It was the linchpin that delivered Medicaid expansion – the key to a bipartisan compromise last year for an over $500 million health program.

But the work requirement for New Hampshire’s Medicaid expansion is in trouble.

Weeks after the requirement kicked in on June 1, more than 20,000 people had still not reported their employment or logged an exemption, the state’s Department of Health and Human Services has said recently. The state’s effort to let people know it applies to them is falling short; few are answering their phones long enough to be told what to do.

“I’m obviously very concerned,” said DHHS Commissioner Jeffrey Meyers in an interview Tuesday. “And (I) feel that despite the department’s, I think, significant efforts for outreach that there are still a lot of people who don’t fully understand what the program is and have not received any direct counseling on it.”

Now, the program faces a crucial deadline. July 7 – Sunday – is the last day in which recipients under the program can submit evidence that they meet the first month’s 100-hour working or community engagement minimum. Those who fail to do so or apply for an exemption will be found out of compliance, with one more month to “fix” it before being kicked off coverage.

“I’m waiting to get a full report right after the close of business on the seventh as to all the information we have,” Meyers said. But amid thousands of such cases, the commissioner is sober-minded.

And a bigger decision now looms for Meyers and his department: whether to suspend enforcement of the program entirely.

Last month, New Hampshire lawmakers scrambled to pass legislation to allow the mandate to be voluntarily suspended until more Medicaid expansion recipients can be contacted. This week that bill, Senate Bill 290, lands on Gov. Chris Sununu’s desk. If he signs it, DHHS may act on it.

“Obviously should (SB) 290 become effective with the governor’s signature, I’m going to take a very close look at it,” Meyers said. “Look at the information we have, and I’m going to act accordingly.”

Meyers and Sununu will appear at a press conference Monday morning to make an announcement relative to SB 290 and the work requirement, a spokesman for Sununu said Friday.

For health care advocates, the urgency is real: If those 20,000 Medicaid expansion recipients do not get in touch with DHHS by Sunday to detail 100 hours of employment and community engagement over the month – or explain their exemption – they will receive an automatic letter by July 10 telling them they are out of compliance, according to present law.

If the same recipients failed to correct that by the end of July, they could be kicked off health coverage entirely in early August.

Adding to the frenzy is a federal lawsuit against the Trump administration seeking to end New Hampshire’s work requirement completely. Observers expect a preliminary decision in coming weeks if not months.

The circumstances have brought all sides to the table. Sununu and lawmakers have both said in recent weeks that the lack of awareness raises alarms and could warrant a suspension.

New Hampshire’s work requirement has had a long, strained run-up. First passed under a Republican Legislature, the proposed program was rejected by the Obama administration’s Center for Medicare and Medicaid Services, which must approve all state deviations from the Medicaid expansion law.

In 2017, with a new president and a Republican-dominated State House, work requirement supporters put in place an ultimatum: pass and get approved the mandate by the start of 2019 or see the whole Medicaid expansion program fall.

Facing a tight deadline and a faction of Republicans already skeptical of Medicaid expansion, moderate Republicans like Wolfeboro Sen. Jeb Bradley raced last year to come up with a work requirement that could pass federal standards and be palatable to Democrats.

The resulting plan – a waiver request approved by Washington in December –was criticized by health groups on one side as being harmful to health outcomes, and slammed by some Republicans on the other as being too generous with exemption opportunities.

But since implementation, the biggest barrier the program has faced is one all parties can agree with: awareness.

Recipients often don’t answer the phone or respond to mailed correspondence, according to data by the department. Those who do pick up may not hang on the line long enough to give their information or get basic information on what to do.

Meyers said that the department has been doing what they can to reach out to as many recipients as possible. That includes giving incentives for recipients to come into the district offices for counseling sessions.

The attempts ran the gamut. “We mailed multiple letters, we made over 50,000 telephone calls,” Meyers said. But the low response rate has dogged officials from the beginning.

In recent days, officials have tried to step it up with a new approach: door knocking. “There are teams of people actually who have gone door to door, reaching out to people we haven’t heard from and don’t have information from to see if we can provide information.” That also means providing forms for recipients to fill out as and when they need them, Meyers said.

But on Monday, with the release of final numbers for the month of June and the governor’s announcement, the situation could change.

Dawn McKinney, policy director for New Hampshire Legal Assistance – which is a party to the federal lawsuit – said the problems are widespread.

“Based on the requests for assistance that we’ve gotten from beneficiaries over the last few weeks, the difficulty that they’re having with forms and exemptions for medical frailty, and the difficulty we’ve discovered with people posting work hours online, we are really concerned that tens of thousands of people could lose their health coverage,” McKinney said. “…We continue to maintain that work requirements are illegal and we will wait to see how things play out in the courts.”