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
Digital tools can enrich, but is there a downside to too much screen time? Some pediatricians and parents are now raising concerns about the classroom laptops, tablets and apps, partly because school districts are adopting digital tools in droves.
Last year, primary and secondary schools in the United States spent $5.4 billion on 12.4 million laptop and tablet computers, according to International Data Corporation, a market research firm known as IDC. “The concern is that many programs students use in school are entertainment and gamified,” said Dr. Scott Krugman, a pediatrician in Baltimore County, who supported recently proposed state legislation that would develop optimum health and safety practices for the use of digital devices in schools. “We felt these are things that should be tracked and monitored.”
Baltimore County Schools also recommended that students take activity breaks from computer tasks every 20 minutes and leave their devices inside during recess. They may even have to play and talk with each other. Hmmm, old school, I guess?
If you’re driving right now, it’s far more likely you are reading this on your phone than you would have been a year ago. Despite a harrowing surge in traffic fatalities, American drivers appear to be getting worse at avoiding Instagram, e-mail and other mobile-phone distractions while driving. More people are using their phones at the wheel, and for longer periods of time, according to a study published Tuesday from Zendrive, a San Francisco-based startup that tracks phone use for auto insurers and ride-hailing fleets.
“As you have more young drivers on the road, and as people increasingly become addicted to their smartphones, it will continue being a major health issue—almost an epidemic—in this country,” said Zendrive founder Jonathan Matus. From December through February, Zendrive technology monitored 4.5 million drivers who traveled 7.1 billion miles, comparing the results with the year-earlier period. Roughly two out of three of those people used a mobile phone at least once.”
One of the few bright spots of the study is that drivers tend to use their phone as they first start out on a trip, perhaps ending a message thread before settling in for the journey. While that window of time isn’t any safer than any other moment behind the wheel, Matus believes it may present an opportunity for changing behavior. A publicity campaign urging drivers to finish screen work, or just catch up on Instagram, before setting out could produce results. “Legislation, by itself, is clearly not enough,” he explained.
It will kill you! But just don’t take my word for it. I am not even going to get into pot-smoking or drunken-driving, but let’s just say that human judgements become flawed when drivers and pedestrians go around stoned. Let’s take a look at some recent statistics published by the National Highway Traffic Safety Administration (NHTSA). Perhaps most alarming is the dramatic rise in pedestrian deaths on our streets where you may have thought was the safest place to be.
The increase in pedestrian deaths, which account for 16 percent of all traffic fatalities, may be the most discouraging news of all. There were 5,987 of them in 2016 according to the NHTSA. Expectations are that 2017 will end up with a toll at least that high. That’s a rise of 22 percent from the 4,910 registered in 2014. Maybe it’s time for every municipality to get serious about distracted walking, as it is called, even though distracted driving is plainly a bigger concern.
Put away your mobile technology devices while walking (or driving). Heads up, everyone!
I think it used to be a novelty. At least that is how I remembered going to a Horn and Hardart Automat when I was a boy and being intrigued by the process of opening tiny glass doors to retrieve your favorite dishes. It has been a while since I have experienced this self-service feature but from what I have read about today’s automats are that they are more technologically enhanced and offer a more varied menu that would even appeal to vegetarian diners. Now it appears that diners are frowning upon “faceless dining.”
Eve Turow Paul recently wrote in Forbes magazine that “the links between technology and increasing rates of loneliness, depression, and anxiety. Many in this young generation battle a creeping sense of nugatory existence by connecting over a meal – whether it’s by cooking for family, dining out with friends, or chatting with others online about gluten-free recipes. My research clearly shows these human-facing moments and different instances of interaction help soothe this digitally-connected generation.”
Funny, I don’t remember family meal times as always being a “soothing experience.” But I guess that we all got to know more about each other in a “face-to-face” way.
P.S. Happy Halloween 👻, everyone. I will be back next Friday after a Halloween break with family. I hope it’s not too scary!
Last Saturday in Washington, D.C. (and in more than 600 cities worldwide) Bill. Nye, the Science Guy, was one of the Leaders of the nationally-organized March for Science (technology a strong enabler). He addressed the crowds this way: “Greetings, fellow citizens. We are marching today to remind people everywhere, our lawmakers especially, of the significance of science for our health and prosperity.” Meanwhile in the White House, a few hundred yards away, “so-called President” Trump was putting the finishing touches on a one-page news bulletin detailing the tax benefits and major reductions for the wealthiest Americans in his new plan. I don’t think he was as concerned about insuring continued scientific progress that would advance Americans’ “health and prosperity.” To the contrary, he was still working on how to repeal and replace Obamacare.
