FAYETTEVILLE, Ark. — Susan Ferguson, a physician in the tattered village of Lincoln, Arkansas, describes the expansion of Medicaid in her state in 2015 as "the best thing that ever happened here."

Patients she had never seen, or hadn't seen in years, appeared in her clinic to receive checkups and seek treatment for lingering illnesses after the state implemented its version of the Affordable Care Act. For some, lack of insurance meant "the chest pain they'd been ignoring for five years required open-heart surgery when they could have walked away with a stent."

Others finally received prescriptions for psychiatric, pulmonary and autoimmune disorders they previously couldn't afford.

Now, patients across the state are disappearing again.

In June, with encouragement and approval from the Trump administration, Arkansas was the first state in the country to impose a work requirement on Medicaid. Exemptions were granted for those deemed ill, caring for dependents or currently employed. Everyone else had to report that they were working or engaged in another approved activity, at least 80 hours per month.

The result: Since September, about 1,500 Arkansans reported working enough hours to keep Medicaid – while more than 12,200 failed to report and lost their insurance. And 6,000 Medicaid recipients are at risk of losing their insurance in December. Critics are blasting the state for outreach measures that they say failed to inform Medicaid recipients of the new rules, as well as for requiring poor Arkansans to use a web portal for the program, noting the state that has low levels of internet literacy and access.

The sudden health-care crisis in Arkansas has rung alarms in Washington, D.C., where the Department of U.S. Health and Human Services has already granted permission for similar programs to three other states. Nine more applications are pending. On Nov. 8, an advisory commission on Medicaid called on HHS Secretary Alex Azar to force "a pause in disenrollments" in Arkansas. The commission described the low level of reporting as "a strong warning signal" that the program in Arkansas is not working for many poor residents on Medicaid – "with high stakes for beneficiaries who fail."

The program, called Arkansas Works, is an outgrowth of a Republican initiative to nullify Obamacare's extension of the insurance program to healthy adults. In a 2017 interview, Seema Verma, the director of the Centers for Medicare and Medicaid Services, called the Obama policy "a major, fundamental flaw" and that Medicaid "was not designed for an able-bodied person."

Without a legislative fix from Congress, the Trump administration asked states to require such recipients to find a job, a test of a hypothesis that employment increases a person's chances of "improved health, well-being … and independence as contemplated in the objectives of Medicaid."

But policy experts say that Arkansas is actually punishing, intentionally or not, a slice of the population that is already distressed – folks with little education, poor health, with limited access to and understanding of the internet, and who often can't afford transportation to work.

"Our position is that this is not a proper use of authority in Medicaid," says Judy Solomon, a senior fellow at the Center for Budget and Policy Priorities, a left-leaning think tank in Washington, D.C. "The central objective is to provide coverage to people who wouldn't otherwise have it. Taking it away from people for not meeting work requirements runs against that."

When Arkansas gained permission from Washington to implement the work requirement in March, it launched a massive campaign to alert affected recipients that they must now report their work activity to keep their Medicaid benefits. That included about 60,000 letters mailed to beneficiaries, 150,000 phone calls, 200,000 emails, 15,000 text messages and numerous social media posts.

But the cascade of Arkansans who've lost their insurance indicates that the outreach has largely failed. "The state tried to do a pretty robust outreach campaign, but these people are hard to reach," says Robin Rudowitz, a Medicaid expert at the Kaiser Family Foundation.

Such is the case with Ferguson's patients, about 40 percent of whom are on some form of public assistance. The 1,700 people of Lincoln live among empty storefronts, mobile homes and broken roads. Many people she sees are in "survival mode" because of cyclical poverty. "Their parents didn't graduate high school, so they don't finish high school," Ferguson says. "They're living too many people in a trailer in bad condition, with mold infestation. They need firewood. They have a hard time getting food, paying for utilities. It is heartbreaking."

Exacerbating the problem was the two-step process of receiving an account number in the mail, which requires a working address, and then plugging the number into a website. "Many don't have access to computers and aren't capable of doing these things," Rudowitz says. "The reporting piece has been a big obstacle."

Critics also charge that the state rushed to implement the program but then failed to move fast enough to evaluate how it's working – or not. With many thousands now kicked off Medicaid, there is still no plan in plan to assess the implementation and consequences, though one is under consideration.

The state Department of Human Services has made other options available, such as allowing enrollees to report by phone through their insurance carriers and allowing registered reporters – a person trusted by the Medicaid recipient – to issue the work requirements on their behalf, according to Marci Manley, the state agency's deputy chief of communication. And Republican Gov. Asa Hutchinson recently praised the program, hailing it for "cleaning out the system, encouraging people to work."

In the meantime, a trio of nonprofit advocacy groups are challenging the work requirement in federal court. "It appears the state is fully committed to trying to use work requirements to kick people off Medicaid," says Kevin De Liban, an attorney for the plaintiffs. They argue that the requirement is onerous, counterproductive and that only Congress has the authority to change Medicaid in such a way.

De Liban has reason to be hopeful. The case is going to a federal judge who has already ruled against a similar program in Kentucky, preventing it from ever getting off the ground. But by the time of the verdict in June, Arkansas Works was already underway – the result of a compromise among state politicians after a battle over whether to keep Medicaid expansion at all.

But even a successful court case won't necessarily end the program. Kentucky has modified its proposal and re-submitted it to the federal government for approval. More lawsuits are likely to follow and could climb the ladder to the U.S. Supreme Court.