The Washington PostDemocracy Dies in Darkness

A job-scarce town struggles with Arkansas’s first-in-nation Medicaid work rules

Mike Rogers spins doughnuts on his four-wheeler in an empty lot next to a shuttered grain operation in Marianna, Ark. He works for a federal prison north of town, saying he appreciates the health insurance coverage. (Michael S. Williamson/The Washington Post)
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Marianna, ARK. — At the center of Court Square in this old Mississippi Delta town, the monument to the county’s Confederate dead is inscribed: “No braver bled for a brighter land. No brighter land had a cause so grand.”

It has been a long time since Marianna or surrounding Lee County could be described as bright. Along the square, a storefront funeral home sits empty, along with two former drugstores, a department store, a jeweler, a barber. Gone, too, is Ronny’s dollar store, which let customers buy clothes on layaway. The National Guard Armory closed down and became a senior center, until that also closed.

This community — scarce on jobs and among the poorest in a poor state — provides an early reality check on how hard it is to carry out President Trump’s vision of a social safety net that requires most able-bodied people to work, or try to work, in exchange for government health benefits. Nearly 10 months ago, Arkansas became the first place in the nation to impose work requirements on the part of Medicaid that expanded under the Affordable Care Act. Seven other states have won the Trump administration’s blessing to begin the same idea soon, and seven more are waiting in line.

The president and Republican governors contend that this abrupt turn in Medicaid, one of the most enduring legacies of the Great Society of the 1960s, will propel poor people to economic self-reliance. In Arkansas, however, 18,000 people so far have lost their insurance, including 85 here in Lee County, state figures show.

The view from this Delta town is that confusion about the program is rampant, and people scoff at the idea that jobs are waiting for those willing to work.

“I am a big fan of work and people working,” said Rep. Reginald Murdock (D), a veteran state legislator from Marianna. But with jobs so scarce here, even at a time of low unemployment statewide, “threatening people with their insurance wasn’t a proper way to do it.”

On Wednesday afternoon, a federal judge in Washington threw a significant roadblock into Arkansas’ program, issuing an opinion saying the rules “cannot stand,” and in a separate decision, rejecting the start of a similar program in Kentucky for the second time— decisions likely to have ripple effects on states with similar aspirations. The same jurist, U.S. District Judge James Boasberg, had delayed Kentucky’s imposition of work requirements last summer, ruling that Trump’s health aides had inadequately considered the effects on people needing insurance.

The twin opinions cast doubt on the Trump administration’s re-envisioning of the public insurance program, telling federal health officials they must reconsider the two states’ applications with an eye towards the effect on poor people who depend on such coverage.

The Trump administration is calling Medicaid work requirements a positive "incentive" for beneficiaries, but critics say they're a harmful double standard. (Video: Jenny Starrs/The Washington Post, Photo: Rogelio V. Solis/The Washington Post)

Both Arkansas Gov. Asa Hutchinson (R) and U.S. Health and Human Services Secretary Alex Azar had suggested the Arkansas program was helping people become more independent, contending most of the people who lost benefits have found steady work. But the state lacks data so far to back that up.

“What the state is doing is kicking tens of thousands of people off health care, under the guise of an experiment that they aren’t even collecting any data about, let alone analyzing it,” said Kevin De Liban, a Legal Aid lawyer in northeast Arkansas who is active in the federal lawsuit against the program.

Some of the people who lost their health-care coverage had failed for three months to perform the required 80 hours per month at a job or other “community engagement” activities, monthly state reports show. More failed to correctly report they were following the rules.

For now, the evidence is sketchy as to whether the work requirements are motivating people to find jobs with pay and benefits to wean them off public insurance.

From the program’s start last June through last week, more than 11,000 people on Arkansas Works, as the expanded Medicaid program is known, got new jobs, according to state figures. But the state does not know whether these jobs went to people cycling in and out of work — common in poor, job-scarce areas— or whether the requirements motivated them to find work. Nor is there data showing whether these new jobs come with better wages or health benefits.

Evidence is scanty, too, of whether the requirements are leading people to get help in training for a job or searching for one.

The number of recipients actually submitting required monthly reports about job searches, work hours and other activities is small. Last month, just 88 Arkansans in the program reported taking part in education and training, while 155 reported getting state help with a job search. According to state workforce figures, just four people in Lee County have sought such help.

Gillespie, the DHS director, acknowledged that as the nation’s first such program, Arkansas Works will need fine-tuning. The state is preparing to contract for two evaluations in the next few months.

But already it is clear that some are being harmed.

