Agency warns Trump administration of Medicaid work requirement consequences

Medicaid work requirements, which have been approved by CMS in a handful of states, could have dire consequences for the thousands of people who have lost their healthcare insurance coverage as a result of the programs, according to a non-partisan legislative branch agency.

The Medicaid and CHIP Payment and Access Commission (MACPAC) sent a letter to the Trump administration expressing concerns over the 8,462 individuals in Arkansas who have already lost Medicaid benefits as a result of the work requirement program there.

Arkansas became the first state to implement a work requirement program in June, requiring a certain population of Medicaid beneficiaries to report at least 80 hours of work or work-related activities per month.

In late October, Wisconsin became the fourth state to receive approval for its Medicaid waiver to implement a work requirement program, which CMS refers to as community engagement programs. In addition to Wisconsin and Arkansas, Indiana and New Hampshire have approved waivers. Kentucky, which originally had an approved waiver for work requirements, saw its program blocked by a judge and is still mired in legal proceedings. Another 10 states have submitted waivers to CMS for similar programs.

Disenrollment concerns

MACPAC reviewed Arkansas’ “first-in-the-nation” program, noting it was “highly concerned about the disenrollment” of the thousands who lost their Medicaid coverage early on in the implementation. The commission, which is tasked with making recommendations to Congress, secretary of HHS and states on Medicaid and CHIP issues, urged HHS Secretary Alex Azar to pause disenrollment “in order to make program adjustments to promote awareness and compliance,” the letter reads.

Concerns over awareness have been previously brought to light, as some beneficiaries may end up losing their Medicaid coverage simply because they aren’t aware of their reporting responsibilities. The short timeline between implementation and loss of coverage––beneficiaries lose coverage if they fail to report work hours three months within a year––also may have contributed to a high number of individuals out of compliance. MACPAC noted the Medicaid population is “historically hard to reach and educate.”

MACPAC also took issue with the online reporting part of Arkansas’ work requirement program, which is the only method for beneficiaries to report their work hours.

“This approach may be challenging for beneficiaries given limited Internet access in the state and multi-stage process for establishing an account and entering information,” the letter reads.

Furthermore, Section 1115 waivers require programs to be evaluated to inform policy development, but Arkansas does not have an approved evaluation design, according to MACPAC. Therefore, measures and data on employment, transitions to other healthcare coverage, health status, downstream effects on safety net providers and the ability of beneficiaries to access healthcare after disenrollment have not been available. CMS is currently working with states to develop evaluation guidance for states implementing work requirement programs.

With the ongoing issues on the newly implemented program in Arkansas––and the potential impact on other states going forward––MACPAC urged HHS to pause disenrollments in the state and ramp up education on the reporting responsibilities of beneficiaries.

“During this pause, federal and state governments can make adjustments as needed to promote awareness and compliance, and finalized methods, measures and data collection for robust monitoring and evaluation,” the letter, signed by MACPAC Chair Penny Thompson, concludes.