An electrical line technician works in Vilonia, Arkansas in 2014 Carlo Allegri / Reuters

Arkansas just became the first state to implement work requirements for its Medicaid program. Similar Medicaid waivers have been approved for three other states, and seven more are pending, spurred in part by the Trump administration’s guidance last year.

Now, if able-bodied adults on Arkansas’ Medicaid rolls don’t go to work, study, or volunteer for 80 or more hours a month, they will lose their health insurance coverage in three months. A study by the Urban Institute in May estimated that, this year alone, 22,000 people, or 8 percent of Arkansas’ Medicaid population, could be subject to the work requirements and are not working.

The work requirements reflect the view, among some conservative health-policy experts, that people should be encouraged to get jobs and get off Medicaid. Many liberals, meanwhile, feel that revoking health insurance is a harsh punishment for what could amount to a lack of skills, transportation, or knowledge. Three consumer advocacy groups, in fact, sued the Trump administration to stop the work requirements.

“The inevitable coverage gaps from Arkansas’ work requirements and coverage lockouts will worsen beneficiaries’ health, which is one reason why major physician organizations oppose work requirements in Medicaid,” wrote Judith Solomon at the Center on Budget and Policy Priorities.

I recently spoke with Cindy Gillespie, a former health care advisor to Mitt Romney and the current director of the Arkansas Department of Human Services, about what the work requirements do and don’t mean for Arkansans. We met at the Spotlight Health Festival, which is cohosted by The Aspen Institute and The Atlantic. A lightly edited transcript of our conversation follows.


Olga Khazan: Do you have any concerns that the work requirements on Medicaid will cause people to lose coverage, and if not, why not?

Cindy Gillespie:  We’ve started our work requirements with the 30- to 49-year-old group. Within the 30-to-49-year-old group, we’ve exempted out anybody with a child in the home, anyone who is caring for an incapacitated person, anyone who has a short-term incapacitation, drug, and alcohol rehab.

We end up with a small population of able-bodied adults who are working less than 80 hours a month and, who, as best we can tell, are not full-time students or not in any sort of activity that would prevent them from being able to get into job training, job search, education, some kind of GED, all of these different type of areas. Our focus is to get those individuals … get them working with the Department of Workforce Services, career education, someone who can help them identify what their barriers are to actually looking for a job, getting a job, engaging in the community, doing volunteerism, doing job search, all of those sorts of things.

Our focus is to really concentrate on those individuals and see if we can move them further up the economic ladder. After three months of non-compliance, a person will lose their coverage for the rest of the plan year. Not permanently. If the individual does not, for some reason, engage in that period, they can come back into the program in the next plan year.

Khazan: Why not just do the engagement into the programs and not have the stick of the losing coverage?

Gillespie: Last year we tried a work referral, where we tried to refer everyone in the program to all the different services that were available. We had an extremely low take-up rate. People just didn't pay attention. This is actually engaging, not just the individuals, but it is engaging an entire support network around them.

For example, the insurance carriers, they have a vested interest in that person now because [if] that person rolls off the insurance plan, then that carrier won't be getting paid for them anymore. They have a vested interested in putting their network to work, reaching out and getting with the person. The same with all of the groups that work around the state with different individuals. They all have a vested interest now in helping make sure that the individuals do, in fact, get into the system.

Our department of Workforce Services actually sent all of our Arkansas Works beneficiaries a letter and told them ... We want to help you get, to education, to job training, to job search, to what you need.

You are seeing a lot of engagement that I don't think you would see unless everybody had got really excited and involved in the program. The media even in our state, they were great at doing sessions with different advocacy groups this week. Helping them understand how this works, what to do, that got covered by the media. Lots of things are letting more people know.

At the end of the day all that creates more knowledge, not just from those who have the work requirement but among all of those who don’t. Now they are going to see more and hear more about the services that are available. We find, constantly, people don’t know of the services that are available. When you tell them, they don’t pay attention. Now we are hoping they will pay attention and take advantage of the services.

Khazan: Do you anticipate that a lot of people will lose coverage as a result of the work requirements?

Gillespie: I got asked this yesterday by somebody. They said, "You are doing it for savings.” I said, “We have not taken any saving in our budgets. We did not take any for this year. We have not taken any for next year. We have left it at the assumed rate of everyone staying in.”

Khazan: So you don’t anticipate anyone losing coverage?

Gillespie: I can’t say that, obviously. We have a massive amount of churn that goes on. I think last month we had about 5,000 people that came off of Arkansas works, due to some accuracy efforts we have going on. There is a massive churn that goes on in these programs, there will be people who roll on, there will be people who roll off. I won't know until September whether or not, there’s any that actually lose their coverage for the remainder of this calendar year because they did not do anything over the next three months.

Khazan: Is there a concern at all, that if someone does lose coverage as a result of this change, that will actually make them less likely to work or to do some of these activities that you are trying to encourage?

Gillespie: Your question presupposes that someone who is working and meeting their requirements loses their coverage. If they are working, they are not going to lose their coverage.

Khazan: Is there a possibility that this rule could get expanded to include people who are of different ages; or who have children in the home; or some of other populations that are excluded for now?

Gillespie: That would be way down the road. We are rolling this out over two years, this year is the 30-49 year olds. Next year is 19-29 year olds. That is as far as the program has been set up at this time. We are just starting with one group, working and focusing on them, learning lessons from that and then next year we will take the next group.

Khazan: They are supposed to show their progress online, through an online form. Is that still the case?

Gillespie: Yes.

Khazan: What happens to people who don’t have internet access at home?

Gillespie: If there is someone who can not access the portal, either because of what you said or because perhaps they can’t read and write ... which is why we really want to get a hold of them and get them into educational programs that can help them. Let’s just say they have a reason they can’t; we have set up a program of registered reporters, so that they can have someone else put it in for them. They can call someone who is a registered reporter and they can put it in for them. They don't have to go somewhere. The insurance carriers have set up their operations to have registered reporters, so that when they reach out to people, if they haven't been able to get in to the portal, they can actually help them over the phone do that.

We also have places they can go, not just our offices that have set up kiosks, but all over the state. The access is there, if someone has something to report.

Khazan: Did the state consider other mechanisms to get people engaged in some of these work or educational programs, other than losing their health insurance coverage? Like paying a slightly higher tax rate or some other penalty?

Gillespie: You are talking about individuals whose income is less than $800 a month. They are not paying taxes.

Khazan: Other than taxes, no other mechanisms were considered?

Gillespie: No, that is the primary mechanism that you have because they don't pay premiums, they don't pay copays, they pay no cost at all. We have tried already to require a very, very, very small payment towards premiums. Most of the individuals did not do it. This is something people can do even if they don't have money. It will help them get to where they do have money. That's our hope.

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