Elizabeth Cloinger, 47, who lives in a trailer next to her cousin’s house just outside town, thought she was complying with the new rules. She has been on Medicaid for years and already had a job, working seven days most weeks as a home health aide. Her wages — 9.25 an hour, with 50 cents more for hospice patients — and her hours met the new rules. Yet she received a June letter saying she needed to verify that her income made her eligible, or she would be cut off.

She called the listed phone number and faxed information to a state employee in Pine Bluff. She was told that, like many people, she was exempt from the work requirements — in her case, because she was caring for her 20-year-old daughter recovering from a car accident and her 3-year-old granddaughter.

But on Aug. 18, she received another letter, saying she had been terminated because she had not verified her income. In December, four letters arrived saying she needed to update her email address, then 11 more in January. Each letter told her to create an online account. She doesn’t have a computer and didn’t realize that the program requires everyone to get an email address.

This winter, she applied to get her insurance back and is still waiting for an answer. Statewide, about 1,900 of the 18,000 people cut off last year have regained coverage since January, when they could reapply. The state does not keep track of how many reapplied and were denied.

In all these months, Cloinger hasn’t seen a doctor for the swelling in her right foot, which makes it hard to stand for long. Nor has she addressed the throbbing around the scar from her hysterectomy two years ago.

“I won’t go” to the doctor, she said, having just finally paid off — in $10 monthly installments — a hospital bill for the X-rays she needed for a torn tendon before she got onto Medicaid.

“I am just putting it in God’s hands,” Cloinger said. “He is going to let me stay on this Earth to see my grandbaby be raised.”

The kind of life on the edge that she leads is common here in Marianna, which has essentially been on a long slide ever since it grew up along the L’Anguille River, a Mississippi tributary, as a regional shipping hub. This early spring, the river is swollen from winter rains. The town’s population, 4,115, is lower than a century ago.

Of Arkansas’ 75 counties, Lee ranks 73rd in life quality, according to the national County Health Rankings project. Computers are so scarce that even the public library has a sign out front saying it does “not offer the Internet” — a problem for the work requirement’s first several months, when people could not yet phone in their monthly reports.

For now, some people on Arkansas Works are confused — because of both a lack of understanding about what rules apply to them and contradictory information from the state.

Murdock, the legislator, and leaders of a historic health clinic in town anticipated those problems — and knew the lifeline to health care that insurance brings. The Lee County Community Clinic has been here since 1969, when VISTA volunteers overcame the resistance of white residents opposed in those days to black and white patients being treated by the same nurses and doctors.

Last summer, a month before the first people were cut off from Arkansas Works, Murdock and clinic leaders teamed up on a workshop about the new requirements. They handed out fliers at barber shops and public housing complexes, ran radio ads, and got a donation of finger sandwiches for the 150 people, at least, they expected to show up. They set the time for the hour between when those with a job got off work and when many went to church on Wednesday night.

Yet when the evening arrived, only one family showed up — and they came mistakenly thinking they might get help finding work. Melissa Buford, who works at the clinic helping people sign up for insurance and doing community health work, thinks people didn’t understand that the rules apply to them.

Murdock kept trying to spread the word at churches and barber shops. Buford got a kiosk put inside the clinic to help people do their monthly reporting in a county where just 45 percent of homes have Internet access. Of the patients she offered to help, one man has taken her up on it.

In such a poor Delta town, she now believes, “to make job search a requirement, that is just wrong, because the jobs are not here.”

Even her 31-year-old daughter, Conisha Gatewood, got caught up in the confusion. Living in Forrest City, just north of here, Gatewood was a clinic patient until she was referred to an obstetrician-gynecologist for nonstop menstrual bleeding caused by ovarian cysts. But when she arrived for a September checkup, she was told she no longer had insurance. “I was like: ‘Yes, I do. They sent me the papers in June.’ ”

She thought she had done everything right, creating a password and an online account. The state had used an automated system to fill in her child-care job and work hours. A letter from the state confirmed that, she thought, telling her she did not need to search for a job because she already worked. But then another letter came, telling her she needed to do a job search after all.

“I was so confused,” Gatewood said. “I already had a job. No one could tell me what I needed to do.”

By the time she was cut off, she had found a better-paying position, selling cellphones inside a Walmart. In January, she reapplied to Arkansas Works — and was rejected because her December phone sales, high for the holidays, put her just over the income limit.

She should go to her doctor this month, but she hasn’t made an appointment. She has also stopped filling prescriptions, including for the birth control pills that correct her bleeding.

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