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Work requirements don’t work

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South Carolina is the latest state to take steps to impose work requirements on Medicaid beneficiaries. Other states have been legally barred from implementing work requirements, for good reason. In a recent decision to block Medicaid work requirements in Arkansas, a federal judge said that the Secretary of Health and Human Services, in approving waivers for work requirements for federal benefits at the state level last year, “had failed to ‘consider adequately’ the impact of Arkansas’s plan on Medicaid coverage.”

This is a massive understatement. The expansion of work requirements represents nothing less than an explicit effort to make health coverage harder to get. South Carolina concedes as much, with their own estimates projecting that more than 11,000 people will lose coverage over five years.

Why do work requirements cause so many people to lose Medicaid – even when they’re employed and continue to need coverage? Since Arkansas was the first state to tie work requirements to Medicaid, I worked with my colleagues at the applied behavioral science firm ideas42 to map the unforgiving steps and onerous barriers that Arkansans face to maintain their coverage. The primary lesson from Arkansas was that other states should stay far away from work requirements. Not only do work requirements not work — they are little more than a game designed to be lost. 

Want to see for yourself? Let’s play the game

Your first challenge is learning about new rules. In August 2018, nearly three months after the new work requirements took effect in Arkansas, 75 percent of 18 Medicaid recipients interviewed hadn’t heard anything about these rules. The state of Arkansas found that only 20-30 percent of the emails notifying Medicaid recipients of the requirement were opened. And the president of the Arkansas Foundation for Medical Care, which ran a call center to reach out to recipients, said that many people couldn’t be reached by phone or mail at all. If you have bad cell reception in your home, or the letter goes to an old address, you’ve already lost.

If you managed to hear about the work requirements, move on to the next challenge: setting up your Arkansas Works account. Roll the dice to find out if you already have an email address (15 percent of Americans making under $30,000 a year, 31 percent of Americans without a high school diploma, and 13 percent of Americans with only a high school diploma do not use email). Need to create an email account? Roll the dice to find out if you are among the nearly 30 percent of Arkansans who do not have internet access at home. If you are, or you plan to access the site on your mobile device (the site is not mobile friendly), go back one space and try again later.

Maybe last turn you accessed the internet at home or the public library, but you also need your reference number to set up your account, which is in the letter you probably don’t have anymore. Hopefully you can call during business hours to get the number. You may not learn until after getting home for a late dinner that the Arkansas Works website closes every night from 9:00 p.m. to 7 a.m. (don’t ask why, we have no idea). So budget enough time during the day to log in, maybe when you’re at work — the very hours you’re supposed to report to comply with work requirements. If you don’t have a job, sorry, no Medicaid for you. Start over and play again once you’ve found a job.

If you’ve made it this far, you’re rewarded with your final challenge: working enough hours, and more importantly, figuring out how to report it on time. This stage of the game is rife with potential traps: your hours could get cut, the part-time website malfunctions, your kid gets sick and you have to stay home with them, your ride to work has a family emergency. If you land in any of these circumstances this month, you could easily drop below your required hours. More frustratingly, one of those circumstances could prevent you from reporting your hours, which is the same as not working for all intents and purposes. If you can’t work or report enough hours for three months, it’s game over for you too. Try not to need a doctor until next year.

That’s right: in Arkansas if you are deemed noncompliant for just three months, you lose Medicaid coverage entirely and can’t reapply until the next calendar year, like the more than 18,000 Arkansans who’ve lost their coverage since June 2018, when the work requirement went into effect. To be fair to South Carolina, their rule would be slightly different; if you are deemed noncompliant there for three months, your benefits are suspended for three months, or until the work requirements are met. If you have acute or chronic medical needs in that window, though, three months of lost coverage is still too high a price to pay.

Of course, people are resourceful (and some are lucky), so you may have worked enough hours and successfully reported them: Congratulations, you’ve reached finish and have won the game, but just for this month. To keep your health care, play again next month, and the one after that, and the one after that.

Having trouble following along? This cruel “game”— straight out of Kafka for kids — is an unfortunate reality for many people, and violates the core principles of everything we know about reducing poverty. Worse, evidence shows that all this hassle and pain does nothing to improve labor market participation. 

Nonetheless, the Trump administration is appealing the court ruling that blocked work requirements in Arkansas and Kentucky, and several states like South Carolina continue applying for waivers that would allow them to install work requirements. Unless cruelty is the point, these states would do well to stop playing with people’s lives, and instead adopt evidence-based policy that actually helps people. I can’t say it enough: work requirements don’t work.

Anthony Barrows is a managing director at ideas42. He has worked more than ten years in the public and non-profit child welfare sphere in direct service, supervision, training, advocacy, project management and system improvement. 

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