The voices of Urban Institute's researchers and staff
October 30, 2018

Under Medicaid work requirements, limited internet access in Arkansas may put coverage at risk

Four months after Arkansas implemented work requirements in its Medicaid program, state data indicate that 8,462 enrollees have been disenrolled due to noncompliance for three months of the year. These people will not be permitted to re-enroll until January of next year. An additional 4,841 enrollees have been noncompliant with Medicaid work requirements for two months and are at risk of disenrollment next month if they do not meet the requirements in October.

Arkansas’s program mandates monthly online reporting of completed work hours or other approved activities and of qualifying exemptions for enrollees who have not been previously identified as exempt or in compliance by the state. Enrollees can also report their hours over the phone or in person to “registered reporters,” people who have been granted permission to document work hours or qualifying exemptions online on behalf of enrollees.

Several insurance carriers have volunteered to make registered reporters available to help beneficiaries, and the state’s director of the Department of Health and Human Services has indicated that county offices will provide reporting assistance as well.

The state emphasizes an online portal as the primary means for Medicaid enrollees to report their completed work hours or qualifying exemptions, but our analysis finds that 18 percent of Arkansans lack internet access in their homes, including access through a cell phone. Internet access is especially limited among low-income households, Medicaid enrollees, and households in the southern regions of the state.

Relative to the rest of the nation, home internet access in Arkansas especially limited

Of the 16,757 enrollees who did not meet the work requirements in September, 16,535 (98.7 percent) reported no work or community engagement activities for the month.  There could be many reasons for enrollees not reporting their hours—they could be unaware of the new requirements, unable to complete work or work-related activities, or unable to successfully report fulfilled work activities or document qualifying exemptions online.  

Findings from interviews of 18 Medicaid enrollees in August in Craighead, Greene, and Randolph counties found that enrollees had low awareness of the work requirements program and that enrollees were concerned about using the online system due to not having a computer or a smart phone. No enrollees in these interviews were aware of the registered reporter option for reporting work or other qualifying community engagement hours.

Using Census data from the American Community Survey in 2016 (the most recent year available), we provide estimates of household internet access for all states. Eighteen percent of all Arkansans report no home internet access, including no access through a cell phone, the nation’s third highest rate (see figure below).

When we restrict our analysis to nonelderly, nondisabled adults between the ages of 19 and 49 in Arkansas – the age group that would be affected by Medicaid work requirements – we find that Arkansans living in the southwest and southeast regions have much lower internet access relative to the rest of the state (Table 1). The share of nonelderly adults with no home internet access is 20 percent in the southwest region and 25 percent in the southeast, more than double the 8 percent rate in the central region, where Little Rock is located.

map of Arkansas

 

table 1

Lack of internet access is a larger challenge for low income Arkansans and for current Medicaid enrollees (Table 2). About 1 in 5 adults ages 19 to 49 (20 percent) with incomes below 138 percent of the Federal Poverty Level (the income limit for Medicaid eligibility in Arkansas) report having no internet access in their homes.

Similarly, 20 percent of nondisabled, nonelderly Medicaid enrollees in that age range report having no internet access in their household. Region also makes a difference. In both the southwest and the southeast, more than 30 percent of Medicaid enrollees report no internet access (Table 1).  Those with no internet access are likely to face greater time and information burdens associated with complying with the work requirements.

table 2

Many Medicaid enrollees in Arkansas rely on cell phones for internet access, which raises additional concerns

Because Medicaid enrollees who were interviewed expressed concern about reporting hours using their cell phone, we also assess the types of connections people have in their homes. We classify people with internet access into three groups: those without paid subscriptions to the internet (whose connection types are not identified in the survey), those with internet access only through their cellphone, and those with broadband, dial-up, satellite, or other connections.

About 1 in 5 nondisabled Arkansan Medicaid enrollees and low-income Arkansans ages 19 to 49 have internet access solely through their cellphones.

Forty-two percent of nonelderly, nondisabled Medicaid enrollees in Arkansas ages 19 to 49 report either not having any internet access in their household or having only cell phone access. Beyond the barriers people without internet access face, those with exclusive cell phone access may also experience reporting problems given concerns that have been raised that the online portal is not mobile friendly and is difficult to access on cell phones.

Further, many of the state’s qualifying community-engagement opportunities (e.g.  training and volunteering opportunities) are posted and updated online only which may make it more difficult for these beneficiaries to learn about them. 

To report hours through the online portal, enrollees without home internet access may be required to use computers available at public sites such as a library. The state has posted information on locations of available computers and has determined that 92 percent of enrollees live within 10 miles of a public access site, but travel to such a site may create an additional barrier to successful reporting.

In a previous analysis of Medicaid enrollees likely affected by work requirements in Arkansas, we estimated that between 5 and 8 percent of affected enrollees had no access to a vehicle in their households.

While accessing the online portal is one hurdle for Medicaid enrollees, the ability to navigate the online portal system presents other challenges. The online portal requires that enrollees register their email accounts and link their insurance coverage to the site. Reporting work activities each month requires at least 13 steps, and documenting exemptions requires at least 11 steps.

The intended goal of Arkansas Medicaid work requirements is to promote “self-sufficiency and economic security” among its beneficiaries. But the loss of coverage due to lack of internet access in the household, exclusive reliance on a cell phone, or challenges navigating the multiple online reporting steps could undermine those goals.

Photo by Nong Mars/Shutterstock.

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