Medicaid work requirements like Kentucky’s are fundamentally flawed and “can’t be fixed,” according to a report released this week by a research group in Washington, D.C.

The report from the Center on Budget and Policy Priorities highlights the complexities involved with such programs, including Kentucky’s section 1115 waiver, Kentucky HEALTH.

With these programs, “the rules themselves on who is exempt, how long exemptions last, when someone may have good cause not to comply in a particular month, how to claim good cause or an exemption and what activities count are complicated and difficult to understand,” said Judith Solomon, a senior fellow of the center.

Solomon, who wrote the report, also notes that people who are eligible for Medicaid tend to work in places, such as restaurants, retail and construction, that have “volatile hours and little flexibility,” making it difficult to meet the required hours, even while employed.

Judith Solomon, senior fellow of the Center on Budget and Policy Priorities | Courtesy of the center

“Think of a woman, for example, working in retail who doesn’t have paid sick leave, gets sick and can’t meet the monthly requirement,” Solomon said in a media call. Or “someone between jobs who needs to hold onto his coverage to successfully find new employment.”

Kentucky received the green light in November to proceed with Kentucky HEALTH after a legal challenge by more than a dozen Medicaid recipients, who said the program would jeopardize the health coverage of tens of thousands of Kentuckians. An early estimate from the state predicted that 95,000 people may come off the Medicaid rolls in the first five years.

Starting in April, the state of Kentucky is set to implement an 80-hour-a-month work requirement that will be phased in by county or region. Eligible adults, ages 19-64, will have to complete about 20 hours a week of work or “community engagement,” such as volunteering or job training, and report their progress to the state.

The Kentucky HEALTH program, which also includes premiums, a My Rewards account and other features, was to start last July but was sidetracked by a judge’s ruling that sent it back to the federal government for further review.

Meanwhile, Arkansas began implementing its program in June and had dropped nearly 17,000 people from the Medicaid rolls as of early December because of the individuals’ failure to comply with the work rule for three months.

“Other states that implement work requirements will see the same unintended consequences as Arkansas is experiencing,” Solomon contends in the report. “After evaluating the initial data from Arkansas, the nonpartisan Medicaid and CHIP Payment and Access Commission recommended that the administration immediately pause on allowing any more people to lose coverage in Arkansas as well as on approving work requirements in other states. Both the Trump administration and state policymakers should heed that recommendation.”

Last fall, a spokesman for the Kentucky Cabinet for Health and Family Services disputed that the state would become the next Arkansas and told Insider that the state has made extensive preparations toward getting its Kentucky HEALTH program up and running.

Much of the attention on Arkansas’ shedding of beneficiaries has focused on the difficulty of reporting hours online, giving the impression that employment requirements would work if states made it easier for people to report their hours, Solomon said in the call.

However, “the fact is work requirements can’t be fixed,” she said. The extent and speed of coverage loss may vary from state to state, “but every state work requirement will have the unintended consequence of taking coverage away from people who are already working or who should be exempt based on disability or other reason.”

That’s partly because “increased paperwork and red tape are unavoidable in implementation of work requirements,” Solomon said. “And they are certain to have the unintended consequences of causing eligible people to lose coverage.”

People with disabilities are particularly vulnerable, Solomon said, because they may not be able to obtain proof that they can’t work and should be exempt.

Also, people with mental illnesses are unlikely to be able to navigate the complex requirements, and homeless people may not receive adequate information, Solomon said. Still others “may struggle to balance work and caring for their families with meeting complex documentation requirements” by state deadlines.

Solomon’s report notes that there has been low awareness and understanding of the work requirements among beneficiaries in Arkansas despite outreach efforts.

Kentucky holds monthly stakeholder forums on Kentucky HEALTH that are staged in various parts of the state and live-streamed on Facebook. It also has a website with background on the program. But that doesn’t necessarily mean that “people who should remain eligible aren’t going to end up having their coverage taken away,” Solomon said, noting that notices to beneficiaries can be hard to understand.

Emily Beauregard

Emily Beauregard, executive director of Kentucky Voices for Health, said she is concerned about what’s happening in Arkansas.

“What’s happening in Arkansas should be viewed as a flashing red warning signal to Kentucky,” she said in a news release. “Working Arkansans are losing their coverage because the reporting requirement is too onerous and disabled adults aren’t being protected. It would be irresponsible to move forward with implementing the same requirements and penalties in Kentucky when we know that it will lead to tremendous coverage losses.”

Although Arkansas was the first to implement its Medicaid work requirement, other states have approval, including Indiana, Maine, Michigan, New Hampshire and Wisconsin, according to the center.

“Making timely reports every month and documenting hours or exemptions will be challenging for beneficiaries in all states with a work requirement even if beneficiaries can report by phone (which Arkansas beneficiaries can now do as of late December) or in person,” the report says.


Darla Carter is a hometown girl who recently joined the staff of Insider Louisville to mostly cover health. She previously served as a longtime health and fitness writer for The Courier-Journal, where she also worked for the Metro, Neighborhoods and Features departments. Prior to that, the award-winning journalist wrote for newspapers elsewhere in Kentucky and Tennessee, covering a range of topics, from education to courts. She's a graduate of Western Kentucky University, where she studied journalism and philosophy, and is the proud mom of two young children.


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