Kellen Silver

Kellen Silver

Guest Contributor Kellen Silver is an undergraduate junior at Yale University, studying Global Affairs.

As of August 2018, eleven states have applied for federal approval to implement work requirements for Medicaid beneficiaries, according to the Henry J Kaiser Family Foundation. Proposals from four of these states, Kentucky, Arkansas, Indiana, and New Hampshire have been approved and are in various stages of implementation. Arkansas and Kentucky’s plans are in the most advanced stages, and both officially include a requirement that work or community engagement hours, such as volunteer service, must be reported online. It seems likely that other states will follow this example in an attempt to modernize Medicaid determination processes. However, in all four of these states with approved work requirements, at least one in five households do not have access to home internet service.

Without home internet service, individuals subject to work requirements would need to visit a public library or other community space to use a computer, introducing new barriers due to lack of transportation, scheduling difficulties, and limited time on shared computers. Kentucky’s Partnering to Advance Training and Health (PATH) program, the state’s proposed Medicaid work requirement, also included an integrated mobile app. While this can help to ease the strain on individuals who are complying with the requirements and have difficulty reporting them online, it does not rectify these difficulties for individuals subject to work requirements who are looking for work. This group faces traditional barriers to digital inclusion in the job market, such as difficulties in applying for jobs online, creating résumés, and networking with employers. The vast majority of job searchers use the internet to look for a job, 79% in 2015, creating a disadvantage for digitally unconnected individuals in the market. All of these factors make it more difficult for an individual in this situation to complete and report work requirements, creating an additional risk of losing Medicaid coverage.

Based on a report published by the Urban Institute in March, 63 percent of Kentucky Medicaid recipients who would have likely been required to comply with PATH requirements, over 200,000 people, do not have access to home broadband internet service. Of this 200,000, almost half are already working, which means they were at risk of losing their Medicaid benefits simply because they could not access the online PATH reporting system, even though they would have been completing their required hours.

In Arkansas, Medicaid work requirements have already been rolled out in a pilot phase, with a plan to introduce work requirements for larger and larger proportions of Medicaid beneficiaries over the next few years. According to the Washington Post, more than 4,300 Arkansas residents have already lost their Medicaid coverage since the pilot phase went into effect in the spring. Overall, Arkansas has the deepest digital divide of any of the states with approved work requirements, with 45 percent of households lacking access to home broadband internet service, according to the American Community Survey (ACS). In a May report, the Urban Institute estimates that almost 60,000 Arkansas Medicaid beneficiaries likely subject to work requirements do not have access to home broadband, 22,000 of whom are already working. Similarly to Kentucky, Arkansas’ work requirement compliance can only be verified through an online system, leaving tens of thousands of beneficiaries at risk of losing coverage due to lack of digital access.

While Indiana’s Healthy Indiana Plan (HIP) and New Hampshire’s Health Protection Plan (NHHHP) are still in their infancies, and seven other state proposals are still awaiting approval, most will probably follow Kentucky and Arkansas’ in incorporating an online reporting system. In the digital age, healthcare, especially state-sponsored healthcare, has become yet another sphere with which digital inclusion intersects.

One of the best ways to combat the digital divide is through low-cost internet plans offered by internet service providers. The eligibility requirements for many of the major low-cost internet plans, including AT&T Access, Spectrum Internet Assist, and Comcast Internet Essentials, are based on whether or not an individual in the household receives Supplemental Nutrition Assistance Program (SNAP) benefits or National School Lunch Program (NSLP) free or reduced-cost lunch. Both SNAP and NSLP recipients are officially exempt from work requirements under the Kentucky and Indiana Medicaid programs, and may be exempt in other states as well. In states with these exemption criteria, individuals subject to work requirements would most likely be ineligible for low-cost internet, rendering one of the most powerful digital inclusion tools powerless. As political trends swing toward supporting work requirements for Medicaid beneficiaries, digital inclusion should be at the forefront of the conversation, and finding new solutions for combating the digital divide to support those ineligible for low-cost internet should be prioritized.

Legislators need to pay attention to digital inclusion as a key part of any major policy decision. As government services move online, the needs of residents must be put first. The internet and digital tools have the power to make delivery of these services cheaper and more efficient, it can incur life-altering costs on digitally unconnected residents. Once everyone is connected, paper forms and redundant processes can become part of the past. Until then, we have work to do.

The Kentucky Helping to Engage and Achieve Long Term Health plan, Kentucky HEALTH, which contains the PATH requirement, was struck down in federal court on June 29, 2018. U.S. District Judge James E. Boasberg’s decision nullifies the program’s approval by the federal Department of Health and Human Services, and delays its implementation indefinitely. Judge Boasberg’s decision sets a legal precedent for opposing Medicaid work requirements in the future, leaving the fate of Kentucky’s work requirements, and those of other states, unclear. The decision does not mention digital inclusion.