Alternative Headline: Medicaid Work Rules Add Hurdles
[MM Curator Summary]: New Medicaid work rules risk millions losing coverage, while Code for America pushes states to adopt simpler, human-centered systems to reduce reporting burdens.
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Terry Gerton I want to start by having you give us a little bit of background on Code for America, what you are and what you do.
Danny Mintz Sure, Code for America is a 501c3 non-profit civic technology organization. We work shoulder to shoulder with government to help government meet people’s needs more effectively in the digital age. In practice, what this means is that we try to make government programs more hassle-free to access and government agencies more efficient and effective at meeting their goals.
Terry Gerton Well, that hassle-free part is the next piece I want to talk to you about, because in the reconciliation bill that passed this summer, there was a tremendous addition of requirements for Medicaid and SNAP recipients to document their work, to add new work requirements. And I know Code for America has been working on that very kind of issue with a number of states. So can you tell us first what these additional work requirements mean for the recipients of these benefit programs, and how Code for America helps make that process easier?
Danny Mintz So the new community engagement requirements, as they were called in the bill that were introduced for Medicaid, impose very significant new policy and new operational hurdles up front for folks who are trying to access Medicaid to get their health coverage. In practice, what it says in the legislation is that folks need to be working at least 80 hours a [month] or meeting that requirement through volunteering, through participation in a work program. Or through being in school at least half time or more, or they need to earn at least $580 a month in income. While that sounds pretty cut and dry on paper, in practice what we’ve seen in our work in a wide variety of public benefit programs is that communicating that you are meeting these requirements or that you meet an exemption from these requirements can be very significant challenges for people who are trying to get or maintain their health coverage.
Terry Gerton So for an individual, what kinds of information do they have to provide, and how complicated is that process?
Danny Mintz You know, it can range from pretty easy and straightforward if they have a job situation where all their income is reported on a W-2 from a single source at the end of the year, to what is much more common among people who are participating in the low-wage labor market, which is conveying a wide variety of information about work that they’ve done as an Uber driver, as a driver for DoorDash, babysitting that they may be using to pay their bills, other sources of income for a three-month period that goes back before they applied for Medicaid. One huge change in this version of work reporting requirements from what we’ve seen in the past is that the approach that the bill took to Medicaid was to look back before the date of application. So for somebody who’s trying to get access to medical care, states have an option of looking back either one month or up to three months. That means if you lose your job, you better apply for Medicaid right away, because if you have lost health coverage because it’s no longer provided by your employer and then try to apply after two months or so, when you need to get a prescription refilled or need to go see the doctor for a checkup or some urgent issue, it’s going to be quite likely that folks will no longer qualify because of the very reason that they’ve lost their health coverage. CBO estimated that about 5.2 million people are likely to lose health coverage as a result of the new requirements in the law.
Terry Gerton I know that Code for America has worked with many states — California, Minnesota, Louisiana — to try to simplify the benefits application process. What sort of lessons have you learned from that work that could be especially applicable to this new requirement?
Danny Mintz It’s a great question, Terry. We’ve learned two key lessons. One is that there are a lot of improvements that can be made through automating data exchanges at the state level as much as possible and simplifying the mechanisms that people use to submit information to government agencies. We’ve also learned that there are real limits to what technology improvement can do. So we have a great deal of experience in trying to make government technology more human-centered. Easier for people to understand, less jargony, and easy for folks to use on a mobile phone with a limited-bandwidth connection from their homes in rural areas that have unreliable internet access. Not all government technology is set up to meet those needs as it is now, but even when government technology is set up for those needs, there are still very significant practical hurdles that people can encounter simply in understanding what the requirements are, gathering information to meet those requirements, and conveying that information effectively to the government. We saw in Arkansas in 2018 and 2019, when Medicaid work requirements were briefly implemented there, that a huge number of Medicaid participants lost coverage, despite the fact that they were likely already meeting the requirements in practice, because they didn’t know that they needed to separately report their income on a monthly basis and their participation on a monthly basis. We would anticipate that even with really significant and well thought-out efforts to inform the public about what these new requirements are and what they mean, that there are still going to be the same kind of challenges that people not covered by government programs may find when trying to interact with private insurance and understand all of the rules and regulations that cover their ability to access care.
Terry Gerton I’m speaking with Danny Mintz. He’s the associate director of safety net policy at Code for America. So Danny, let’s go back to that human-centered design for a minute. We’re going to assume that everybody who’s in state government that’s responsible for implementing these programs really wants to do it and do it well, so that people who are eligible for these benefits can receive them. What are the key points in terms of designing this kind of new reporting requirement so that it can be successful?
Danny Mintz It’s very important that governments, as they’re designing new systems, are testing those systems with the people who are going to be using them. And this is true both for members of the public who are going to be using systems to get and maintain their coverage, and for the workers who are using the information that’s submitted through these systems to process cases and ensure that medical coverage is still accessible to people who still qualify to receive it. We are strong advocates of working incrementally to put things into the field, test them, and improve on them. We know that government technology doesn’t always follow that pattern. We also know that states are facing very significant budgetary pressures in the near future and that there’ll be a strong impetus to get technology in the field as quickly as possible. We would advise states to try as much as possible to take the burden off of members of the public to report information that states might already be able to access from backend data sources. And this means not just using the sources that they have, that they’re very familiar with, but also looking into new opportunities to gather data from increasingly common forms of low wage and variable hour income, like gig work and other ones.
Terry Gerton So there’s a period before these new rules go into effect, presumably that’s to allow the federal agencies to write their regulations, but also to allow states to prepare to implement this. What should states be doing now to make sure that they’re ready when the timeframe begins?
Danny Mintz States should be looking closely at what capabilities they have in their systems and what the gaps are likely to be in terms of getting information, particularly about folks who might be exempt from these requirements. You know, SNAP has a long history of similar work requirements that have slightly different parameters, but what SNAP and Medicaid doesn’t is an interview. So in the SNAP program, states and county agencies have a chance to talk with people who are applying and really assess their situation. In Medicaid, states don’t have that option. And so states should be thinking really carefully about how their applications are structured, how they’re asking about information that’s going to be critical for people to supply in order to demonstrate either that they’re meeting these requirements or that they are exempt from them. And states should thinking about how they’re going to adjust their processes on the worker side to make it easier to flag potential areas for follow-up, to make sure that folks keep their health coverage, don’t start going into medical debt or overwhelming emergency rooms.
Terry Gerton I know as you’ve been working with states, you’ve probably been seeing a growing uptake of this concept of human-centered design and simplifying benefits. Do you think that these new rules around Medicaid and SNAP might be sort of the tipping point in terms of moving states sort of collectively towards a more empathetic and effective benefits application process?
Danny Mintz Well, I would hope so. I think in practice, some of the new policies in the reconciliation bill that passed this past year are going to make it a little bit harder for states to implement technology flexibly, because states will have fewer resources to do so. I think we do see a big shift in this new budget environment towards states trying to find efficiencies, do more with less, and human-centered design is a huge part of that. I think what remains to be seen is how states are going to be able to execute on those goals. It’s definitely the case that states are more aware of the need to provide services in ways that are empathetic and human-centered from the first interaction that a person has with government through to their whole case lifecycle. I think there are still structural challenges in place for how states can actually put that into practice.
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