Arkansas Advocates for Children and Families released an issue brief this week on the changes that Governor Hutchinson is seeking for the state’s Medicaid expansion program. The brief argues that the governor’s proposals — which still await federal approval — would increase the number of uninsured Arkansans, risk disrupting coverage for beneficiaries and run counter to the purposes of the program.
Once known as the private option and since re-branded by Hutchinson as Arkansas Works, the state’s Medicaid expansion program provides health insurance for more than 300,000 Arkansans who make less than 138 percent of the federal poverty level (that’s around $16,600 for an individual or $34,000 for a family of four). Hutchinson, as readers of this blog will know, asked the federal government this summer for a waiver of Medicaid rules in order to enact alterations to the program, including work requirements and a reduction in eligibility that will boot more than 60,000 working poor Arkansans from the rolls.
Arkansas Advocates notes that this is the third waiver request since the original private option program was implemented in 2014:
That means the program has basically changed every year. This causes confusion, not only among consumers but also providers. That confusion can disrupt coverage and inflate
Obviously, policymakers should seek to improve policy. But this is an important point and tracks with my own reporting over the last three years: Beneficiaries are thrilled to get coverage but have often been frustrated by the confusing processes the state has put into place for the program. (Note that the private option itself — using private companies to insure low-income Arkansans rather than using the Medicaid program directly — created an additional layer of complexity that has sometimes befuddled beneficiaries and likely adds to the cost of the program.) Ever since Medicaid was expanded, state officials have implemented convoluted policy regimes in order to win political favor from a Republican legislature thirsty for conservative talking points — but much of this tinkering has led to bureaucratic complexity, red tape, and confusion that undercuts policy objectives and can create hurdles and gaps in coverage for beneficiaries. Two of the most convoluted schemes — a byzantine version of health savings accounts and a scheme to route beneficiaries to employer-sponsored coverage — were abandoned as unworkable just a year after being implemented.
As beneficiaries try to navigate this maze, the state has woefully underinvested in outreach. Making matters worse, the state’s blasé attitude toward the program renewal process — including shockingly poor communication and a notice process that violated federal law — led to tens of thousands of beneficiaries being kicked out of the program despite the fact that they were eligible according to the state’s own data.
It is not a record that inspires confidence as the state embarks on Hutchinson’s scheme to initiate a new bureaucracy for tracking the work activity of more than 100,000 people, along with a difficult transition for tens of thousands of working poor Arkansans off the program and (in theory) onto private coverage. The headlines and catchphrases sound nice for the right-wing legislature, but this type of transition will take a massive and focused effort on outreach and accountability — or the state’s low-income citizens will fall through the cracks.
From the Arkansas Advocates issue brief:
Expanding the assistance available for low-income families to navigate the complex and ever-changing health care landscape could help mitigate the coverage losses that would inevitably follow an approval of these proposed amendments. Without adequate outreach to families and careful monitoring of the impact of these proposed changes, we could be rolling back what has been a remarkably successful effort to improve the health of all Arkansans. To ensure Arkansas Works continues to work for low-income Arkansans, DHS should develop a detailed plan for ongoing outreach and education for both consumers and providers as a condition of implementing the requested policy changes. Health education materials should be offered at the appropriate reading level to ensure consumers can understand them. In-person assistance should be offered to help families navigate our complex health care system and adequately research their coverage options.
DHS should collect data and evaluate the impact of these changes, as well. The criteria DHS should look at includes the number of people who became ineligible for Arkansas Works; the number of former enrollees who applied for a marketplace plan or other coverage; the number of enrollees who successfully paid a premium and enrolled in coverage; and the number of former enrollees who did not sign up for coverage. Information about beneficiaries who are subject to work requirements, including job placements and retention rates, should be gathered and analyzed, too. This data should be collected and reported quarterly.
Amid ongoing debate in Congress about the future of the health care system, it’s important that leaders in this state continue to put families first by ensuring everyone has access to comprehensive, affordable coverage.
