Benjamin Hardy

Arkansas Nonprofit News Network

Nannette Ruelle is watching three numbers tick downward as the year comes to a close.

The first is the number of doses left in her Advair inhaler, which she normally uses three times a day to control her asthma. As of Nov. 17, she had 35 remaining.

The second is the number of pills in her bottle of Gabapentin, which her doctor told her to take three times daily for chronic neuropathic pain in her feet and ankles. She had three as of Nov. 17.

The third is the number of days left until she can refill those prescriptions: 44. She was kicked off her Arkansas Works health insurance in September and will be locked out until Jan. 1.

Ruelle, 38, lost her coverage at the end of August due to Arkansas' new requirement that certain Medicaid beneficiaries report their work hours to the state. For the past two-and-a-half months, she's been carefully rationing both her medications, allowing herself a Gabapentin only when the nerve pain becomes so bad she fears she won't be able to do her job. Ruelle works 25-35 hours a week at a chain restaurant in Little Rock, where she makes $9 an hour.

"It's some serious stuff. They're just playing around with people's lives, and I don't think it's fair," she said in a recent interview. "What if I wake up one morning and I can't even function because my feet are hurting and I have nothing left?"

Ruelle said she first recalled hearing about the requirement in May, when she was working a minimum wage job at a different restaurant. The instructions on the notice she received from the state Department of Human Services were confusing, but she tried to do what the letter demanded.

"What happened was that I got my information and I tried to fax it to them. The fax wouldn't go through, so I tried calling them, and I never got an answer on the phone. I went up there and they were out of the office," she said.

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When she got no reply after leaving voicemails and visiting her local DHS office, Ruelle said she gave up.

"I just quit trying, because you can only try so many times before it's like, 'OK, you're closing the door in my face,' " she said.

Over the last three months, DHS has removed 12,277 people from Arkansas Works — the state's Medicaid-funded insurance program for low-income adults — for not reporting their work hours. Thousands more will likely join them in December.

The rule, which began for the first subset of beneficiaries in June, requires able-bodied adults under age 50 to report at least 80 hours of "work activities" each month. (In 2018, the requirement applied only to those ages 30-49, but it will begin including 19- to 29-year-olds in 2019.) Those who don't comply for any three months in a calendar year are kicked off Arkansas Works and locked out until the new year begins.

Ruelle's attempts to reach DHS were unsuccessful in part because the agency only allows people to report their work hours through a website, rather than by fax, phone or mail. This online-only requirement is unlike any other reporting required by DHS. The agency places no such restriction on the way beneficiaries submit other information, such as a change of address — just their work hours.

DHS first sends Arkansas Works recipients who must meet the work requirement a letter directing them to https://access.arkansas.gov. As of Nov. 16, that URL sent users to a general DHS landing page containing information about voter registration, not health insurance.

From the landing page, a beneficiary must navigate a series of menus to reach a login page, where he or she is prompted to create a new account. (Doing so requires an active email address.) Then, the user must locate a unique "reference number" contained on the letter from DHS "to link your online account to your healthcare coverage." Only then can the beneficiary enter work hours.

Ruelle said she tried to follow this process but ran into problems there, too.

"You set up passwords and stuff, and the passwords won't work. ... It would tell you your user ID was invalid and then it would tell you your password's invalid."

"I tried to call them to help me go through all that stuff, and I couldn't ever get a response," she said.

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DHS spokeswoman Marci Manley said local offices have resources on hand to help beneficiaries report their hours.

"We have computers and kiosks available, and a staff person can offer one-on-one assistance," Manley said.

Arkansas is the first state to implement a work requirement in its Medicaid program. Kentucky attempted to launch a similar rule earlier this year, but a federal judge in the District of Columbia sided with a group of plaintiffs and blocked the policy in June before it went into effect. A lawsuit challenging Arkansas work requirement is now before the same judge, but a ruling isn't expected until 2019.

Governor Hutchinson, who received permission from the Trump administration in March to implement the work requirement, has said the "common-sense" policy is saving taxpayers money and incentivizing Arkansas Works beneficiaries to move up the economic ladder.

