Services, about 32,000 fewer people were receiving Medicaid expansion benefits as of July 1 this year, compared to when the rules went into effect in June 2018. Currently, about a quarter of a million Arkansas residents are enrolled in the program.
Advocates say even Medicaid recipients not subject to the work requirements were affected by the increased volume and frequency of verification requests for everyone on the program. “There are lots of administrative ways to create barriers to participation,” says Lower-Basch. For example, DHS may send a form to the wrong address, and then cut off the person from Medicaid for not returning it.
Despite this dismal record, the Trump Administration is appealing the court decision that forced Arkansas to suspend enforcement of its work requirements and prompted Kentucky to abandon its plan. Oral arguments are set for October 11 at the U.S. Court of Appeals for the District of Columbia Circuit. Governor Hutchinson of Arkansas has indicated a desire for the case to go to the U.S. Supreme Court. Meanwhile, a number of other states are looking to implement their own requirements.
Indiana’s “Gateway to Work” project has already begun, but the state won’t be removing people from Medicaid until January. Utah, Ohio, and Arizona have yet to start their approved programs.
Conservative leadership in both Michigan and Wisconsin put plans for work requirements into place before both states elected new Democratic governors. But a lame-duck Wisconsin legislature pulled a fast one on newly elected Democratic Governor Tony Evers and transferred all decision power about waivers to the legislature itself. Now Evers may not be able to stop the work requirement from being imposed.
It’s a similar situation in Michigan, with Democratic Governor Gretchen Whitmer. There, because of how the law was written, removing the work requirement would jeopardize Medicaid expansion entirely.
Meanwhile, Alabama, Mississippi, Oklahoma, South Carolina, South Dakota, Tennessee, and Virginia have all submitted plans to federal officials that are pending approval.
New Hampshire’s work requirement began on June 1 and was set to remove people from Medicaid beginning in July. But the state, recognizing that about 17,000 of its 25,000 Medicaid recipients were about to be thrown off the program, delayed enforcement. Then the same federal judge who ruled on Arkansas’s and Kentucky’s work requirements struck down the requirement in New Hampshire.
Lower-Basch argues that as states look to implement work rules on people who need health assistance, they would do well to consider how this has played out in Arkansas. “[This] will happen in any state that attempts to implement these rules,” she says. “It’s not an implementation problem—the fundamental idea is broken.”
Alexander of Arkansas Advocates for Children and Families agrees: “Take note of what happened in Arkansas. You don’t have to repeat our mistakes.”
Sidebar: Medicaid Work Rules, State by State
Pete Ryan
Thomhave sidebar
Since January 2018, when Trump’s Department of Health and Human Services announced that it would allow work requirements for those who receive Medicaid, a number of states have received approval to do so.
Indiana
Before being appointed administrator of the federal Centers for Medicare & Medicaid Services, Seema Verma was a consultant who, alongside then-Governor Mike Pence, helped design Indiana’s Medicaid waiver program. The program instituted premiums for the first time, cutting off people who couldn’t pay. Indiana has now added a work requirement and is the only state currently operating such a program, though it will not begin removing people from Medicaid until 2020.
Wisconsin
Before Republican Scott Walker left office as governor, he signed into law a bevy of legislation to limit the powers of the incoming governor, Democrat Tony Evers, who opposes the Medicaid work rule but now may be powerless to prevent it.
Michigan
New Democratic Governor Gretchen Whitmer is hoping to limit the Medicaid work requirement she inherited from the previous Republican governor. Michigan’s requirement is stricter than in other states; parents with children six or older would be affected, as would adults over the age of sixty-two. One consulting firm’s report estimated that, if Michigan’s work requirement goes into effect as written, as many as 183,000 people, more than a quarter of the expansion population, could lose coverage.
Utah
Because the conservative state legislature refused to act, Utah voters passed a ballot measure to expand Medicaid across the state. State lawmakers responded by both curbing the extent of the expansion and adding a work requirement. The requirement, which will go into effect in January, is less severe than in other states: Medicaid recipients will need to register online, complete a virtual job training, and document their efforts to apply for jobs.
Ohio
Ohio is planning to implement its work requirement in 2021. The state, along with New Hampshire and Kentucky, is among those most affected by the opioid crisis, and there is promising evidence that Medicaid expansion has improved treatment for affected populations. Work requirements could limit access to these treatments for those recovering from addiction.
Arizona
Two years after Arizona expanded Medicaid in 2013, conservative lawmakers passed legislation requiring the state to apply annually for federal permission to implement a work requirement. The state was rebuffed by the Obama Administration, but the Trump Administration approved its request. The work requirement will be implemented “no sooner than” January 2020, according to the state. In a rare recognition of the challenges marginalized communities face, members of federally recognized tribes are exempt from the requirement.
Arkansas, Kentucky, and New Hampshire
Work requirements enacted in these three states were struck down, one after the other, by the same federal judge: James Boasberg of the United States District Court for the District of Columbia. Boasberg, an appointee of President Barack Obama, called Kentucky’s project “arbitrary and capricious.”