

Governor Hutchinson‘s so-called “work requirements” demand that certain Medicaid beneficiaries fill out paperwork on a monthly basis or have their health insurance taken away. There is no evidence that the busybody governor’s requirement is actually helping more people become employed, the requirement’s ostensible purpose. The state has showed scant interest in evaluating how effective the program is at meeting that purported goal, or what the consequences might be for access to care for low-income citizens.

We do know, however, that more than 17,000 Arkansas have lost coverage, and there is increasing evidence that the program’s implementation has been a disaster, leaving even those beneficiaries who are working and trying to comply frustrated and confused.



A new report out this week from the Kaiser Family Foundation examined the issue in a series of focus groups with beneficiaries and interviews with safety net health care and food assistance providers. The study found that many enrollees were unaware of the new requirements or confused about the details of what was required; those who were aware found it difficult to navigate the process of setting up the account required for the reporting. Many of those interviewed were already working or looking for work because of normal economic pressures, but none said that they had gotten jobs because of the requirements.

The state initially required electronic reporting via a web portal, which was widely reported to be glitchy, confusing, and difficult to use. It was offline every day from 9 p.m. to 7 a.m. The Arkansas Nonprofit News Network and others have reported on people who sought help from the state’s Department of Human Services, only to be flummoxed by a bureaucratic trainwreck. Amid a flurry of criticism, the Hutchinson administration finally caved and began allowing telephone reporting, beginning last Thursday, though that is cold comfort to those who already lost coverage.


A tiny fraction of those subject to the requirements have actually managed to successfully navigate the system and report their hours — just 1,428 in November. The governor risibly tried to fudge those numbers, but the reality is that while the program has been successful at purging the Medicaid rolls, less than one in five of those subject to the reporting requirements since the program began have actually done so. State officials have suggested, without evidence, that this is because they’ve gone and gotten jobs; DHS Director Cindy Gillespie opined that it might be because “they don’t value the insurance.”

Based upon the testimony of the beneficiaries themselves, however, the more likely explanation is that the implementation of this complex new bureaucracy has been a scandalous failure. This outcome is no surprise: The state invested no additional funding into outreach or work support services and has a long history of horrifically poor communication efforts with beneficiaries leading to kicking people off the rolls. The initial web portal requirement was designed to skimp further on costs, which helps clarify where the governor’s priorities were. The priority was not making sure that beneficiaries understood the requirements or had supports in place to succeed in the new program. For all of the rhetoric, the priority was not to help people get to work. The one area where the program has been ruthlessly efficient is removing people — including people who are working — from the Medicaid rolls.


The Kaiser report conducted four focus groups with a total of 31 Arkansas Works enrollees in Little Rock and Monticello, as well as interviews with four health care and food assistance providers who work with at-risk populations. The whole thing is worth your time; the report does a nice job of including the stories and voices of those impacted by the governor’s policy, and breaking down the implications for their everyday lives.

Here’s one beneficiary’s experience trying to sign up:

I went online and tried to set up an account. That was unsuccessful. So they listed this 866 number on the paper, so I tried to call and speak to somebody while I was in front of the computer, so they can walk me through it and help me set it up. And that was awful because you never could speak to nobody. And then I got through it give you all these prompts… it said you had to enter in your reference number that come on the paper and it kept saying my reference number was not my number….

Another:

Tried creating the account, went through the reference number problem. Finally got a reference number. And then when I went to log back in, they said my password changed. To get your password changed, you gotta call the actual website. Once you get to the actual website, they reset your password, but presumably it’s only good for that one time. So when you try to log back in the next week to do your stuff again, you have another new password change…That’s how the website is

Another:


I got a letter in the mail telling me that I had to do this, this, this and this and this, and I if I didn’t that I would be put on probation. And if I still didn’t complete it, then I would be [dropped]. I tried to those things that they required and I couldn’t. I ran around in a circle.

