States Race to Get the Word Out About New Medicaid Work Requirements

Dan Gorenstein (DG): Massive changes are coming to Medicaid over the next few months. 

Millions of people will need to take steps they’ve never taken before to keep their health insurance.

That’s why city and state officials, health insurers and advocates have begun to mobilize. 

Outreach Montage:  I’m canvassing, I’m door to door // To date we’ve given 82 presentations // 25,000 letters have gone out //  I mean, it’s literally been, like, we are reaching out to anybody that we can. 

DG: This is a moment when missing your mail could mean losing your health insurance. 

That’s why states are leveraging new-school technology and launching old-school boots-on-the-ground campaigns.

Jenny McGuigan Babcock: They’re not trying to sell a pair of shoes. They are trying to make sure that these patients who very much need to retain their care understand what’s happening with this.

DG: Today, as outreach efforts ramp up, we head to one operation in Camden, New Jersey and take stock of approaches unfolding across the country.

Colleen McCauley:  We have a lot of fricking work to do, you know, let’s go! 

DG: From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

*****

DG: About a dozen people trickle into an eighth floor conference room in downtown Camden. Philadelphia’s right across the river. 

There’s a woman here in her 20’s, a few middle-aged folks. Most people are older — lotta gray and white hair. One guy gets around with an oxygen tank.

They’ve all come to the Camden Coalition’s office to get trained over plates of pizza and fries.

Sheryl Mathis (SM): We’re gonna talk about who will be able to keep Medicaid coverage. When is all of this happening? What should we be telling family members, friends? 

DG: The Coalition is a nonprofit that’s worked with people who have complex medical and social needs for nearly 25 years. 

They’ve run over a dozen trainings since Republicans last year passed new restrictions on Medicaid.

In January, roughly 20 million people will start to face more eligibility checks and need to prove they’re working, volunteering, going to school – or exempt – to keep their coverage. 

States across the country are tapping health care groups like the Coalition because of their hard-won relationships.

CEO Kathleen Noonan.

Kathleen Noonan (KN): The state has turned to us to really go out and get to all of those groups that are like in between the cracks and basically say, “Do they know what’s happening?”

DG: The stakes are sky high. The Congressional Budget Office estimates some 7 million people could lose their coverage due to these and other changes to Medicaid.

That’s likely going to include a bunch of people who are still eligible. Harvard researcher Adrianna McIntyre says that will happen due to things like missing mail or making a paperwork mistake.

Adrianna McIntyre (AM): It’s one more ball to keep in the air, right? You’re just throwing another ball at families that are trying to juggle a dozen balls already.

DG: Back in 2018, Adrianna says, the state of Arkansas gave us a kind of preview of what’s ahead when it put similar work requirements into place.

Many people got automatically excused, but the rest needed to confirm they were working or had a valid exemption.

AM:  You didn’t have to prove it. You didn’t have to use pay stubs. You just had to check a box. And we still lost something like 80% of enrollment. 

DG: 80% — more than 18,000 people, most of whom were still eligible. 

Everybody knows this is going to be a heavy lift.

The good news: States have been here, or something close to here, before. Just a few years back, the feds lifted a pandemic-era freeze on eligibility checks. States had to suddenly start verifying if tens of millions of people still qualified for coverage. 

A big reason I wanted to come to Camden is because the Coalition is deploying some of the best practices learned from that time.

First up: Training trusted messengers.

On top of coaching up local doctors and nurses, the Coalition is prepping community members who have the ear of their friends and neighbors — people like 44-year-old Toya Walker, who I met at that training on the eighth floor back in September.

DG: And are you from Camden? 

Toya Walker (TW): Yes, I’m from the city of Camden, been here for 44 years and counting now, and I’m also raising my family in the city of Camden. 

DG: Toya’s plugged into the schools, where she’s a social worker helping families find food, housing, money to pay their utility bills.

She knows a lot of people living on the edge. Toya’s worried about what might soon happen to them.

TW: If I spoke to 10 people about the changes, maybe one person might know that it’s coming. I think we have a long way to go. 

DG: Knowing how much work there is to do, Toya is ready — even raring — to go.

TW: Just get the word out, just get it out. Like, I’ll shout it out.  Let me know that I’m about to lose insurance! 

DG: But Toya has not been able to get the word out — at least not yet.

She and thousands of other people in similar roles across America have been stuck waiting — waiting on lots and lots of details.

TW: Actual timeframes; what the reporting is gonna look like; is there a grace period? What exemption actually looks like because, you know, you say chronic illnesses, but what chronic illnesses?

DG: Federal health officials have been slow to clarify some of these new rules and that’s bogged down state efforts to pass clear messages along to partners on the ground.