He's pointed to an unemployment rate near record lows as evidence jobs are available for anyone willing to work. Beneficiaries also get some credit for other activities, like school, volunteering or searching for jobs. The state Department of Workforce Services operates dozens of centers statewide that stand ready to help people find employment or training, Hutchinson says.

The governor has also noted the broad exemptions built into the program. Anyone with a dependent child in the house is exempt from reporting, as are full-time students and certain people with high-end medical needs, among other categories. DHS also automatically exempts people whose incomes were at least $680 per month when they first applied for Arkansas Works, under the assumption they're working enough already.

The requirement applies only to the "Medicaid expansion" population under Obamacare, thus excluding anyone receiving federal disability payments (Supplemental Security Income, or SSI) and those in other "traditional" Medicaid categories.

In September, when the work requirement first began cutting people from the Medicaid rolls, Hutchinson listed reasons why people might not be reporting. "One, they could have ... obtained other insurance coverage," he said. "Or it could be that they moved away out of state without notifying DHS. Or it could be that they simply don't want to be part of the workforce. They're able-bodied, but ... they don't desire to do it."

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To Ruelle, though, losing health coverage only makes it harder to participate in the workforce.

"When I work, I stand, you know? I stand on my feet for hours a day," she said. "I don't like taking medicine, period, but facts are facts: I need to be out of pain in order to work. I can't work if I can't even move."

Her asthma, meanwhile, gets worse when the weather turns cold; she starts wheezing when she goes without the Advair inhaler for too long, she said.

Ruelle signed up for Arkansas Works insurance soon after she was released from prison in January 2017. She'd been serving time for a drug offense.

"I went to prison over bad choices in my life. I got mixed up with the wrong crowd, got into using narcotics and drinking heavily and stuff like that, and I paid the price for it," she said.

Now, Ruelle said, she's four years sober and determined to stay that way.

"I'm really trying, I really am. I work a 12-step program. I have sponsees [people she sponsors]. And I don't mess up, because I don't need them looking at me and saying, 'Oh, it's OK to mess up and stuff.' ... No, I'm trying to save my life. I'm doing the things I need to do in order to keep my life stable."

Originally from the Pine Bluff area, she's now intent on starting fresh in a new town. "I'm trying to set a foundation here in Little Rock," she said.

But she's worried about what happens when her prescriptions run out.

"I mean, I've thought about this, and it's steadily going off in my brain. I'm having to function with a smile on my face in pain, but I do it. Don't get me wrong, I love my job. ... I love my customers, I love making them smile, and I get to do that. It's part of my job, customer courtesy, and when you're in pain, it's really hard to smile. It really is."

Ruelle's job offers health insurance to supervisors but not to lower-level staff, she said. She's talked to an independent insurance agent who's arranged for her to get insurance on Jan. 1, either by re-enrolling in Arkansas Works or by enrolling in the health insurance marketplace, where she would pay a small premium. Until then, she'll keep working as best she can.

"I mean, I gotta pay bills, so I work," she said. "I have to pay rent."

Ruelle is frustrated the state has ended her coverage.

"This was put in place to help us, and it helped us for like a short period of time, and then it was like ... whoever the caseworker is didn't do their part," she said. "They're getting paid to do their job, but they're not even doing it."

Dealing with DHS, she said, makes her feel "like you're just a number on a sheet of paper. That's exactly how they treat you." It fills her with the same sense of powerlessness she had when she was incarcerated. "If that were the case, why didn't I just stay in prison?

"I served my time, and I'm ... a resident of the United States of America, Little Rock, Arkansas," Ruelle said. "I'm a resident here, and I pay my taxes, which helps pay them, so I would expect something in return. I'm paying you, so I need some help back."

This reporting is made possible in part by a yearlong fellowship sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund. It is published here courtesy of the Arkansas Nonprofit News Network, an independent, nonpartisan project dedicated to producing journalism that matters to Arkansans. Find out more at arknews.org.