By Harris Meyer
November 15, 2018 - Modern Healthcare
Nearly 4,000 Arkansans in October lost their Medicaid
expansion coverage in October because they failed to comply with the state's new
work requirement, joining 8,462 other low-income adults who
lost benefits in the previous two months.
State officials reported Thursday that 3,815 of the 69,041
people subject to the so-called community engagement requirement in October were
noncompliant for three months and were dropped from Medicaid. They will lose
coverage for the rest of 2018 and can only reapply in January.
The total
number of people cut off of coverage in October in the state's Medicaid
expansion program, dubbed Arkansas Works, was 15,081.
Of that number, 25%
were axed due to noncompliance with the state's requirement that they spend at
least 80 hours a month working, volunteering, going to school or receiving job
training, while 28% were dropped because they failed to supply the requested
information.
The state said 6,002 additional people have been noncompliant for two months
and are at risk of losing their coverage at the end of November.
Only
about 1,525 of the 69,041 people subject to the work requirement in October
reported meeting the 80-hour-per-month work requirement.
Total enrollment
in Arkansas Works now stands at 245,553, down 12% from 279,602
when the work requirement started in May.
Arkansas Gov. Asa
Hutchinson said in September that the program's goal is to boost labor
participation and increase work training and assistance to able-bodied people
who want to work. The Republican cited state data showing that about 1,000
people gained job training or employment as a result of the program.
But
experts and provider groups have expressed alarm about the coverage losses and
the viability of the state's complex work and reporting requirements.
Beneficiaries can only report through an online portal.
The Arkansas
Hospital Association has said it would like to see the requirement halted.
Providers fear the new system will disrupt care for people with chronic
conditions and drive up uncompensated-care costs.
Medicaid and CHIP
Payment and Access Commission Chair Penny Thompson recently urged HHS Secretary
Alex Azar to pause disenrollments pending closer examination of the structure of
Arkansas' program. She also noted that the state has no CMS-approved evaluation
design in place to study the effectiveness of the five-year work requirement
waiver program, which was approved by the CMS earlier this year.
"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," Thompson wrote to Azar on Nov. 8.
In
a Nov. 1, 2018 letter to Arkansas' Medicaid
director, the CMS itself was critical of the state's evaluation approach and
requested a revised design. The letter said the state's declared evaluation
outcomes, such as "culture of work" and "personal life stability," are not
well-defined. It also said the revised evaluation design should include an
assessment of outcomes for people who are disenrolled for failure to comply with
the work requirements. For example, the CMS said the state should study whether
losing coverage is associated with poorer health outcomes.
Meanwhile,
U.S. District Judge James Boasberg in Washington is hearing a
lawsuit challenging the CMS' approval of the Arkansas Medicaid waiver
permitting the community engagement requirement.
In June, Boasberg
invalidated the CMS' approval of a similar requirement waiver in Kentucky on the
grounds that the agency did not adequately consider its impact on coverage.
Following that ruling, the CMS held a new public comment period on the Kentucky
waiver and is expected to re-approve it in some form.
Two other
Republican-led states, Indiana and New Hampshire, also received CMS approval
this year for a five-year demonstration waiver to establish a community
engagement requirement. Their programs haven't started yet. It's possible that
the New Hampshire Legislature—with Democrats in control of both chambers after
this month's midterm elections—will try to block the program from going
forward.
Ten other states have requests pending to establish similar
Section 1115 demonstrations.
In addition, there are discussions in
Idaho, Nebraska and Utah, three states
where voters just approved Medicaid expansion, about including a work
requirement. Similar discussions are taking place in Montana,
where voters just shot down a tobacco tax to fund a renewal of Medicaid
expansion, and in Alaska, where an anti-expansion Republican was just elected
governor.
The Trump administration in January encouraged states to seek
work requirement waivers.
In Arkansas, beneficiaries must report that
they were either meeting the community engagement requirement or that they
qualified for an exemption, such as for a disability. They can only report
through an online portal run by the state Department of Human Services. There is
no option for reporting by phone, mail or in person.
Many beneficiaries
have not been contacted about the new work and reporting requirements and either
aren't aware or don't understand them, according to a recent report by the Kaiser Family
Foundation.
Enrollees may be hard to reach by phone due to unstable
housing or other factors, and a large percentage lack email or internet access,
the report found. In addition, the online reporting process is complicated and
confusing, even to advocates and providers that have tried to help
beneficiaries.
"The most likely reason for noncompliance is that
(Medicaid expansion enrollees) simply do not know about the new requirements or
else do not know about or understand the online portal they need to navigate in
order to successfully comply," said Bruno Showers, senior policy analyst at
Arkansas Advocates for Children and Families. "I hope that next month's report
will bring better news, but that seems very unlikely unless changes are made to
how the program is being implemented."