It’s got Toya agitated. 

TW:  I need clarity. And I need clarity now because me having clarity means that I can inform the people in the community, and the parents, and the residents that I work with so that they can be well-informed. 

DG: The problem, of course, is there’s little time to waste.

At the training I attended in September, Sheryl Mathis sticks to simple actions that people can take right away.

SM: One of the most important things: encourage folks to open their mail. Check that junk mail pile, right? If you got it, don’t ignore it.

DG: When the training does veer into some of the details that are available, I get a glimpse of how hard it’s going to be for people like Toya. 

As trusted and as committed as these messengers are, they are not Medicaid experts.

One of the trainers, Victor Murray, answers a simple-sounding question: Does this work requirement apply to everybody?

Trainer: So it will not apply to everyone. There’s a term being thrown around called, like, medical frailty, right? And so if a person has a medical condition that doesn’t allow them to work, right? 

Trainee: So they’ll make them work from home, like if they can do something from home? 

Trainer: Well, no, so they will not have to go through that process at all. But the state has to define what are the guidelines, what are the definitions, so the state is doing that now.

DG: The interaction is equal parts unsatisfying and confusing, but it’s what the Coalition has to go on for now.

Toya leaves with a lot of questions, and at the same time, she knows she’s got to get out there.

About three and a half weeks later, Toya heads to her first event: manning a table at a meeting of local elementary school parents.

TW: I look at myself as being like a first responder. Without that information, you know, coming from a trusted source like myself, it’s like what’s gonna happen to the people?

DG: Part two of the Coalition’s playbook: Wisely use limited resources. 

Easy to say, harder to pull off.

The last time the Coalition faced an outreach push like this at the end of the pandemic, data chief Aaron Truchil says lots of people had lots of questions.

Aaron Truchil (AT): Upwards of 40% didn’t know that action was required to keep their coverage.  The needs were sometimes pretty basic, but also consequential. So how do I get back into my account? I’m locked out. Where is my renewal? What am I supposed to submit? 

DG: The Coalition has a contract with the state to reach close to one quarter of everyone in New Jersey who’s up for a Medicaid renewal. 

The small nonprofit only has four part-time staffers dedicated to this effort. 

To maximize time, they fire off texts, saving calls for households with multiple people on Medicaid or numbers that bounce those texts back. 

To further stretch their resources, the Coalition has tapped a data analytics firm to help them run real-time communication experiments. 

Erek Dyskant, a partner at Inroads, is leading the charge.

Erek Dyskant (ED): How much additional lift do they get, for example, by texting someone before you call or asking someone to opt in to a phone call before you call?

DG: Erek says those experiments could help boost response rates by two or three points. Do that a few times over and thousands more people could stay insured.

These experiments can also save precious staff time, for example, by figuring out who’s good with just a text. And that’s key since these new eligibility requirements aren’t a one-and-done deal — they’re going to keep happening every 6 months.

ED:  We want to do everything we can on day one. But also, we want to prepare for this being a marathon, and that means doing, you know, more randomized trials for what it is that really helps people to take action to remain covered. 

DG: Even with better data and the lessons from COVID, the team will be slammed.

The Coalition’s Marisol Caban says they know they’ll have to pull more staff in as things ramp up. A couple years back, that meant sending their chief financial officer knocking on doors.

Marisol Caban: It’s a scary-ass thing. It’s a scary-ass thought to think that so many people might lose their coverage. We’re gonna need all hands on deck for it, you know? That’s our community.

DG: The third and final piece of the Coalition’s playbook: Prepare for fallout.

Texts, phone calls, trusted messengers. They only get you so far, says Harvard’s Adrianna McIntyre. 

AM:  I just think that people should temper their expectations about how effective that’s going to be. There’s going to be a lot of confusion, and I think we’re kidding ourselves if we think we can completely fix that. 

DG: Adrianna goes back to that Arkansas experience. 

There was a ton of communication: 900,000 letters and emails from the state, radio ads, TV ads. And still, all those people lost coverage — many who were qualified. 

At the Coalition in Camden, CEO Kathleen Noonan expects tens of thousands people in their part of the state to lose their insurance. 

And the consequences for some of their sickest patients could be dire. 

KN: We know that when people avoid care, that, if they have chronic health conditions that aren’t treated, that they die. I mean, that’s just the reality.

DG: Given that risk, in collaboration with other nonprofits, the Coalition has started to knit together a net to catch the people who will, inevitably, fall through the gaps.

Drawing up lists of free clinics, helping enroll people in other types of insurance. It’s early, behind the scenes stuff, but Adrianna says most groups are still scrambling just to get the word out.

