Arkansas Lawyer on Medicaid Work Requirements: “Widespread Disaster & Chaos”

BIANNA GOLODRYGA, ANCHOR: Well, millions of Americans are at risk of losing their healthcare coverage, all because of President Trump’s domestic policy law, which mandates work requirements for Medicaid benefits nationwide.

 

A similar policy was implemented in Arkansas seven years ago. And having seen how damaging it can be on low-income and disabled residents, lawyer and founder of nonprofit TechTonic Justice, Kevin De Liban the case against the state in 2019 to overturn the rules. and he speaks to Hari Sreenivasan about his recent New York Times op-ed on this topic.

 

HARI SREENIVASAN: Bianna, thanks. Kevin De Liban, thanks so much for joining us. You wrote an op-ed recently called, “We Saw Medicaid Work Requirements Up Close. You Don’t Want this Chaos.” What is the relevance of Medicaid work requirements in Arkansas and how does that translate into what might and what likely will happen in the rest of the United States?

 

KEVIN DE LIBAN: Well, thank you so much, Hari. Back in 2018, Arkansas was the first state to ever implement work requirements for the Medicaid program. And what we saw is mass coverage losses of 18,000 people losing coverage in only five months of the work requirements with many more threatened if they had continued. We were able to put a stop to them through the court process and lawsuits. But now what’s happened in the reconciliation bill is the Republicans have mandated that every state implement these draconian cuts, which are gonna boot millions of people off of Medicaid, make them less healthy, cause chaos to their health systems and social services systems. And just end up in widespread disaster and chaos.

 

SREENIVASAN: Okay, so let, let’s assume the steelman defense for a second, for the other side. The people who wanted to propose this in Arkansas and are doing this for the rest of the country, their thinking, their best case thinking is, is, listen, we want to cut down fraud, waste, abuse. That’s the famous slogan. But they also, they say, look, we want to encourage people back to work. We don’t think that it’s onerous to say that if you are, you know, able bodied, that you should have to contribute something to our economy to be able to get some of these benefits. What’s wrong with that thinking or at least how it was implemented in Arkansas?

 

DE LIBAN: Well, first of all, 92% of Medicaid beneficiaries already work, have caregiving responsibilities, go to school or have disabilities. So there’s actually no problem here. The real fraud is that you would design a system to cut people off benefits in mass scales – we’re talking millions and millions of people – and force them to be less healthy so that they’re less able to work, less able to participate in community and less able to do the things that we all want out of a kind of a decent life. 

 

Now, there were studies done in Arkansas that showed that the work requirements, these penalties did nothing to actually increase employment. In fact, they were correlated with a decrease in employment. And that’s for obvious reasons, right? People need to be healthy in order to be able to work, right? Think about low wage workers. You think of gas station attendants, certified nursing assistants who work in nursing facilities or in people’s homes, restaurant servers, or dishwashers, or line cooks, landscapers, day laborers. All of these jobs require immense physical exertion, right? You have to be on your feet all day. You have to lift things and lift people. If you are not healthy, if you have untreated arthritis or a back sprain or an ankle or wrist problem, you’re not gonna be able to do this work. And so these penalties have it all backwards. If you have Medicaid, you can go get the treatment you need to be healthy so that you can work and otherwise kind of participate fully in community, in the life that we all want for ourselves.

 

SREENIVASAN: So, look, the supporters of these measures would say, I, I, I’m not trying to kick the people off who are legitimately there, but I just wanna document this, right? I mean, I’ve created websites where someone can go in and, and submit their proof of work. What’s so difficult? Why is the paperwork onerous? Have there been kind of studies that looked at the layer of bureaucracy and what that does in terms of kicking people off who deserve the care?

 

DE LIBAN: Yeah, basically you’re buried under avalanches of paperwork. So this is what happened in Arkansas, right? And these are disingenuous people offering disingenuous points. The way that people lose coverage is because they can’t end up complying with this in-navigable process to establish that you’re already doing what the program says you should continue to be eligible for which is work or volunteer or take care of other people or whatnot. And so, for example, in Arkansas, I was a legal aid attorney, so I helped hundreds of people, my team and I helped hundreds of people directly try to maintain their eligibility and thousands more through community education efforts. So first you don’t even necessarily know if you’re on the type of Medicaid that is subject to the work requirements, ‘cause In many states, Medicaid is not called Medicaid. It’s called something else. In Arkansas it was like Arkansas Choices, or Arkansas Home, or Arkansas Works, or various other names. So you don’t even know if this applies to you in the first place. 