The report’s overview on these issues:

The majority of those who were aware of the requirement to set up an online account reported problems doing so and could not get assistance. Some tried to set up an account but did not have the right reference numbers or passwords. Many said that the process was complicated, and it was difficult to get in touch with someone at DHS to get help. Many participants tried to call and were on hold for very long periods of time or transferred to multiple people before getting help. A number of enrollees gave up and were left with negative perceptions about DHS. One participant who was working but disenrolled from coverage was unable to successfully report hours after experiencing multiple problems with the reference number and account passwords. Several enrollees mentioned the fact that the online portal shuts down every evening at 9 pm for maintenance as an additional barrier to reporting because the portal was not open when they were most likely available to use it. A number of people in the focus groups knew about the DHS processing or call center in Pine Bluff. Notably, one enrollee who worked as a software technician had difficulty navigating the online account set-up process and ended up losing coverage for failure to successfully report her work hours. She was unable to set up her account because the portal would not accept the reference number from her notice and unable to reach a live person on the phone for help for some time; she was finally told to fax documents to Pine Bluff, but still was disenrolled and had to navigate an appeal. Many enrollees in the focus groups who tried to complete the online account process were not confident that they set up or reported information correctly. Many recalled receiving individualized help when they first signed up for AR Works coverage because it was difficult to navigate the new online processes and systems. Providers noted that support from enrollment assistors that had existed in 2014 was no longer available but still needed to help enrollees navigate the online account setup and reporting.

The report breaks down the actual DHS mailed notices on the requirements, which are long and confusing, and often bury the most important information. Here’s the summary of the focus groups’ perspectives on the letters:

Most enrollees did get a letter, but the large majority did not fully read the letter and/or understand the new work or reporting requirements or the consequences of failure to comply, including coverage loss for the remainder of the calendar year. Enrollees described the letters as confusing and long, and many enrollees did not get to the second page. Many said their lives are busy and complicated, and they put the letters aside without fully comprehending the information because they had to focus on more immediate and pressing needs. For example, one enrollee said that she was focused on her alcoholism recovery and getting back on her feet so the notices went unread. Others were focused on meeting basic needs like affording food and utility bills. Safety net providers observed that those with low literacy levels or limited English proficiency would have greater difficulty understanding the information, given the complicated rules and reading level required. In a few instances, individuals had moved recently within the state, and despite having reported an address change to DHS, notices and other mail were not getting delivered to the correct address.

More on the initial internet reporting requirement:

Many do not have computers or reliable internet access, especially those in rural areas, and others are not comfortable using computers. One Monticello participant described repeatedly being unable to get her account page to load on her cell phone when she tried to report her hours; after spending an hour on the phone with DHS, she was unable to get the problem resolved and “gave up.” Many who were not comfortable with computers or with low levels of computer literacy faced more trouble. Some in more rural areas do not have reliable internet or cellular phone service which complicates the process of setting up the online account. Many use phones instead of computers to access the internet, but filling out forms, involving navigating multiple steps and screens, can be difficult on a phone. Many in the focus groups did not own a computer so need to use a computer at the library, although some had access to a work or home computer (with college students most likely to report having a computer). A number of enrollees, particularly in the older group already subject to the work requirements, were not comfortable using computers and preferred one-on-one assistance or paper to filling out forms online. … A common comment among the Monticello participants was not having any cellular service at home, especially for those living “out in the country,” and having to come “into town” to get a signal. Another Monticello participant who did live “in town” also described sporadic cellular service. Those with wifi described the connectivity as “going in and out.” A provider noted that some of the Delta region had no cellular service, with the only option to access the internet at home being a satellite connection, which was prohibitively expensive for those with low wage jobs.

The work requirements aren’t creating an incentive to work, they’re creating a burdensome hassle:

The new requirements do not appear to provide an additional incentive to work, beyond economic pressures, but are adding anxiety and stress to enrollees’ lives. Many focus group enrollees already were working or looking for work before the new requirements were in effect. No one in the groups had gotten a new job as a result of the new requirements. People are motivated to work to make ends meet. The large majority were dealing with financial pressures and struggling to pay bills such as food and utilities based on earnings from low wage jobs. One single parent of a son away at college worked full-time but regularly did not have enough food and went to a relative’s home to eat. Other participants described carefully monitoring their spending on food, watching for coupons and sales, buying less healthy food because it was more affordable, and only buying what was needed for one meal at a time. Other financial pressures included car repairs and utility shut-offs. Safety net providers described their patient population as “living paycheck to paycheck” and working multiple part-time jobs because they could not get enough hours at one job. The new requirements are not incentivizing new work or other activities in which enrollees were not already engaged, but are layering on one more thing to deal with in enrollees’ already complex lives and causing added stress because no one wants to lose their coverage.