AM:  We’ve not devoted a lot of attention yet to what I might call the cleanup bucket. Providers need to start thinking about what they’re going to do when people show up for the appointment they made four months ago when they still had Medicaid.

DG: That kind of scenario is a version of what Jennifer, one of the Coalition’s trusted community messengers, found herself in this past summer. 

Jennifer had to cancel an important doctor’s visit after she abruptly lost her Medicaid.

Jennifer: I try not to think about it, ’cause then I don’t want the stress, you know, for the whole blood pressure thing. But like, it’s scary. 

DG: Jennifer asked us to only use her first name out of concern for her family’s privacy.

The 46-year-old mom of two lost her insurance over a paperwork error.

It’s exactly the kind of mix-up — a misunderstanding about the amount of money she makes driving for DoorDash — that more people will be vulnerable to as new requirements kick in.

Jennifer:  I’m one person, so can you imagine all the letters they’re sending out, all the documents they’re sending out, and then the people trying to send documents back in? Like, this is going to be overwhelming.  And then what’s gonna happen to the people who are getting cut off?

DG: When we meet in early September, Jennifer tells me she has called the state four times to clear up the error and get her Medicaid back. 

And each time, she’s been told she will get a call or a letter. Nothing, though, has come. 

The choices Jennifer’s facing offer a glimpse of what could be ahead for millions of people around the country.

She’s skipping blood pressure meds trying to stretch her prescriptions.

Jennifer:  I gotta figure out how am I gonna make 20 pills last for 30 days, basically. 

DG: She’s got a small tumor that an endocrinologist checks on every few months, but not lately.

Jennifer:  I had to cancel that appointment. I had another appointment for my regular doctor. I had to cancel that doctor’s appointment because I can’t afford a bill.

DG: Jennifer says she’s looking into a couple free clinics where she could get help. While she works on that, she thinks about her sister who died two years ago this December.

Jennifer:  They think she had a heart attack. And me not taking my blood pressure pills, it brings me to that. And for me, having to skip a day or two days, like I don’t want my kids to find me in my bed because I had a stroke or heart attack and I can’t get medical attention in time.  

DG: Kathleen with the Camden Coalition also worries about where all these newly uninsured folks will turn. 

Safety-net hospitals estimate that these Medicaid changes will push more than $100 billion worth of unpaid care onto their backs over the next decade.

At that weight, Kathleen knows the safety net will rip.

KN: I  think that there are people like me that are just holding out for some, you know…

DG: Some 11th hour fix?  

KN: Some 11th hour fix. I don’t know what we’re gonna see. Right now, to me, it depends on state government to really start to see the destruction that this is going to wreak on its communities and say, what are we going to do? Like, what kind of special measure are we going to take? 

DG: The Coalition and others are now lobbying New Jersey to use state money to fund care for people set to lose their Medicaid.

When we come back, we move from old-school outreach to the new-school technology states are using to keep people insured — and Jennifer hears back about her coverage.

BREAK

DG: Welcome back. For the second half of our show, we’re leaving the Garden State and going national. How else are folks around the country working to roll out these major changes to Medicaid? 

Let’s bring in senior reporter Leslie Walker, who has been following these efforts closely. 

Leslie, hello.

Leslie Walker (LW): Hello! 

DG: So, just of the gate here, I’m wondering how many other groups or states out there are following a playbook like the Camden Coalition? Is this what everyone is doing or are they more of an outlier?

LW: Yeah, so really tough question to answer. There’s not some master database out there of everything everyone is doing in every state right now.

But generally, experts agree that states know roughly what they need to do here. They need to train messengers, target outreach, and prepare for the fallout.

That’s a tall order, though, says Kinda Serafi with the consulting firm Manatt Health.

Kinda Serafi: State Medicaid budgets are extremely tight. I mean, it’s very hard to be able to do really important things, like really finding the time and resources to do trainings so that everybody understands the rules. I don’t want to say communications is a luxury item, but it does feel like it’s not always at the top of the list.

LW: Now, Congress did allocate $200 million to help states with this rollout and some states are using that for outreach-related work. But one expert also told me that money goes fast, given how much states have on their to-do lists.

Just this month, Dan, a handful of Democratic governors from states like Maine and New Mexico sent a letter to HHS pleading for more time to prepare. 

DG: So it’s clear at least some states are really feeling the crunch.

LW: Absolutely. 

DG: Given how squeezed some states are, Leslie, I’m wondering about the role of technology here. Like, how are states using tech to try to lighten this workload both for their own staff and all the people on the program?

LW: Yeah, that playbook boils down to four words: Automate everything you can. Harvard’s Adrianna McIntyre again.

