Aaron Wernham, MD, MSEditorial by Dr. Aaron Wernham, MTHF CEO
Starting this summer, health care will look very different for many Montanans. The federal government passed work requirements for Medicaid.
In Arkansas, where work requirements were piloted, thousands of people lost their health care coverage not because they weren’t eligible, but because of paperwork errors, mail sent to the wrong address, and deadlines people weren’t aware of.
Montana has the opportunity to soften the blow of this added step by making smart use of information the state already has to determine who is meeting the new requirements, and who is exempt from them. This is an opportunity to build an efficient, user-friendly enrollment system that keeps people from losing access to care unnecessarily.
When states redetermined Medicaid eligibility after the pandemic, Montana had one of the highest shares of people disenrolled — two-thirds lost coverage because of procedural reasons, not ineligibility.
This is a pivotal moment, especially for many Montanans navigating serious illnesses. Roughly 75,000 Montana adults are currently covered by Medicaid. An estimated 29,000 of them could lose coverage because of the looming work requirements: most of those people are working or exempt from work requirements.
Accessing health care is already complicated enough. It does not have to be this way if the state prepares well for implementing work requirements. Our new report outlines how.
First, Montana should use state wage and income data to automatically identify Medicaid enrollees who are meeting work requirements. Since there are people whose jobs don’t produce the same type of pay stub — such as workers driving for Uber, providing childcare, or delivering food — the state should also explore other data sources, such as the Work Number and consent-based data sources.
Montana can also establish automated systems to identify people who are exempt from work requirements. For example, by linking to other state and federal databases to identify people who are exempt because they’re enrolled in Temporary Assistance for Needy Families (TANF), the Supplemental Nutrition Assistance Program (SNAP), or veterans who are disabled.
Second, the state should carefully design a system that automatically exempts anyone who is “medically frail” from work requirements.
As a doctor who has treated many Medicaid patients, I worry about what’s at risk: Without a well-designed system, people in the midst of cancer treatment, insulin-dependent diabetics, people with advanced heart disease, people in recovery from substance use disorders, and many other Montanans with serious illnesses could suddenly lose access to life-saving care.
Montana can prevent this by developing a carefully designed, automated system that draws on Medicaid insurance claims and the state’s health information exchange to identify everyone who should be exempt from the new requirements.
Third, Montana can make enrollment and renewal forms as easy to understand, access, and fill out as possible. For new enrollees who are medically frail, the state can develop a simple, user-friendly self-screener to include in the application. A hard-to-read, hard-to-access form is an unacceptable reason why someone can’t go to the doctor when they are sick or hurt.
Fourth, the state can reinvest in front-line enrollment staff — particularly in rural areas and Native communities — and create more phone call-back slots for applicants that need help.
Fifth, the state can work with partners, including health care and social service providers around the state, to help design user-friendly forms and materials and make sure notices about the new policies reach everyone who needs to know.
Finally, frequent, public data updates to track coverage loss as Montana rolls out the new work requirements will help the state course-correct quickly if things don’t go as planned. Data can serve as a “canary in the coal mine” to warn the state about problematic patterns of people losing coverage and help us adjust on the fly.
This work for the state up front will keep more people from losing coverage and put less strain on our health care providers and hospitals, which impacts everyone regardless of what kind of insurance they have.
It’s up to Montana to design a system that makes sure as few people as possible fall through the cracks and lose care. Let’s show other states what’s possible.
