Health care professionals and consumer advocates found it "very complicated" and "nearly impossible" to use a state website to report on Medicaid recipients' compliance with a work requirement that has since been struck down by a judge, according to a report released Thursday by a policy research organization.
"Described by key informants as 'clunky' at best, and 'horrible' at worst, the website was reportedly slow, confusing and not-user friendly," researchers with the Washington, D.C.-based Urban Institute wrote.
A spokeswoman for the Arkansas Department of Human Services said the site, which also can be used to apply for Medicaid and other benefits, is being redesigned.
"We are simplifying language, making the portal easier to use, and we are building in time for feedback from people who would use that site," Marci Manley said. "Our goal is for the site to be as easy as possible to use."
The work requirement, the first ever added by a state to its Medicaid program, resulted in 18,164 Arkansans losing coverage for noncompliance before U.S. District Judge James Boasberg of Washington, D.C., threw it out it in March.
The federal government and Arkansas have appealed Boasberg's ruling.
Another Urban Institute report, also released Thursday, found a similar lack of understanding among Arkansas food-stamp recipients about that program's work requirement, which remains in effect.
The institute "carries out economic and social policy research to 'open minds, shape decisions, and offer solutions,'" according to its website. Founded in 1968 by President Lyndon B. Johnson's administration, it describes itself as independent, but other sources frequently describe it as "liberal" or "center left."
In assessing the Arkansas Works website, the Urban Institute used interviews with enrollees and others in May to examine the implementation of the requirement that began in June 2018.
Those interviewed included 21 "key informants," including state officials, health care providers, health plan representatives, consumer advocates and policy researchers, according to the nonprofit.
The organization said it also conducted two focus groups with 29 Medicaid recipients in Little Rock.
In addition to difficulties using the website, many recipients said they didn't understand the work requirement or the notices about it that they received from the Human Services Department, researchers said.
Manley said in an email that the agency is reviewing "all notices and communications across the department to make sure we are using a client-centered approach."
"The goal is to make sure the information we send from our various programs is clear and tells the client the information they need to know, the actions they need to take, and where they can get help in a simple, direct way -- while complying with state and federal laws and regulations," she said.
To meet the work requirement, Medicaid recipients who didn't qualify for an exemption had to spend 80 hours a month on work or other approved activities, such as volunteering or looking for work, and report what they did by using the website.
The requirement applied to enrollees in Arkansas Works, which covers people who became eligible for Medicaid when the state expanded it in 2014 to cover people with incomes of up to 138% of the poverty level.
This year the income cutoff is $17,236 for an individual or $35,535 for a family of four. More than 246,000 people were enrolled in the program as of Sept. 1. Most enrollees receive the coverage through private plans, with the Medicaid program paying most or all of the premium.
Urban Institute researchers noted that the website's reporting portal was only operational from 7 a.m. to 9 p.m. and occasionally crashed, "which caused recipients attempting to report hours to either start over again when the site was back up and running or call the state by phone for help."
"Some beneficiaries, having never had an email account before, said they forgot their email addresses and passwords and would also have to call the state on the phone to get a new password."
Manley said site was meant to be user-friendly.
"We acknowledge that people may have different levels of experience and computer literacy, so engaging with the online portal may not have been the same experience for everyone," she said.
She added that the department made changes to the site in response to feedback from users and added options for enrollees to report work hours over the phone or through someone -- such as a friend or relative -- they designated as a "registered reporter."
In the report, the Urban Institute researchers said none of the focus group participants knew about the option to designate a "registered reporter."
Health care providers and health plan staff members also said they didn't receive any training on how to offer the assistance, according to the report.
Manley said the Human Services Department distributed information on the work requirement, including the option to serve as a registered reporter, to "a variety of stakeholders," including substance abuse treatment providers, pharmacists, health clinics, homeless shelters and others.
"Depending on the needs of the organization, group, or person, that outreach included in-person trainings, question-and-answer sessions, sending fact sheets and instructional materials, holding webinars, making presentations and doing direct outreach/calls/conversations," she said.
The department in August 2018 expanded its call center hours and in December added the option for enrollees to report their hours over the phone and simplified the process for full-time students to claim an exemption.
"However, information about these new options was conveyed to Arkansas Works enrollees by the routine mail and phone calls from the state, so key informants speculated they were not widely understood," Urban Institute researchers wrote.
Although state officials sought help from the University of Arkansas for Medical Sciences' health literacy team to improve the readability of letters and educational materials, that "effort seems to have been unsuccessful," institute researchers wrote.
"[K]ey stakeholders and beneficiaries universally raised concerns that the letters produced by DHS were still too dense and confusing," the researchers wrote. "One health care case manager described a letter from DHS as a 'blanket of words' that was 'very hard to understand.'
"Several other key informants, despite completing college and being highly literate, expressed that they found the information confusing and commented that they could certainly understand how enrollees might struggle with the materials."
Other states implementing Medicaid work requirements should consider performing more outreach to recipients, allowing more options for recipients to report their compliance, offering more exemptions and providing more assistance to help recipients find jobs, Arkansans interviewed for the Urban Institute's Medicaid report recommended.
A report in December by the San Francisco-based Kaiser Family Foundation, based on focus group interviews with 31 Arkansas Works enrollees, found a similar difficulty among enrollees in using the site and a lack of knowledge about the requirement.
Boasberg ruled on March 27 that President Donald Trump's administration exceeded its authority in approving work requirements in Arkansas and Kentucky by failing to consider how they would affect the Medicaid program's goal of providing health coverage to needy people.
In July, he threw out a work requirement that had been approved in New Hampshire for the same reasons.
A requirement that took effect in Indiana this year is also being challenged in a federal lawsuit.
Oral arguments in appeals of Boasberg's ruling in the Arkansas and Kentucky cases are set for Oct. 11.
According to the Kaiser Family Foundation, Arizona, Michigan, Ohio, Utah and Wisconsin have also received the White House's approval for work requirements but have not yet begun implementing them.
Metro on 10/04/2019