Many of the Republicans pushing for Medicaid work requirements — permanent program cuts that will strip up to 14 million people of their health care coverage — likely have no idea what it takes to comply with them. We do. As legal aid lawyers, we were on the front lines helping low-income people in Arkansas keep their health care coverage when the state rolled out work requirements in 2018. The policy caused chaos for everyone involved: people receiving Medicaid, hospitals and health clinics, pharmacies, social services organizations and state agency caseworkers. No officials serious about governing should willingly create such problems for their own state.
Over 18,160 people in Arkansas lost coverage in only five months before courts halted the policy. Many were our clients. Adrian McGonigal had chronic obstructive pulmonary disorder, for which he received treatment. At the time he held a job working 30 to 40 hours a week at a poultry plant, which paid more than any other job he’d had before and should have satisfied the requirement. But the state’s system for automatically identifying working people was faulty, and Mr. McGonigal struggled to navigate the complex monthly reporting system on his own. Unable to report his work, he lost Medicaid, couldn’t afford his C.O.P.D. medications, wound up in the hospital emergency room several times, lost his job and never fully recovered. For the next several years he struggled in various minimum-wage jobs, earning much less than he had at the poultry plant. Sadly, he died in November.
We saw many working people face similar challenges. Our clients ran the gamut of low-wage work: fast food workers, restaurant dishwashers and servers, construction workers, janitors, landscapers, motel cleaners, gas station clerks and nursing assistants. Many had disabilities, and their ability to continue working depended on getting treatment to manage chronic pain, asthma, injuries, cancer and mental health conditions. Some lost coverage simply because they couldn’t navigate the policy’s complicated requirements and labyrinthine reporting process. Others lost insurance because of the instability of low-wage work: Bosses cut their hours or laid them off without warning, limited public transit narrowed their options or they lived in struggling rural areas where jobs were hard to come by. When the state cut them off, their health worsened and many lost jobs, as well as the ability to work new ones.
Nobody on Medicaid was free from the tumult. Despite outreach from the state, there was widespread panic, as people didn’t know if they had the type of Medicaid that the new requirements applied to. People received confusing 10-page letters from the state Medicaid office, which often contradicted other coverage letters people received around the same time. The website to report compliance shut down every night at 9 p.m., and when it was running, it was so complex that we put together video tutorials to help people navigate it successfully. (Many still couldn’t.) People spent hours on the phone or at agency offices trying to figure out their status or fix errors, often needing a lawyer’s help. In some cases, they had to pester their employers for extra proof of wages or statements that met the state’s requirements. All told, 18,164 people were terminated because of noncompliance with the work requirements, and thousands more people lost coverage because of related paperwork burdens.
What’s more, these penalties operated as a tax on key economic sectors. Hospitals and health clinics, many already barely surviving in rural areas, assumed additional costs to untangle billing nightmares, absorb more uncompensated care and help confused patients document their eligibility for coverage. Local nonprofits, including services for the homeless, domestic violence shelters, food banks, soup kitchens and senior centers, spent their scarce resources trying to help people comply. Pharmacists dealt with the desperation of people learning for the first time that they had lost coverage and would have to pay out of pocket for their prescriptions.
The state Medicaid agency also bent under the weight. Agency management sloughed off the thankless and time-consuming tasks of cleaning up endless system errors, figuring out workarounds and calming frantic people to overburdened caseworkers. At one point, the state’s call centers were so overwhelmed that the agency expanded its hours of operation, which still didn’t prevent lengthy wait times.
These widespread burdens underscore the pointlessness: Ninety-two percent of the targeted Medicaid recipients already work, are in school, have family caregiving responsibilities or have disabilities. When work requirements were imposed in Arkansas, they did not increase employment. In fact, there’s reason to believe that they could counterproductively hurt employment. That’s because when you take away people’s health insurance, their otherwise manageable health conditions turn into unmanageable work barriers.
This kind of disastrous policy doesn’t come cheaply, either. A U.S. Government Accountability Office report estimated that administering work requirements in Arkansas alone cost over $24 million in state and federal funds for less than a year of operation. When four other states sought to implement work requirements, the report estimated the cost at $382 million. A more recent work requirement program in Georgia cost $87 million. The only way to cover these costs is to kick people off Medicaid. The game is rigged.
What happened in Arkansas isn’t an outlier, but an omen. The plan currently under consideration in Congress will be worse and more destructive than what we saw. If passed, it will require states to adopt work requirements, but each state will decide how many months people must demonstrate compliance to get insurance, how often enrollees must verify compliance (with a minimum of twice per year), what exemptions are available and what someone must show to prove compliance or get exemptions.
Hostile states will weaponize these penalties to deny people Medicaid, while states that want to minimize coverage losses will not be able to fully shield their enrollees. We saw similar dynamics at play in 2023-24, when all states had to redetermine the eligibility of their Medicaid recipients after pandemic coverage guarantees lapsed. More than 25 million people lost Medicaid, with termination rates highest in Republican-controlled states, such as Utah, Texas and Oklahoma, and lowest in Democratic-controlled states, such as California, Oregon and Connecticut.
Better technology won’t be enough to stave off harms. The computer systems used to automatically verify compliance can’t obtain or analyze accurate data for all targeted recipients, a point Arkansas now concedes. Rather, these systems threaten Medicaid loss by sending recipients requests for additional information when they detect small, meaningless differences in income reported from different sources. Lost or slow mail, confusion or delayed agency processing can all lead to lost coverage. More advanced technology hasn’t proved to help, either. Attempts by state governments to use algorithms and artificial intelligence — to determine benefits eligibility in Texas and Florida, to decide how much home care disabled people need in Arkansas or to detect unemployment fraud in Michigan — have all failed. Indeed, 50 states implementing 50 sets of penalty rules through 50 different technology systems seems a certain disaster.
No matter where they live, if this bill passes with the work requirements intact, Republican officials will all face years of slogging through the muck they created. They should expect huge coverage losses for constituents, disgruntled employers who can’t depend on a healthy, stable work force, rural hospital and clinic closures, overburdened social services, understaffed government agencies with burned-out caseworkers and endless media reports about the morass. In the end, voters may have to teach them that cruelty is no way to govern.
Kevin De Liban and Trevor Hawkins are lawyers who successfully sued to stop Arkansas’s Medicaid work requirements.
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