In addition to concerns about the transition, Arkansas Advocates raise a number of concerns about the substance of the governor’s requested changes. On “partial expansion,” the governor’s proposal to reduce the eligibility line from 138 percent FPL down to 100 percent FPL:
The most concerning waiver request that will negatively impact low-income families is lowering the income level for Arkansas Works eligibility. DHS estimates the proposed change would make 60,000 Arkansans ineligible for Arkansas Works. Federal regulations require the state to make sure that those who make between 100 percent and 138 percent of the poverty level receive comparable coverage to those who remain eligible for the Arkansas Works program. The proposed strategy to meet
this requirement is to transition people from Arkansas Works to either Marketplace plans or employer-sponsored coverage.
But research and experience from other states show that many consumers will not be able to afford these alternate forms of coverage. Ample evidence shows that even small premiums and cost-sharing can result in loss of health care coverage. This is precisely what transitioning Arkansas Works enrollees to private insurance would do. These effects are especially likely for those with lower incomes closer to the poverty level.
On work requirements:
[T]here is little evidence that work requirements increase employment or reduce poverty, particularly in the long-term. Work requirements add an unnecessary barrier to coverage for enrollees and, due to administrative costs, an unnecessary fi nancial strain on the state budget. Work requirements would also lead to an increase in health care costs overall, as individuals denied insurance coverage from failure to comply with work requirements would be forced to seek treatment in more costly emergency room settings.
Work requirements are based on the false assumption that many people who receive Medicaid benefits could be working, but choose not to work. In fact, almost 80 percent of adults on Medicaid are in working families. Of those who don’t work, more than half would qualify for an exemption. Those include taking care of an ill family member (28 percent), being in school (18 percent), looking for work (8 percent), or having retired (8 percent). Another 35 percent of Medicaid recipients who do not work report having an illness or disability that prevents them from work – making work requirements especially counterproductive for this population. In fact, research suggests that Medicaid expansion supports and enables more people to work.
Arkansas Advocates also highlights another requested change by the governor that has flown under the radar a bit — the elimination of 90-day retroactive eligibility. Currently, enrollees in the program are retroactively covered for any medical expenses arising in the three months before enrolling. The Obama administration already granted a waiver that would allow the state to begin coverage only once a beneficiary was enrolled, but attached certain conditions for the state to prove that it would protect continuity of coverage. The state is now asking the Trump administration to remove those conditions and allow it to eliminate retroactive coverage immediately. From the issue brief:
Medical emergencies are unpredictable and costly. The current 90-day retroactive eligibility policy helps ensure that low-income families don’t incur burdensome medical debt that they are unable to pay. It covers any medical debt incurred three months prior to enrollment in Arkansas Works. Health care providers and the state also benefit from retroactive eligibility. Doctors and clinics are not left with unpaid bills for treatment they’ve provided. This means providers and the state both save money in reduced costs of uncompensated care.
A similar request to waive retroactive eligibility was part of the waiver request from 2016. Arkansas received conditional approval to eliminate retroactive eligibility for Arkansas Works enrollees, contingent on changes to Arkansas’s process of determining eligibility. One of these changes is the implementation of “presumptive eligibility,” a state policy option that allows qualified entities to make temporary eligibility decisions based on,
among other criteria, an assessment of family income.
Presumptive eligibility allows states to enable established community-based providers to make on-the-spot decisions regarding eligibility. Some agencies that other states currently certify to conduct presumptive eligibility checks include Medicaid and CHIP health care providers, elementary and secondary schools, and Head Start programs. In Arkansas, presumptive eligibility currently only exists for pregnant women. This should at least be expanded to the Arkansas Works population before any elimination of retroactive eligibility occurs.
Lots more from the brief, which is available at the Arkansas Advocates website.
It remains unclear when the Trump administration will respond to the waiver request. We noted yesterday that federal guidance on work requirements is expected in the coming weeks; it is likely that waiver approvals — which will almost certainly face legal challenges — won’t come until that guidance is released. Hutchinson had originally hoped to implement the changes on Jan. 1, but state officials say they will need 60 days once approval is received. The Hutchinson administration has consistently expressed confidence that his requests will be approved; few doubt that the Trump administration will approve work requirements or ending retroactive eligibility, but the request to reduce eligibility is considered a tougher ask.