After a federal court rejected CMS approvals for Medicaid work requirements in Arkansas and Kentucky, you might think Indiana would reconsider its own similar Medicaid waiver plan.
But no, the State has not budged from its plan, which kicks in July 1. Ignoring the question of whether they can even do this under the law, state officials, and some others, insist that Indiana is better prepared than Arkansas, which cost more than 18,000 people their Medicaid coverage in just 6 months – or about one in five people subject to the new requirement.
Dr. Jennifer Walthall, Secretary of Indiana’s Family & Social Services Administration, argued that other states approaches are “fundamentally different” from Indiana’s. The bottom line: we can’t ignore something that’s illegal. And beyond that, we need to call out Indiana’s attempt to distance itself from the Arkansas calamity. Because when we look under the hood, we’ll find Indiana’s rather superficial differences will do little to prevent coverage losses like we saw in Arkansas. In fact, some of these policies may well make things worse.
For example, Indiana will phase in the number of required monthly hours before reaching 80 hours per month in mid-2020. Arkansas maintained a constant 80 hour threshold, but phased in by age group and region. During autumn 2018, about four out of five people who needed to actively report compliance (hours or exemption) either did not report or reported no hours at all. Interviews with enrollees point to poor state outreach and widespread confusion about what the requirements were and how to actually report. It is not clear how Indiana’s staggered phase in will resolve this reporting problem, especially given the evidence of ongoing confusion around preventive care incentives and health accounts in the so-called Healthy Indiana Plan (HIP). Moreover, changing the required monthly work hours every three to six months during rollout will likely exacerbate confusion.
Indiana’s reporting process itself may also lead to mass confusion and coverage loss. Unlike Arkansas, Indiana chose to postpone its compliance review to December each year. While this avoids the rolling monthly coverage loss reports that raised alarm bells in Arkansas, it greatly increases the chance of a massive suspension of benefits at year’s end. With no warning notices until November, expect tens of thousands of previously unaware enrollees to spend December scrambling to navigate a new reporting system, backdate their monthly reports, and recall when and where they worked since June. Those who fail to do so face coverage suspension for all of 2020. They will regain coverage only if they know to complete and report required work hours or exemptions in the following year. In Arkansas, fewer than one in four terminated enrollees had reenrolled as of mid-May, five months after their lockout period ended.
Certainly, Arkansas’ rollout was disastrous, but there is little evidence that Indiana’s will be substantially better. HIP will allow reporting by phone or computer. Arkansas began with internet-only reporting, and added a phone option in December. The phone option led to no measurable increase in reporting. Indiana’s approach also asks enrollees to submit separate reports for each day and each activity they complete, which is not user friendly.
One blog praises Indiana for its “clearly written” website introduction and criticizes Arkansas for providing notice written above the ninth grade level and for burying key information too far down the page, which “unnecessarily complicat[es] the letter’s message.” I compared Arkansas’ notice against Indiana’s web introduction using Microsoft Word’s reading level tool. Both registered a 9th grade level. This Indiana work requirement handout (reading grade level: 10.0) begins with the following:
Indiana is at the onset of a jobs explosion! In the next 10 years, we expect to need some 1 million workers to fill jobs.
After a full, laudatory paragraph on jobs, the handout introduces the work requirement. In a smaller font and not in bold-face. Specific hourly requirements appear at the bottom of the page.
Beyond reporting, we can expect other Indiana provisions to create compliance problems. Indiana’s work requirement cutoff is 60 years old. People over 50 are far more likely to experience barriers to work, often due to poor health or disabilities. A Kaiser Family Foundation analysis found 53,000 Hoosiers aged 50-64 with Medicaid who reported a disability but do not qualify for federal disability benefits (SSI). Many or most are enrolled in HIP, and understandably, few are employed. Only 13 percent work 20 or more hours per week. Subjecting even part of this group to work requirements will force thousands to seek medical exemptions or other relevant exemptions, a process that simply creates more red tape that will lead to more suspensions. Some who retired before 60 may have to return to work to keep coverage. Like most other work requirement states, Indiana has not significantly increased available supports to fund occupational training or help more individuals with disabilities (or other employment barriers) to find and maintain jobs.
Similarly, while other states have exempted any parent with a dependent child under 18, Indiana only exempts one parent per household with dependents under 7. Indiana’s design will increase pressure on low-income parents who often struggle to find affordable child care that fits often unstable or irregular work schedules. Acknowledging this concern, Indiana has proposed to raise its dependent cut-off age, but only to under 13, not 18. Thousands of parents would still be affected.
We could split hairs over reporting processes, outreach materials, or exemptions all day long. It’s not worth it. Taken together, any “differences” between Arkansas and Indiana do not point to a radically improved outcome this time around. The fundamental truth is that work requirements, no matter how you structure them, are legally suspect and cannot be fixed. Low-income families already have plenty of incentive to make a living without adding an illegitimate and ill-conceived Medicaid work requirement. They face multiple barriers to good, secure employment. Most work nonetheless, often in unstable, low-paying, thankless jobs. Medicaid, for its part, reduces some work barriers by helping people get and stay healthy. That’s its purpose. If Indiana officials want more people employed, they should get out of the way and let Medicaid do its job.