 

If it does apply to you, you might get 10 page letters that are indecipherable, even to somebody like myself who’s a lawyer, right, and has practiced law – really hard to understand. If you try to call to get more information about what the letter’s actually saying or what you have to do, you’ll end up waiting on the phone oftentimes for hours. And even if you get through to somebody, they might not provide you relevant information that you need to comply. Then maybe you’ve done it right? Maybe you’ve gone through and completed the, the website and thought you did what you had to do to keep coverage. But no, that was only good for one month and you have to do it every month. Or you got an exemption that said you’re good for two months. But now you have to remember in the third month to go back and sign on. If you didn’t log in in the last 30 days, you’re locked out of your account automatically. And then you have to call somebody to go ahead and get permission, basically reset on their side so that you can enter the website again. 

 

In Arkansas’s case, the website closed every day at 9:00 PM. So you just have these floods of bureaucracy, of paperwork, of red tape that you have to jump through. And republicans very well know any proponent of work, of these penalties knows, that folks will not be able to jump through all the hoops and that they’ll get tripped up and that they’ll lose coverage. And that’s what justifies the cost savings, is it’s that you’re kicking people off coverage.

 

SREENIVASAN: You know, when somebody says, oh, 18,000 people in Arkansas, it sometimes becomes an abstraction. And in your op-ed, you wrote about an individual named Adrian McGonigal. Tell us a little bit about his story.

 

DE LIBAN: Yeah, so when we met Adrian, I think was in his late thirties, right around 40. He had just gotten his best ever paying job working at a poultry plant in northwest Arkansas. And it paid better than a lot of the low wage minimum wage jobs that he had had before. And he was working okay, and he reported his work requirement compliance as, as was required. Then suddenly he goes and he goes to the pharmacy and is told that he has to pay for his medicines for his chronic obstructive pulmonary disorder or COPD. The pharmacist – Adrian asked why I have Medicaid. The pharmacist said, no, you don’t, you’ve been cut off. So Adrian walked out that day without his COPD medications. Sure enough, his COPD, which he’d struggled with for many years, kicked in. He ended up in the hospital multiple times in a short timeframe.  The employer tried to accommodate him for what they could, but eventually he missed so much time that the employer had to let him go. He didn’t get his insurance back until we at Legal Aid of Arkansas stepped in and got it back. 

 

But by that time, it was too late. His job was lost, his health had worsened. And for the next several years, he would struggle amongst various minimum wage jobs, never, ever returning to kind of the level of, of income that he had under the job at the poultry plant. And very, very sadly, Adrian passed away last November. So this is just one example, Hari of the real life consequences of these penalties is Mr. McGonigal, Adrian was working, he was doing everything he should have been doing. He still lost coverage, he lost his health, he lost his job, and he was never able to recover or have any hope at a, you know, at a more economically prosperous life because of that coverage loss.

 

SREENIVASAN: What’s wrong with this kind of blanket, broad brush to, to sort of paint these people out to be, you know, moochers that are seeping off the system?

 

DE LIBAN: It’s really sad to me because I’ve worked with low income people my whole life. People are doing the best they can with what they’ve got. These myths and stereotypes that demonize poor people don’t account for the reality that almost everybody is working, taking care of family members, going to school, has a disability, and is really doing the best that they can with what they’ve got to, to eke out a meager existence. I can tell you Hari, the social safety net in the United States is meager. People don’t get cash benefits. People might get a little bit of money in food stamps, but you try feeding a family on 6 or $7 per day, right? People get Medicaid coverage that, again, is only useful to go get medical treatment that you need that allows you to continue working. So it is a very difficult precarious existence to be a low income person in America.

 

SREENIVASAN: And Kevin, tell me a little bit about the cost benefits here. Is the benefit of the, you know, kicking these people off Medicaid, is it worth the cost of setting up the infrastructure to try to do this in the first place?

 

DE LIBAN: So in Arkansas, I think the total was 24, 26 million spent. In Georgia, it was in the hundreds of millions estimates for how it was gonna be deployed in Kentucky was in the hundreds of millions. So yes, it’s gonna cost hundreds of millions of dollars for states to pay to private contractors.

 

And that to me is an abject failure of, you know, of, of morality, and it’s an abject failure of good policy, to your point about kind of the cost benefit analysis, there is no benefit to this. What you’re doing is you’re making people poorer, less employable. You’re making, you’re making it so that the employers in your state have a less reliable, less healthy workforce. You’re making it so that the hospitals in your state are more likely to close, especially if they’re in rural areas and absorb more uncompensated care. You’re overwhelming your state social services and you’re taxing your own state caseworkers, who oftentimes are devoted public servants, but working in very hard conditions. And so there really isn’t any material benefit to these programs other than cutting people off in this case to save money, to justify tax cuts for the richest, the richest Americans and buddies of, of, you know, the, the people who are proposing these laws.

 

SREENIVASAN: So I, I know that you and your colleagues filed suit against Arkansas and were able to successfully stop it there. And I wonder, I guess, what is the lesson learned from that for one, your clients, but also is this possible then in I guess 49 other states to do the same thing? Because this is a different process than what was instituted in Arkansas versus what’s coming through the reconciliation bill. Right?

