How States Can Incorporate Human-Centered Design in Medicaid Work Reporting Requirement Systems
Jamila McLean spoke with The 80 Million about how states can center people in implementing Medicaid work reporting requirements.
Author: Amanda Eisenberg
Editors: Patti Boozang and Kinda Serafi
tl;dr
Medicaid work reporting requirements are coming in 2027, and states have the next year to get their systems in order. It’s an uphill battle: They face major implementation challenges, especially in designing systems that are accessible and equitable for all users.
A human-centered approach is essential: States should prioritize user experiences, flexible technology and diverse communication strategies — pairing digital tools with in-person support and community partnerships to reach vulnerable populations.
States must design systems that can easily adjust to policy changes and implement lessons learned while also integrating new, ongoing data sources that will reduce administrative burdens and prevent coverage losses.
The 80 Million Impact
Newly minted Centers for Medicare & Medicaid Services (CMS) Deputy Administrator Dan Brillman, who prior to his government role was co-founder and CEO of health tech company Unite Us, said in 2021 that “when we talk about transforming the health care delivery ecosystem, we should stay core to our mission and vision. This can only be possible by providing the best technology and solutions that improve health across communities.”
Jamila McLean couldn’t agree more.
As states and Washington, D.C., embark on building technologies to track and verify Medicaid work reporting requirements, they should think about the end user experience — which will vary depending on their health status, the type of work they’re doing, their support system and other factors. A seasonal worker with an inconsistent work schedule will have different challenges demonstrating their eligibility than an unsheltered person without access to a smartphone or a mailing address to receive notices. States need to prepare for these challenges and think creatively about how they will purchase or develop the technology to verify eligibility, including for those who should be exempt from the work requirement, along with how they communicate with these different populations. work requirement, along with how they communicate with these different populations.
McLean, who serves as the health equity director at the Robert Wood Johnson Foundation-funded State Health and Value Strategies (SHVS) program, sat down with The 80 Million for an interview on how states can consider adding that extra human touch to Medicaid work reporting requirement systems and communications:
The 80 Million: How do you think about human-centered approaches to policy implementation, particularly for Medicaid work reporting requirements?
Jamila McLean: The human-centered approach focuses on how systems work in reality rather than conceptually. It considers how people actually interact with platforms, including both average users and those on the margins who may have unique challenges that are often forgotten. For Medicaid work reporting requirements, it means understanding the reality of how people use data and technology to report their work activities or to raise their hand to say that they are someone who should be exempt from those requirements.
80M: We hear that states are inundated with technology vendors claiming to have solutions that will make implementing these new requirements easier for states and people. What’s your advice for states evaluating these solutions?
JM: As I wrote about recently for SHVS, there is a huge opportunity to mitigate coverage losses for eligible Medicaid enrollees by using technology and data solutions — but those solutions have to be well-designed for users, whether applicants, enrollees or agency staff. I share some key principles that states can consider as they evaluate vendor solutions, things like probing how a vendor has developed and maintains their solution to mitigate bias and whether and how solutions have been tested and validated by real people.
80M: We spoke with one Medicaid expansion enrollee who struggled to prove her eligibility in a state that already has these requirements, even though she provided paperwork to the state proving she did 80 hours of community service. Is this a state tech problem, a staffing problem, or both?
JM: It’s definitely a mix of both. States have different eligibility platforms and enrollment processes that vary by state and enrollee type. The specific challenge with Medicaid work reporting requirements is that compliance activities include a range of activities (employment, community service, education) and, with the exception of employment, such information is not yet able to be verified using data sources. The entire ecosystem isn’t set up today to share this diverse information, creating complications both technologically and for staff training. In her case it sounds like the data wasn’t there, and she had to provide paper proof. Things went downhill from there.
80M: How do you balance the push toward technology solutions with the reality that many low-income people don’t have smartphones or broadband access? A new pilot found that texting Medicaid enrollees wasn’t as effective as maybe the administration would like to believe.
JM: Technology offers opportunities, but it can’t be the only solution. Many people don’t have smartphones or laptops, and even text messaging can be challenging due to message length and costs. Medicaid statute requires states to maintain in-person, mail, online, and phone assistance options, and these will be essential pathways for people trying to respond to this new requirement. So will investing in navigators and support systems that don’t rely solely on technology.
States can also leverage the full spectrum of communications to let people know what they need to do and how when this new requirement starts, rather than relying on a single approach. While some people are tech-savvy, others lack access to technology or live in areas with limited internet. States should examine what worked during the Medicaid unwinding process.
80M: Which populations are you most concerned about falling through the cracks with work reporting requirements?
JM: Several groups and communities that have been historically disadvantaged by systemic barriers are at high risk:
Homeless or housing unstable individuals who can’t receive mail notifications and may lack consistent internet access.
Rural communities with broadband issues.
Seasonal or gig economy workers with fluctuating incomes who may meet requirements one month but not the next.
People volunteering at small local organizations where hours may be difficult to verify.
Communities of color who are disproportionately represented in the gig economy.
Mixed-status households where some members have reporting requirements while others don’t.
80M: Do you see equity issues arising as states implement this new requirement?
JM: Absolutely. Stakeholder advocacy is crucial to head off potential equity issues and address them when they do arise and states should engage with stakeholders early and consistently throughout this process to prevent inequitable process from being built into the system. For example, being “medically frail” exempts an individual from having to meet the new work requirement and states have some flexibility in defining what makes an individual medically frail. If a condition like sickle cell anemia, which predominantly affects Black Americans, isn’t included in state medical frailty definitions that could lead to a disproportionate impact for Black individuals..
80M: Any final advice for state Medicaid directors implementing these requirements?
JM: States should design their data and technology systems to allow work requirement policies to be changes or toggled on or off as policies change, they learn through implementation experience, or during emergencies like pandemics. It will be problematic if work requirement technology systems can’t be easily modified when needed.
The Bottom Line
States can act decisively to ensure Medicaid work reporting requirements do not become another barrier to coverage for eligible people, including in their policy decisions, technology procurement, and implementation design. Early and ongoing engagement with people subject to the requirements — gig and seasonal workers, people who may require exemptions, rural residents, and those without reliable internet — is essential to understand the real-world impact of systems and processes. Flexibility is key as states build technology and data infrastructure, so requirements can be quickly adapted as experience requires, laws evolve, and unforeseen emergencies occur. Technology is also not enough. Robust in-person assistance, call centers and partnerships with trusted community organizations are critical to reach those at risk of losing coverage.
The stakes are high: Only by prioritizing human-centered design, adaptability and user experience can states build Medicaid systems that truly serve all eligible residents.