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