Arkansas again seeks Medicaid work requirement waiver
Arkansas is again seeking a Medicaid work requirement that state officials say incorporates lessons learned from previous attempts.
Republican Gov. Sarah Huckabee Sanders on Tuesday shared a letter to U.S. Department of Health and Human Services Secretary-Designate, Robert F. Kennedy Jr. and a waiver request to the Centers for Medicare and Medicaid Services (CMS) requesting the implementation of a work requirement for 'able-bodied, working-age recipients' of the state's Medicaid expansion program — Arkansas Health and Opportunity for Me (ARHOME).
The waiver will be submitted to CMS following a 30-day public comment period, State Medicaid Director Janet Mann said.
Arkansas became the first state to implement a work requirement for some Medicaid recipients in 2018, but a federal judge halted the policy the following year. Arkansas was one of 13 states to receive permission to impose work rules on some Medicaid recipients during Donald Trump's first administration. With his return to the White House, more states might again apply for work requirements from an administration that's demonstrated it's amenable to them, according to Stateline.
It costs Arkansas more than $2.2 billion annually to support the roughly 220,000 'able-bodied, working-age adults' on ARHOME, an estimated 90,000 of whom are unemployed, according to the letter. If the waiver is approved, the work requirement would apply to Arkansans ages 19-64 who are eligible through the new adult expansion group, have an income at or below 138% of the federal poverty level and are covered by a qualified health plan, according to the waiver request.
'The requirement is simple — you want to receive free health care paid for by your fellow taxpayer, able-bodied working-aged adults have to work, go to school, volunteer or be home to take care of their kids,' Sanders said at a press conference at the Capitol.
Learning from past issues with the program, state officials said the new waiver differs from previous work-requirement attempts in that it removes the burden of reporting requirements from recipients through the use of data matching. Data matching refers to the practice of comparing different sets of data to identify similarities and relationships.
Additionally, state agencies will use multiple forms of communication to connect with recipients, and when beneficiaries fall out of compliance, they will be suspended from the program instead of disenrolled, state officials said.
Medicaid eligibility was expanded during the COVID-19 pandemic, but when the public health emergency ended last year, the Arkansas Department of Human Services began 'unwinding' the extension by disenrolling clients the agency considered ineligible.
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Between April and September 2024, more than 184,500 Arkansans lost coverage because they did not provide necessary eligibility information. In some cases, beneficiaries likely declined to submit renewal paperwork because they no longer qualified for coverage, state officials have said. But advocates have argued that some still-eligible beneficiaries likely lost coverage because they never received proper notification or encountered problems when trying to return renewal information.
Arkansas Advocates for Children and Families said it was unable to comment on the details of the requested CMS waiver because DHS did not provide a copy prior to Tuesday's announcement, but the nonprofit organization did have concerns about the waiver's effect on Arkansas.
'Although the state is looking at the various problems that occurred during the last round of work-reporting requirements, the bottom line is that Medicaid is not a workforce or a work-incentive program,' AACF said in a statement. 'It is an insurance program for low-income adults and children.'
Noting that 130,000 of the 220,000 able-bodied individuals on the program are currently working, AACF said this highlights that despite common messaging about Medicaid recipients, the majority have a desire to work and provide for their families.
During the state's first attempt at a Medicaid work requirement, more than 18,000 Arkansans lost health insurance coverage between Sept. 1 and Dec. 31, 2018, for failing to meet those work-reporting requirements, according to AACF. Of those removed, 97% were compliant or had exemptions, but still lost coverage.
Proposed Medicaid cuts would hurt rural areas, including Arkansas kids, researchers say
The loss of health care coverage can lead to higher health care costs for all Arkansans because of increased emergency room usage, hospitalizations and unreimbursed medical care, according to AACF.
'Hospitals could be impacted, and people will lose their jobs when they become too sick to work,' AACF's statement reads. 'At a time when families are living paycheck to paycheck and struggling with the high cost of living, now is not the time to take away people's health insurance while forcing taxpayers to foot the bill for more unwanted bureaucracy.'
Work requirements are already part of other federal assistance programs, such as the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) program, DHS Secretary Kristi Putnam said Tuesday. The 'Pathway to Prosperity' waiver is about helping Arkansans learn about new opportunities, seek new skills and pursue new careers, she said.
'The goal should be for Medicaid to be a safety net, and we should routinely see healthy adults moving from government dependence to economic independence, improving their health in the process,' Putnam said. 'It is not punitive. It is about purpose.'