 

DE LIBAN: Well, so what the reconciliation bill will do is mandate that all 50 states adopt provisions like what happened in Arkansas. So what you’ve got is a recipe for chaos, right? 50 states using 50 different systems and 50 different sets of rules. Because the way the bill is written is that there are few things that are mandated federally, but states – like the federal government will then interpret those things and then states will have some discretion within that. So yes, you’re gonna have 50 sets of rules and it’s going to be mass chaos. 

 

And what Arkansas did is probably kind of a run of the mill version of what most red states will do, or at least the best of what most red states can be accepted to do, expected to do. And so you’re gonna still get these mass coverage losses, right? 18,164 people lost coverage in only five months, right? Arkansas’s a state of 3 million. And so maybe there’s some context there. 

 

When you expand this to states like Texas, Florida, or bigger states, Kentucky, California, New York – whatever the state tries to do, even those states that really wanna minimize coverage losses, there’s no way, there’s no way to prevent eligible people from losing coverage, right? Just like Adrian and just like many of our other clients. And so what you’re gonna see is just coverage losses on massive scales, millions and millions of people. The congressional budget office estimated, I think it was close to seven or 8 million just as a result of these policies. Other estimates that take Arkansas as the baseline suggest many, many more. So that’s what you’re gonna see is Arkansas is a fair example of what’s to come. It’s an omen. And any state that is implementing these requirements is going to have to struggle through and end up cutting people off coverage that should still have it.

 

SREENIVASAN: So what’s the timeline for this? I mean, how fast are we likely to see people lose Medicaid coverage?

 

DE LIBAN: So the coverage losses won’t hit until after the midterm elections. And I think that was very intentional by the drafters of the bill. But what you’ll start seeing immediately is states having to make changes to their contracts with different kinds of government contractors and to their technology systems so that the infrastructure needed for these kind of penalties will be in place by the time that they go live, you know, a year and a half from now. So that’s some of the immediate changes you’re going to be seeing. And states I imagine are gonna spend, you know, tens of millions, hundreds of millions of dollars that are gonna go to, you know, private contractors to build systems that are gonna break and end up cutting people off of coverage in a relatively short period from now.

 

SREENIVASAN: You know, look, someone watching this they’re gonna quote the White House website, which I’ll say here, “as the president has said numerous times, there will be no cuts to Medicaid. You know, the one big beautiful removes illegal aliens and forces work requirements and protects Medicaid for the truly vulnerable.” Are these cuts?

 

DE LIBAN: Absolutely, these are cuts. Right? The only way that you get the kind of savings that is required by the reconciliation process is if you cut people from Medicaid. And all estimates are that the reconciliation bill is gonna cut up to kind of 17 million people out of kind of health insurance through Medicaid and the Affordable Care Act subsidy program. And so you’re gonna have more and more people be uninsured, more and more people getting treatment from emergency rooms, which is more costly, people being crushed under medical debt and all the, you know, adverse kind of consequences to society, whether it’s hospitals or social services or state workers or Medicaid providers or other people that just aren’t gonna be able to survive in this kind of new paradigm. So these are cuts, and they’re cuts all around.

 

SREENIVASAN: You know, I want to ask about another hat that you wear as the founder of Tectonic Justice. And it’s a, it’s a, a new undertaking to try to fight the impacts of artificial intelligence on low income communities. And just for our audience, kind of, what have you found so far in how AI is part of the decision making that could impact whether or not somebody qualifies for, whether it’s Medicaid or SNAP benefits or social security, or lots of other parts of the safety net?

 

DE LIBAN: Yeah, so first of all, AI is coming for all of us. And it’s being used by government agencies, landlords, employers, other people with power to make decisions about the core life areas of all of us, but particularly low income people. So where we work, how we live, how much rent we pay, what benefits we get, the nature of whether medical treatments are approved or not. All of these things are being decided right now by powerful people using AI. And all 92 million low income people in the US. That’s people kind of within eye shot of poverty –  200% of the federal poverty line – have some key aspect of their life decided by AI. Now, almost always, this ends up being harmful, right? People lose access to benefits, their housing opportunities become restricted, rents go up, job opportunities go down. And when you’re hurt by artificial intelligence based decision making, you really have nowhere to turn to help you kind of assert your rights.

 

And so, Techtonic Justice is an effort from various experiences I had as a legal aid attorney in Arkansas to recognize that this is a real threat to the wellbeing of all of us, but particularly low income people. And so that we start now devising strategies and investing resources into fighting back against these forms of injustice that are really tricky, that you don’t know that AI is being used. If you do know AI is being used, you don’t know how it works or why it works that way or how to fight back. And so Techtonic is meant to try to help us fight against this kind of impending threat to, you know, justice everywhere.

 

SREENIVASAN: Kevin De Liban, thanks so much for joining us.

 

DE LIBAN: Yeah, thank you so much for having me. Hari.