AM: Automation is the ballgame even before you get to the point of communication. The best way to keep people covered is to ask as little of the enrollee as possible.

LW: Adrianna’s point, Dan, states are going to want to automatically prove as many people as possible are exempt or meeting these new requirements. That leaves fewer folks for groups like the Coalition to reach in these higher touch ways, like canvassing or calling.

DG: Yeah, in theory automation could help people from losing Medicaid unnecessarily and it could stretch those ‘extremely tight’ state budgets.

So Leslie, when it comes to automation, what are we actually talking about? AI?

LW: Some states have begun experimenting with AI. One survey from KFF showed at least six states are doing that, with a bunch more considering it. 

But even before this whole AI boom, some states had been getting better at scraping data — from people’s taxes, their wages — to automate these Medicaid renewals.

DG: Right, that was a big emphasis, I know, during that last wave of eligibility checks at the end of the pandemic. 

LW: Yeah, but progress here has been uneven. 

Nearly a dozen states still automate something like 35% or less of their Medicaid renewals. But more than a dozen automate over 65%.

To boost those rates, some states are asking people to share more data like about their employer or their income.

DG: Sounds like this could get pretty personal. I gotta imagine buy-in here is gonna be tough.

LW: Yes. I mean remember when we interviewed New York Medicaid director Amir Bassiri earlier this spring? Trust was his top concern at the time.

So I called his staff a few weeks ago to see how down people have been to share this data. Less than 10% of folks have opted in so far.

A similar pilot in Louisiana saw just 7% of people giving the OK.

DG: Leslie, you talked to Amir’s team. It’s early days, but what do they make of these anemic numbers as we get closer to crunch time?

LW: Jason Carey, who’s Amir’s chief marketing officer, told me he’s not all that surprised by where they’re at.

Jason Carey (JC):  I like to call this our direct deposit moment, because we’re really trying to change behavior. You know, it may take a little bit of time to get people to trust this new thing, but, like, once you’re on it, it’s great. 

LW: Jason was clear that his team is also investing in those old-school outreach strategies too. He called it this “high tech, high touch” combo.

But they see tech as this longer term investment in making Medicaid enrollment more efficient for the government and less burdensome on consumers.

Jason told me as soon as Republicans passed these reforms, his team saw this silver lining.

JC:  We had this get-together meeting, and everyone was like, “This is terrible.” And then we said, “Okay, like, this is a crisis. We cannot let it go to waste. How are we going to make this thing better for the future?”

DG: And that, Leslie, is also what Republicans have said they hope these reforms do.

Now, New York and other blue states might not agree with the way they’re getting to that goal, but this is something everyone’s hoping we end up with: Medicaid programs that are more efficiently, more effectively run. 

LW: I think that’s right. 

DG: Okay, so, just to kind of bring this all together for folks, we’ve got states both turning to tech and to partners on the ground. Everyone is facing some serious time and money constraints.

As we said earlier, the Congressional Budget Office has projected that 7 million people could lose coverage as a result of all these changes coming to Medicaid.

So the question I have, Leslie, is do the experts you talked to think the outreach and the tech are going to blunt some of those potential losses?

LW: Yeah, as you know, experts are never eager to break out the crystal balls for us. The clearest prediction I heard is that losses are going to vary a lot by state.

I mean, that’s what we saw at the end of the pandemic. In places like Oregon and California, less than 15% of people lost their Medicaid initially. In others, like Utah and Oklahoma, it was nearly 50%.

DG: Leslie, I’m wondering, did those folks ultimately make their way back to Medicaid? Basically, what should we expect in the longer run here after whatever initial shock we see? 

LW: So the research more broadly on Medicaid finds that about 1 in 5 folks return within 6 months after losing coverage.

Now, with these new rules, more people are going to be just flat out ineligible for Medicaid and others will face newer, tougher obstacles, like needing to prove they’re working. So it’s unclear to experts how many people are likely to find their way back to coverage. 

What we do know, Dan, is that time without insurance can be tough. After people lost Medicaid In Arkansas due to work requirements, more than half of them delayed care because they were worried about money. 

DG: Leslie Walker, thank you so much for your reporting on this story.

LW: Thank you, Dan.

DG: As for Jennifer in Camden, she got her Medicaid back this month. She can finally stop rationing her blood pressure medication. 

Jennifer:  It’s really scary not being able to take it. You could have a medical emergency, end up in the hospital. The stress of thinking that for that month that I didn’t have insurance is probably worse than the medical condition.

DG: Jennifer says she’s just glad this whole thing is over — at least for now.

I’m Dan Gorenstein. This is Tradeoffs.