Arkansas is one of five states for which CMS has approved a Section 1115 waiver to condition Medicaid eligibility on meeting work and reporting requirements and the first state to implement this type of waiver. Unless exempt, enrollees must engage in 80 hours of work or other qualifying activities each month and must report their work or exemption status using an online portal by the fifth of the following month. The new requirements were phased in from June through September, 2018 for Arkansas Works enrollees ages 30 to 49, and will apply to those ages 19 to 29 beginning in 2019. Enrollees subject to the new requirements have annual incomes up to $16,753 (138% of the federal poverty level for an individual in 2018). As of December 2018, nearly 17,000 people have been disenrolled due to the new requirements.
Arkansas now requires some of its Medicaid enrollees to report monthly on their work activities to maintain their coverage. This @KaiserFamFound report looks at their experiences based on focus-group discussions in urban and rural areas
This brief builds on our prior analysis of state data and a case study published in October 2018, to include perspectives of enrollees and providers about the new “Arkansas Works” waiver requirements. The findings are primarily based on four focus groups with a total of 31 Arkansas Works enrollees conducted during November 2018, in Little Rock and Monticello, Arkansas to capture both more urban and rural experiences. Focus group participants included those currently subject to the new requirements and some who have lost coverage as a result of the new requirements as well as those who will become newly subject to them in 2019. They may not be representative of all Arkansas Works enrollees as they were successfully contacted via phone and email and had transportation to the group location. To account for these differences and provide a fuller picture of how enrollees are experiencing the new requirements, we also conducted interviews with four safety net health care and food assistance providers in November, 2018. Focus group and interview findings provide new insights into key questions about the early implementation of the new requirements and their impact on enrollees, including:
Are enrollees aware of the new requirements and if so, what is their experience setting up online accounts?
Enrollees were unaware or confused by new requirements. Notices and informational letters were not fully read or understood, and enrollees were unaware of key details including the penalty of coverage loss for the remainder of the calendar year for failure to meet the requirements for three months. Only a few enrollees recalled getting phone calls about the changes to AR Works. While many in the groups had social media accounts, virtually no one got information about AR Works through Facebook or other social media. The younger enrollees who will be phased in to the new requirements beginning in January had started to hear about the program changes, but few had complete information or fully understood what was required to comply.
Many enrollees found it difficult to navigate the process to set up an online account. The majority of those who were aware of the requirement to set up an online account reported problems doing so and had difficulty getting assistance. Many do not have computers or reliable cell phone or internet access, especially those in rural areas, and others are not comfortable using computers. However, the younger group of enrollees who will be phased in to coverage starting in January 2019 were not as concerned about setting up an account and on-going reporting.
“I went online and tried to set up an account. That was unsuccessful. So they listed this 866 number on the paper, so I tried to call and speak to somebody while I was in front of the computer, so they can walk me through it and help me set it up. And that was awful because you never could speak to nobody. And then I got through it give you all these prompts… it said you had to enter in your reference number that come on the paper and it kept saying my reference number was not my number….” Little Rock AR Works enrollee
What effects are the new requirements having on enrollees’ participation in work or other activities?
The new requirements do not appear to provide an additional incentive to work beyond economic pressures, but are adding anxiety and stress to enrollees’ lives. Many enrollees are already working, but may face unstable or unpredictable work hours. Volunteering was not an option for people who needed to pay the bills. More rural areas have few job opportunities. No enrollees had contacted the Department of Workforce Services (DWS) for assistance.
Health insurance through Medicaid supported the ability to work for some enrollees who were able to control chronic physical and mental health conditions, while other enrollees have physical and mental health conditions that make working difficult. Focus group participants reported a range of serious physical and mental health conditions that could interfere with work, but none had been identified as medically frail and therefore exempt from the new requirements. Enrollees’ lives are complicated with a multitude of factors that could affect their ability to work such being homeless or lack of transportation.
“The month that I didn’t take it [medication for narcolepsy], I was knocked out every day. Like while we’re talking, I’d probably be sleep right now…I couldn’t work.” Little Rock AR Works enrollee
Monthly reporting of work or exemption status is confusing and a challenge for most enrollees. Complicated circumstances, lack of computer literacy and limited access to computers or internet are factors that make monthly reporting difficult. In addition, some enrollees who reported successfully had too much income and lost coverage; however, the monthly reporting may not accurately account for fluctuations in income, which can lead to increased churn in and out of Medicaid and disruptions in continuity of care. It was difficult for enrollees to understand the exemption rules and process.
Providers report that the most vulnerable enrollees (those who are homeless or those with more severe physical and mental health disabilities) are most likely to face barriers complying with the new requirements. These individuals are less likely to participate in the focus groups and are more likely to be unaware of changes in program rules and to face challenges setting up online accounts, obtaining or maintain employment and complying with a monthly reporting requirement. Other more immediate needs like shelter, food or dealing with an acute physical or mental health care need will come before filling out online forms. In addition, some providers felt like they were excluded from implementation plans about the new requirements and were therefore not able to best support enrollees. Enrollees face an array of barriers to work and monthly reporting, with most experiencing multiple barriers.
Loss of coverage can negatively affect enrollees’ health and can impede individuals’ ability to work. Enrollees value coverage and loss of coverage would negatively affect their ability to work, especially for those who rely on regular prescriptions to manage chronic physical and mental health conditions. Employer-sponsored coverage is not available or affordable to working enrollees. Medical debt is a concern, especially if individuals had to resort to using the emergency room to access needed care. Loss of Arkansas Works with a coverage lock-out could negatively affect health status, make it more difficult to obtain and maintain work, would increase stress and anxiety, and lead to gaps in care and greater emergency room usage.
“I’m in a halfway house. And the thing is I pay $145 dollars a week rent. It’s like I’m stuck in a rut because I’m in a dead-end job. I don’t make no more than maybe $200 a week. Okay, a $140 of that has gotta go to rent….that’s not counting my gas costs going back and forth to work. That’s not talking about my food…I’m having to come out of pocket because now [after losing coverage for failure to successfully report hours online] I don’t have any health insurance to cover $600 worth of medicine. My inhalers are 400 to $500.” Little Rock AR Works enrollee
“I have a mental illness, I’m bipolar…they can’t get my medicine right, little more manic, little excited…I try to think I’m okay without it and then just, you know…without this insurance I would be in a lot of trouble. I think there was one time, it would have been like $400 a month if I didn’t have insurance. And there’s no way possible.” Monticello AR Works enrollee
Providers interviewed for the report noted that they could face increases in uncompensated care if patients lost Arkansas Works coverage and became uninsured. Providers were also concerned that they would need to hire new staff and redirect resources to helping patients navigate the complexity of the new requirements which would mean cutbacks in other areas without any new revenue to support staff.
While these focus groups provide an initial look at enrollee experience with the new requirements, it will be important to understand more about those who lost coverage as the waiver continues. The state recently issued a press release indicating that, beginning on December 19, enrollees can report work activity by phone. While new reporting options may assist some enrollees, research shows that any additional reporting or administrative burdens create barriers to eligible people retaining coverage. Looking forward, it will be important to understand the implications of coverage loss for enrollees, including their ability to work, as well as providers.