Not all Medicaid work requirements are created equal.
That's the message behind a new advisory by the Medicaid and CHIP Payment and Access Commission (MACPAC), which found that Arkansas' implementation of work requirements in its Medicaid program has led to the disenrollment of some 8,462 individuals.
In a letter to Department of Health and Human Services (HHS) Secretary Alex Azar, the independent commission that advises CMS on policy matters said it was "highly concerned" about the statistics and recommended the state pause the program until adjustments can be made.
The disenrolled individuals in Arkansas were unable to report work and community engagement activities as required by the policy, but the commission argued that the state's approach contributed to the challenges. However, MACPAC cited extremely low rates of successful reporting: A whopping 91.6% of the beneficiaries required to report compliance failed to do so in September 2018.
"The low level of reporting is a strong warning signal that the current process may not be structured in a way that provides individuals an opportunity to succeed, with high stakes for beneficiaries who fail," Penny Thompson, chair of the Commission, wrote in a letter (PDF) that was also sent to Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma, the director of Arkansas' Department of Human Services and several top lawmakers.
Broadly, the commission said the Arkansas' program had failed to provide beneficiaries the appropriate tools in three ways.
- Lack of awareness: MACPAC said Arkansas had failed to educate Medicaid beneficiaries about their new requirements by implementing the program just three months after approving it, giving officials little time to provide education and outreach to beneficiaries. Online-only resources limited the agency's reach.
- Exclusive online reporting: The only way for Arkansas Medicaid beneficiaries to report their compliance is through an online portal. Since internet access is quite limited in Arkansas compared to other states, this has proved a major barrier for beneficiaries. It's also an outlier among work requirement states; most programs provide multiple ways to submit proof of compliance, MACPAC said. Although the Arkansas Foundation for Medical Care (AFMC) has set up some assistance for beneficiaries through county eligibility officers, HHS was unable to provide information on how many beneficiaries were actually taking advantage of that service.
- Limited work supports: Arkansas' justification of work requirements was that they would improve the wellbeing of beneficiaries while encouraging them to move up the economic ladder. A crucial component of that economic mobility is assistance in job searching and work supports, but MACPAC found that Arkansas had barely implemented policies to provide such assistance to beneficiaries. Neither the state's department of human services nor AFMC were directly connecting beneficiaries with resources, MACPAC found, and they were not collecting data on the unmet need for such resources.
MACPAC also warned HHS that it should carefully consider implementation of work requirements in other states that have been approved or are still awaiting waiver approval. The Trump administration has stood firm in its commitment to implement Medicaid work requirements despite ongoing legal challenges.
"As HHS considers these proposals, it should require the development and approval of robust evaluation and monitoring plans to measure whether waivers achieve their intended purposes and provide meaningful information along the way, including the early days of implementation."