Trump would have us all believe that our planet is NOT environmentally endangered. Unfortunately, he is also being supported by a rise of anti-scientific notions – the anti-vaccination movement and climate-change denial in particular. Nye argues that “When you become scientifically literate, I claim, you become an environmentalist. Somewhere along the way, there has developed this idea that if you believe something hard enough, it’s as true as things discovered through the process of science. And I will say that’s objectively wrong.”
Thank you, Bill Nye. May we all “Live long and prosper!” 🖖
There are a lot of things Americans can do to improve the earth’s climate. I know that former Vice President Al Gore is a champion in this effort to reduce global green house gas emissions, but the current resident of 1600 Pennsylvania Avenue is obviously not. Advances in increasing fuel-economy standards for all vehicles is made possible by improved automotive technologies. A car that gets better gas mileage cuts greenhouse gas emissions. This is not an “inconvenient truth.” It is a matter of preserving the planet, and improving the lives of those who live here.
“If every American household drove a vehicle getting 56 miles per gallon, it would reduce U.S. emissions by 10 percent. The American new-vehicle fleet now averages less than half that. It is expected to average 36 m.p.g. in 2025 if Obama administration standards remain in place, according to the Environmental Protection Agency.” As you may already know, “so-called” President Trump is proposing to abandon these goals in the name of helping the American automobile imdustry build bigger gas-guzzlers that his constituency loves to drive. And he also wants to improve their health care plans so that no matter how unhealthy the environment becomes, they will have health coverage that is “bigger and better” than Obamacare. Fortunately, Obamacare is still here, and I only hope that Trump will not succeed in decreasing the fuell economy standards set by his predecessor.
But I guess that when your hero is Vladimir Putin, you begin to think that you can be just like him. Oh, they also have lots of gas in Russia, and I am sure we can have as much as we want if we ever run low.
Have you ever heard of Jini Kim? I think her accomplishments in using technology and software to manage (save?) the Medicaid system in this country is no lesss than heroic. Forget about your “super-dooper” technology giants and highly ranked government bureaucrats. Jini Kim is the sister of an autistic brother who just knew how to make this all work in the “cloud.” She single-handedly built a cloud-computing database of the nation’s 74 million Medicaid patients and their treatment. Remember “Healthcare.gov,” that never really seemed to work as planned. In late 2013, she was one of a small cadre of Silicon Valley technologists, called on to fix it. Who knows what is going to happen now when this part of Obamacare seems to have been fixed, and the Trump administration wants to replace it – with what?
“The Medicaid system covers millions of working families, older people, children and people with disabilities. In fact, 40 percent of Medicaid spending goes to the disabled. Half of long-term care in America, mainly for older people is through Medicaid. And nearly half of the children born in the United States are in the Medicaid system.” Does this sound like a medical system that needs to be scrapped? Replaced with what, when it just seems to have established itself as one of the most efficient health care systems in the country?
Thank you, Jini Kim. You are simply a caring and concerned sister. You are a shining example of how women need to break the “Glass Ceiling” in the male-dominated tech world. (See last week’s post of January 2)
Well, it’s actually called an Accelerated Recovery Program (ARP). And it’s a great way to spend your spare time between your professional athletic performances and preparations for your next game appearance. Just buy yourself one of the ARP machines and plug in (or “tune in” in as they used to say in the 60s, sometimes followed by “drop out”). But in this case, these guys are definitely trying to “tune in” to enhance their athletic performance. Maybe it’s just an example of trusting the old adage, “it can’t hurt.” But it just seems that no one really knows what it can do or actually does?
One professional ice hockey player described the treatment as “It doesn’t seem right, you know.” He also added, “It’s weird to see what your muscle does when it’s on it, how it moves and contracts. It doesn’t seem right. Then once you figure out exactly what it’s doing and get some more information on it, then it starts to make sense.” As a public service, manufacturers should let atheltes and the public know more, but there doesn’t seem to be much research around. In all fairness, there has been one study at the University of Hawaii medical school, which found that ARP “significantly improves” quadriceps strength after ACL (anterior cruciate ligament/knee) surgery. ARP will give you stronger (bigger?) thighs.
