National Health Law Program: Medicaid work requirements are bad policy disguised as flexibility

Flexibility can be extremely valuable in crafting effective health policy—or it can underpin poor policy, with potentially dangerous consequences, experts warn. 

Leonardo Cuello, director of health policy for the National Health Law Program, said a clear example of this is in Medicaid, a program that already affords states significant flexibility to tailor their programs to suit their populations. 

However, recent efforts in several states to implement work requirements for eligibility use flexibility in a way that can hurt enrollees, he said. Cuello’s group is one of the plaintiffs in legal challenges against such requirements in Kentucky—where a judge struck down the requirements—and Arkansas. 

“Not all innovations are a good idea,” Cuello said. "These are not innovations, these are things that reduce spending and reduce coverage."

In Kentucky, for example, the requirements were clearly structured in a way that goes counter to the goal of Medicaid waivers being experiments that “promote the objectives of Medicaid,” Cuello said. That's because the Kentucky HEALTH program would have instituted premiums and eliminated transportation to healthcare facilities. 

RELATED: Kentucky lawsuit won’t decide the fate of Medicaid work requirements in other states 

Cuello was one of several panelists convened by the Alliance for Health Policy in Washington on Friday discussing ways to innovate and provide greater flexibility in Medicaid. The panel also included representatives from Arkansas and the Centers for Medicare & Medicaid Services who disputed the notion that work requirements are aimed at cutting down enrollment. 

In Arkansas, the requirements are an “experiment based on compassion” that aims to boost economic access and enhance the state’s workforce, Cindy Gillespie, director of the state’s Department of Human Services, said. 

“We don’t believe it’s compassion to leave people in poverty,” Gillespie said. 

Implementing the work and “community engagement” requirements are just one facet of how the state is using CMS’ focus on flexibility to enhance Medicaid and the care its members receive, she said.  

For example, Arkansas is also working to better use Medicaid to address the social determinants of health and provide access to a more robust collection of services, such as substance abuse and behavioral health treatment, she said. 

RELATED: HHS ‘undeterred’ by court decision striking down Kentucky’s work requirements 

Gillespie also provided the latest data churn in the Arkansas Works program. In September, more than 15,000 people left the program, including more than 4,100, or 27%, who were booted for noncompliance with the requirements. 

Members who fail to meet the requirements are barred from enrollment for the remainder of the plan year. 

To date, more than 1,500 people have satisfied the reporting requirement, according to the data, but Cuello said that this doesn’t provide a baseline for determining how many of those people are newly employed. He said that it’s likely that the majority of those people were already working. 

Another concern, Cuello said, is that the program’s design may set up many Medicaid enrollees to fail. People who qualify for the work requirements—childless adults between the ages of 19 and 50—are expected to report monthly on their job status, and if they fail to comply for three months, they’re removed. Cuello said that mandating the reporting on an online platform poses a barrier for some enrollees.

Gillespie said that Arkansas has expanded its reporting options to include phone operators, provided by insurers, and in-person reports at county offices. Those options could also be burdensome for enrollees, however, he said, through lack of transportation or adequate phone service in rural areas.

RELATED: Verma puts Medicaid insurers on notice, says CMS will begin ‘targeted audits’ 

As the legal fight in Arkansas is underway, it seems likely that another is brewing in Kentucky as well. CMS has reposted Kentucky’s waiver request for a second comment period following the judge’s ruling. 

Cuello said that should the waiver be approved once again, a second court challenge is sure to follow.

“HHS is not hewing to standards” in Medicaid law by approving the requirements, he said.