Individuals who are suspended from the program can become active again and have their full benefits restored by notifying DHS of their intention to cooperate with personal development plan requirements, according to the waiver request.
DHS also plans to use data matching to identify ARHOME beneficiaries who are 'not on track towards meeting their personal health and economic goals,' according to the state's waiver request. Those individuals will then be contacted by a 'Success Coaching resource.'
DHS is assessing public and private options to fulfill Success Coaching roles, but intends to leverage resources and community partnerships, according to the waiver request.
Details about the nuances of the program's implementation will be determined during negotiations with CMS, Putnam said.
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"The best we can do to preserve our finances is not squander the knowledge we've gathered through research and public health information. There's data that tells us for every dollar invested in treatment, the amount of savings that occur elsewhere in society in terms of reduced rates of incarceration, increased employment rates and more. We need to not lose touch with that as we create our plans, moving forward, to make America healthy." Despite this possible obstacle, Hennepin Healthcare has been largely successful in helping OUD patients transform their lives. Aside from sharing concerns regarding the financial sustainability of the collaborative care program at Hennepin, Winkelman, too, is "extremely optimistic" about the model's future in treating OUD and other disorders. "I've had so many patients in the last two years benefit dramatically from these services, and we've really been able to help patients get back on their feet," he said. "It has improved the quality of health care that we've provided. And I really see it as the standard of care moving forward in primary care." What's on the horizon for collaborative care models? Currently, research is shifting to examine not only how the collaborative care model can address substance abuse symptoms but also the co-occurring mental health conditions. Penn Medicine's Whole Health Study focused on this with a randomized controlled trial designed to assess collaborative care models and their effectiveness in treating patients for OUD and the comorbid mental disorders that accompany it. The study utilized three conditions. In the first, primary care doctors were prescribing buprenorphine and referring patients out for mental health care. Currently, buprenorphine, a Schedule 3 controlled substance, is one of the medications most commonly used to treat OUD and help patients reduce or quit their opioid usage. In the second condition, a collaborative care model was implemented with a licensed clinical social worker and a psychiatrist who were providing mental health treatment within the primary care practice. The final condition added a peer or certified recovery specialist to increase treatment engagement and retention. The study's principal investigator, David Mandell, professor of psychiatry and director of the Penn Center for Mental Health, shared details regarding the initial results the center recently shared with the College on Problems of Drug Dependence (CPDD) organization in New Orleans. "In all three conditions, there's a substantial reduction in opioid use, and [use] stays low for the six months they're in [the CoCM]," said Mandell. "But our collaborative care condition also results in substantial reduction in psychiatric symptoms and even remission from psychiatric disorder, relative to the usual care condition." According to the study's protocol published in 2021, poor treatment retention is relatively common in CoCMs treating OUD. Mandell described a few reasons why this occurs: the location of care sites, which can make it difficult to live one's life during treatment; punitive measures and caregivers' refusal to see patients after relapses; and problems that accompany opioid use, like food insecurity and housing instability. The center recruited participants from among primary care doctors' existing patients; these patients had either initiated treatment or had been in treatment for some time but were still experiencing psychiatric distress. Hence, convincing patients to begin treatment wasn't necessarily part of conducting the study. "One of the really exciting things we see is, across the conditions tested, 80 percent of people stayed in treatment," Mandell said. "This suggests they liked their doctors, thought the treatment was effective and thought people were meeting them where they were." Mandell believes one of the main reasons for this is the harm reduction approach used by Penn primary care doctors, in which they're more responsive to patients' needs and don't use the punitive approach often taken to OUD patients. When asked about the most rewarding part of the trial, Mandell mentioned seeing how much the primary care doctors loved the model, because they've been eager to secure a high level of support for their patients for a long time. Mandell also enjoyed reading patient testimonials, talking about how much they loved their therapists and benefited from their treatment. "The emails we get, where they say, 'You've turned my life around. Things are so great,' relative to what they were. 'I don't know what I would've done without this social worker.' That's very rewarding," said Mandell. To ensure success, Mandell had a multidisciplinary team working alongside him, and working with the members has been one of his favorite parts of leading the trial because of their determination to help this patient population. "This patient population has a lot of stigma around it, and many people are not interested in helping these folks," he said. "They believe, 'You could stop if you wanted,' and 'You get what you deserve.' But these are people really committed to helping OUD patients and figuring out the best way to support them. And that has just absolutely restored my faith in humanity."