Your recovery will happen faster. And as one recovering athlete noted: “I can watch TV and work out.” I wonder what he would recommend watching?
Maybe this is all good news for you pyromaniacs out there, but most people that I know are not amused. I have been traveling a lot by plane over the past few weeks and noticed that the boarding calls for the different flights had some additional information that I was not paying much attention to. They were telling passengers that they could not bring their new Galaxy Note 7 smartphones on the plane. I was not sure what the problem could be, but I do not own one, so I was a little blasé, as they say. HOLY SMOKE! Now that I know why, I am going to begin to listen more carefully.
Here is some background information on Samsung that will explain what a great economic shock this will be to the company and perhaps the whole Korean economy. “Samsung is the best-known brand name South Korea has ever produced, ranking seventh in the 100 best global brands compiled by Interbrand, a brand consultancy. It’s Galaxy smartphones have lifted its – and by extension South Korea’s – high tech image more than any other Korean product.” Ouch! This is going to hurt their export-driven economy dependent so heavily on Samsung and a handful of other family-controlled conglomerates.
So this is surely more ominous than the old “buyer beware” warning. In this transaction the consumer may literally get “burned” in more ways than one!
Ten thousand steps seem to be the preferred number on a daily basis. This little gadget that you wear on your belt or wherever, seems to be revolutionizing personal decisions about where to live or work. I don’t think the number of steps my father took to work had anything to do with where my parents chose to live and raise a family. Commuting distance, of course, played a part but fiscal return was the primary concern with fitness benefits rarely discussed. My father would walk around the Budd Company plant on any given work day, but I believe he was fortified daily with freshly baked pastries and coffee, and never ever thought about counting their steps.
Instead of living in suburbia where motorized transportation became the preferred method of transporting families in the post World War II era, many families (couples) are now looking for residences with a “walkability” factor. Many of these neighborhoods also promise higher home equity down the road, if you can afford to buy there. Recent studies found that the “walkability factor” added more than 72 percent in increased housing value compared with car-dominated developments, where he says prices will fall over time as America ages.
So is Fitbit the cause or effect of everyone wanting to count their steps? Or is it that old competitive spirit that measures our accomplishments against our goals and those of our peers? Only in America?
I hope you like the title of this blog, and I am not even smoking anything while my fingers dance over the keyboard. I stopped doing that years ago, but I still enjoy a couple cups of coffee every morning, so that is the extent of my “high” on this early Friday morning. This story was actually front page news on the New York Times this morning, in the midst of all the tragic world news and mass shootings that dominate our online and print reporting. So I think the news here is that one of our technology giants wants to make us feel a little happier?
Or maybe they are just helping an enterprising business venture come up with a better technological “solution” to a marketing strategy. Perhaps it is just a matter of everything going to “pot” since Bill Gates and Steve Ballmer left Microsoft (sorry, I couldn’t resist). I think Microsoft actually wants to stay as far away as possible from being a “facilitator” for marijuana sales but they obviously see a business opportunity here. The entrepreneur who is the driving force behind this partnership with Microsoft has now begun dispensing marijuana through vending machines in some of the states where marijuana sales are allowed. Far out!
I guess it was just all inevitable. We do live in the land of the free and the brave. So if we can buy pot in a vending machine, what’s next? Beer? I think you still have to “drive-through” for that. Bummer!
Actually my optometrist was the most annoyed health practitioner I have recently visited about having to provide all my prescription information to the U.S. Electronic Health Record (E.H.R.) System. I am not so sure it was about having to do it, but having to do it himself (typing on his laptop) while he completed my eye exam. Maybe someone else could have done that at an additional cost. Not my problem I guess, until I get a bill and see how I have to pay for it, or hope that someone else will (Obamacare?). But most people seem to be more worried about whether their privacy will be protected?
Never really thought about it too much. Why would anyone really want to know anout my health history, but maybe that’s the point. Technology has helped make all this information potentially available to a wide variety of people who want to make us live healthier lives, but similarly there maybe others who would like to use it against us in some way? Or there may be others who just want more control over their personal information regardless of what benefits may be promised. I remember hearing the phrase “you know too much,” being uttered during casual conversations. Maybe this fear of personal information being “exposed” clouds our appreciation of how the sharing of personal health data can improve our general health care.
“Medical research is making progress every day, but the next step depends less on scientists and doctors than it does on the public. Each of us has the potential to be part of tomorrow’s cures.”