(left to right) DHS Director Cindy Gillespie, Governor Hutchinson and CMS Administrator Seema Verma at a signing ceremony for Arkansas's work requirement waiver in March.
Beginning in June, many beneficiaries of Arkansas Works
, the state's Medicaid expansion program that provides health coverage to over 280,000 low-income adults, will have to begin fulfilling a work requirement
or else prove an exemption. Arkansas received a waiver from the federal Centers for Medicare and Medicaid Services in March
to begin imposing work requirements on Medicaid expansion recipients.
Work requirements tend to provoke strong reactions from both left and right. But the devil is in the details: Who gets an exemption? What activities count as "work"? And how do beneficiaries prove to the state they've met the requirement? This last question is especially crucial,
since national studies indicate
that most non-disabled adult Medicaid beneficiaries do work at least part-time. (Arkansas's requirement says beneficiaries must report at least 80 hours of qualifying activities per month, so many part-time jobs would count.) Yet if working people can't report their labor to the Arkansas Department of Human Services, they still could lose coverage.
Arkansas's waiver to implement work requirements contains an unusual wrinkle. It says beneficiaries must report their activities through an online portal created by DHS
— not by physical mail, not by phone, but exclusively over the internet. The issue came up in a legislative meeting on Thursday, as reported by the Democrat-Gazette's Andy Davis
. In a state where many residents lack access to broadband, why mandate online reporting for beneficiaries? Why close the door to other means of fulfilling the requirement?
I asked those questions of DHS Director Cindy Gillespie
in March, soon after the waiver request was granted. She said the online-only reporting requirement was part of a concerted effort by her agency to move toward digital communications in general — but she also acknowledged it was simply more convenient for DHS.
"Our goal, long range, is hopefully to begin to move to where more and more communication between us and all of our Medicaid population can take place online, or through phone or through text or through other mechanisms besides snail mail," Gillespie said. "We get so much snail mail returned, and we all know we are living in a different age."
Mail is often a less reliable way of reaching people than email, phone or text, she said, and DHS needs to adapt.
Gillespie also framed the portal as a means of pushing beneficiaries into better communications habits, therefore acting as a supplement to the work requirement itself. "Having that little bit of computer or phone literacy is important if you are going to be able to be moving up the income ladder," she said. She noted that the work requirement only applies to beneficiaries between the ages of 19 and 49. "We are talking about 30- to 49-year-olds and next year 19- to 29-year-olds," she said. "I mean, a 19- to 29-year-old who in this day and age can’t do that and is able-bodied? You know, they need — we need to help them learn to do that. We need to help them get an email and learn how to deal in
that world, or they will never be successful."
The work requirement will apply just to the age 30-49 cohort in 2018 and expand to include the younger cohort in 2019; beneficiaries aged 50-64 will be exempt from the requirement entirely.
Yet Gillespie also said it would simply be difficult for DHS to allow everyone to report their information in a different way. "The other thing is, on a real practical level, this is the way the world works and we are moving into that. If you implement it in the old-fashioned way of ‘Come into our county office,’ we would have to hire so many people — and that just doesn’t make sense," she said.
About 39,000 people are expected to be subject to the work requirement this year, DHS said in March. Gillespie and Governor Hutchinson have repeatedly said the work requirement is not punitive but is intended to help beneficiaries.
, a senior fellow at the progressive-leaning Center for Budget and Policy Priorities
in Washington, D.C. said Arkansas's requirement that individuals report only through the portal was "really unprecedented" in state Medicaid programs. Because Medicaid is a partnership between the federal government and states, there are rules that states must follow — laid out in the federal Social Security Act, which created Medicaid — when they manage their programs.
I spoke with Solomon in March soon after Arkansas received its waiver from CMS. (She's also been critical
of Arkansas's work requirement more generally.)
Work requirements themselves are a new thing for Medicaid. But when it comes to reporting information in general, Solomon said, the law says "people can do whatever, whether by phone or mail or online, and you can’t restrict those modalities." The online-only rule raises "questions about people with disabilities, without access to the internet, with limited literacy — how they are going to accommodate those people?"
"It's definitely extraordinary. ... I think there are real questions about whether [Arkansas] can even do that," she said.
Arkansas's waiver from CMS is what's called an 1115 demonstration, named for the section of the Social Security Act that allows states flexibility to experiment with their Medicaid programs. A Section 1115 waiver lets a state depart from certain parts of the Medicaid law if it comes up with an alternative way of doing business that meets the fundamental objectives of the program. But, Solomon explained, Section 1115 doesn't allow everything
to be waived.
"There's a very long list of state plan requirements … and that’s what you can waive. Now, there’s a lot of other sections of the Social Security Act," she said. Arkansas cited "expenditure authority" when it sought — and received — permission from CMS to require beneficiaries to report online. Yet it's not clear that "expenditure authority" applies to the question of how beneficiaries report their work activities. "This has nothing to do with expending money. It’s just about reporting ... and I think ultimately these things will be decided in court," she said.
DHS spokesperson Amy Webb said in an email on Friday that the agency had vetted its 1115 waiver request extensively and noted federal authorities did the same.
"Our waiver request had extensive legal review not only from Arkansas DHS but also the general counsels of both HHS and CMS as well as Department of Justice," Webb wrote. "Ultimately CMS was comfortable with and approved our request for online-only reporting."
"We are providing additional support to individuals who need it and are making reasonable accommodations for people who need them. It’s important to point out two other things: the HHS Secretary has broad discretion and that would cover this area; and
the online-reporting is not for enrollment. It’s for reporting work activities/exemptions, which is an important distinction."
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.