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Are work requirements irredeemably flawed?

November 27, 2018

As I noted in an earlier column, Arkansas’s first-in-the-country, first-in-history Medicaid work requirements have been backfiring.

The state has already purged 12,000 residents from the Medicaid rolls over the past three months. These Arkansans are not necessarily being booted because they’re failing to work, however. Some have lost their insurance because the state has made it so ridiculously complicated for them to prove they’re working.

Then, perversely, getting kicked off insurance can also make it harder for poor Arkansans to keep their jobs. Some people — such as Adrian McGonigal, a Medicaid recipient with a severe lung disease — need medication and other care to be productive, healthy workers.

Nonetheless, 13 other states are pursuing similar policies. In fact, the Trump administration has reapproved Kentucky’s Medicaid work requirements proposal, just months after a virtually identical proposal had been blocked by a federal court.

The question now is whether the many problems Arkansas is experiencing are because of specific (and unwise) implementation choices that the state made and are therefore fixable, or whether the very premise of adding work requirements to a health-insurance program is inherently, irredeemably flawed.

There is clearly a political appetite for imposing conditions on lots of public benefits, to make sure no one is “taking advantage.”

Some health policy experts argue that work requirements could make conservatives feel more comfortable with Obamacare’s Medicaid expansion, because work requirements would allow red states to expand insurance on their own terms.

And, to be fair, Arkansas’s policy does seem especially poorly designed.

Among its worst features is that reporting of work hours can be done online only — not by phone, by mail, by fax or in person. Officials chose this setup despite the fact that Arkansas has the lowest level of household internet access in the country. The website is glitchy, too, and doesn’t work well on smartphones.

Craziest of all, the website shuts down every day at 9 p.m. Hey, maybe it needs to go home and see its wife and kids?

Arkansas officials say the whole Medicaid system must be taken down every night to update statewide databases. But database maintenance technology that doesn’t require daily, 10-hour offline gaps is readily available. It has existed for decades.

Arkansas’s policy also doesn’t account for local job-market conditions, including the challenges of finding regular work (and reliable transportation) in rural areas. Nor does it consider the fact that many poor people have unstable living conditions (the state will terminate Medicaid recipients’ insurance for returned mail) and often don’t control their work hours.

All these design issues can feel like Medicaid “termination traps,” says Kevin De Liban, an attorney with Legal Aid of Arkansas, one of the organizations challenging the policy in federal court.

But let’s say you fix all those flaws: You give people more ways to report their work hours (or qualified exemptions, such as pregnancy or illness). You allow more concessions for local work conditions, transient home addresses, unpredictable hours and other barriers to employment, such as lack of transportation or child care.

Could you then formulate a policy that wouldn’t be so dysfunctional or cause so much accidental hardship? Could you have a compassionate, thoughtful system that truly punishes only the shirkers? Only if you want much bigger government, which conservatives generally don’t.

Most nonelderly Medicaid enrollees are already working, according to a Kaiser Family Foundation analysis. Almost all of those who aren’t working have a pretty reasonable explanation for why not, such as disability, family obligations, school attendance or no work available.

Finding, documenting and ultimately punishing the tiny minority of Medicaid recipients whom officials target as “undeserving” would therefore require a major, costly expansion of the administrative state. Arkansas already knows this. That’s why officials made the reporting system online-only, after all, and presumably why they didn’t bother to bring its database software into the 21st century: to save money.

Helping poor people find work, or at least helping them find better work, is a laudable goal. But there are much more effective, and less punitive, tools available, such as expanding the earned-income tax credit or investing in better education and training. And expand programs that help. Think: child care, reliable transportation, reliable internet access.

Perhaps even — gasp — access to health care.

crampell@washpost.com

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