“Let me explain something to you,” one beneficiary said. “Some of us are working because we have to work…I have fibromyalgia. I’m a diabetic. I be in all kinds of pain, but I gotta make ends meet to take care of my home.”

Another explained, “I try to get as many hours as I can because I got bills to pay.”

As has been reported elsewhere, in many cases, the Medicaid coverage itself was providing medicine or health services beneficiaries needed to continue working (others struggled to keep steady work as required because of medical difficulties).

One beneficiary explained:

The month that I didn’t take it [medication for narcolepsy], I was knocked out every day. Like while we’re talking, I’d probably be sleep right now…I couldn’t work.

Another:


I have a mental illness, I’m bipolar…they can’t get my medicine right, little more manic, little excited…I try to think I’m okay without it and then just, you know…without this insurance I would be in a lot of trouble. I think there was one time, it would have been like $400 a month [for prescriptions] if I didn’t have insurance. And there’s no way possible.

More stories:

“I’m in a halfway house. And the thing is I pay $145 dollars a week rent. It’s like I’m stuck in a rut because I’m in a dead-end job. I don’t make no more than maybe $200 a week. Okay, a $140 of that has gotta go to rent….that’s not counting my gas costs going back and forth to work. That’s not talking about my food…I’m having to come out of pocket because now [after losing coverage for failure to successfully report hours online] I don’t have any health insurance to cover $600 worth of medicine. My inhalers are 400 to $500.” —Little Rock AR Works enrollee “I have a mental illness, I’m bipolar…they can’t get my medicine right, little more manic, little excited…I try to think I’m okay without it and then just, you know…without this insurance I would be in a lot of trouble. I think there was one time, it would have been like $400 a month if I didn’t have insurance. And there’s no way possible.” — Monticello AR Works enrollee “It’s a lot to deal with. Especially on top of your day-to-day stuff. If you got kids, you work, you know. You got a house to maintain and then it’s one more added thing; you got to remember to put this in every month.” Little Rock AR Works enrollee “If you don’t go into their website once a month and login, and then go to your access, and all that, then you lose your coverage. But the websites so screwed up that you login and then you navigate to the next page and it logs you out.. . So I don’t know if I’m doing enough to keep my coverage.” Little Rock AR Works enrollee “I’m not computer smart; I’m worried about it. Insurance is important but hard to keep dealing with this.” Monticello AR Works enrollee

There’s much more — on confusion about the complex rules for exemptions and getting those exemptions approved; the difficulty of finding good jobs in rural areas; the challenges of month-to-month reporting for those whose incomes fluctuate, including people losing coverage because one outlier month had a higher income; particular challenges for beneficiaries who are homeless or have more serious physical or mental health challenges; and other issues.

Zooming out, some key takeaways:

Enrollees were unaware or confused by new requirements. Notices and informational letters were not fully read or understood, and enrollees were unaware of key details including the penalty of coverage loss for the remainder of the calendar year for failure to meet the requirements for three months. Only a few enrollees recalled getting phone calls about the changes to AR Works. While many in the groups had social media accounts, virtually no one got information about AR Works through Facebook or other social media. The younger enrollees who will be phased in to the new requirements beginning in January had started to hear about the program changes, but few had complete information or fully understood what was required to comply. Many enrollees found it difficult to navigate the process to set up an online account. The majority of those who were aware of the requirement to set up an online account reported problems doing so and had difficulty getting assistance. Many do not have computers or reliable cell phone or internet access, especially those in rural areas, and others are not comfortable using computers. However, the younger group of enrollees who will be phased in to coverage starting in January 2019 were not as concerned about setting up an account and on-going reporting. The new requirements do not appear to provide an additional incentive to work beyond economic pressures, but are adding anxiety and stress to enrollees’ lives. Many enrollees are already working, but may face unstable or unpredictable work hours. Volunteering was not an option for people who needed to pay the bills. More rural areas have few job opportunities. No enrollees had contacted the Department of Workforce Services (DWS) for assistance.

And the impacts on people’s everyday lives of the governor’s busybody boondoggle:

