Health Navigator Perspectives on Implementation of Healthy Michigan Plan Work Requirements

This qualitative study describes perspectives of community health navigators about the work requirement policy of the Healthy Michigan Plan and experiences of Medicaid beneficiaries with the policy. Question What were the experiences of health navigators and Michigan Medicaid expansion beneficiaries with the Healthy Michigan Plan work requirement policy in 2020? Findings In this qualitative study of 50 health navigators in Michigan, respondents provided positive feedback about implementation of Medicaid work requirements, which used a human-centered design approach. Communication regarding the policy was viewed as improved compared with traditional Medicaid communications, and reporting systems appeared to be more user-friendly; the complexity of the policy and limited language options were barriers to compliance. Meaning The findings suggest that state agencies should seek to reduce administrative barriers and apply a human-centered design approach to alleviate risk of unnecessary loss of Medicaid benefits. Importance In 2020, Michigan Medicaid implemented a new work requirement policy for enrollees in the Healthy Michigan Plan (HMP), the state's expanded Medicaid program. Under the policy, enrollees would be required to report 80 hours of work or other qualifying activities each month or obtain an exemption to maintain health insurance coverage. Objective To assess the experiences of health navigators (and beneficiaries by proxy) with the implementation of Michigan's Medicaid work requirement. Design, Setting, and Participants This qualitative study included health navigators who participated in 11 focus groups from September to December 2020. Focus group questions addressed topics related to implementation and communication of the HMP work requirement policy. A survey was administered to capture background information, assess readiness to assist with navigation, and assess the quality of the state's communication about the policy. Main Outcomes and Measures The main outcomes were general understanding of policy components, communications about the policy, navigation of the exemption process, navigation of the reporting process, and beneficiaries' ability to comply with the policy. Results Of 50 health navigators who participated in the focus groups, 44 (88.0%) responded to the survey and 43 provided demographic information (mean [SD] age, 44.0 [10.5] years). All 43 had at least some college or vocational education, with 27 (62.8%) reporting a 4-year degree or higher, and they resided in geographic regions across Michigan. Navigators indicated that they felt prepared to assist HMP enrollees navigate work requirements. Communication to beneficiaries regarding the new policy was viewed as an improvement compared with traditional Medicaid communications. However, the complex policy was potentially difficult for beneficiaries to understand. Limited language options besides English created barriers for some enrollees. Exemptions were confusing for beneficiaries owing to the numerous categories and sometimes vague guidelines. Those who used the online reporting system generally found the platform to be user-friendly. Navigators expressed concern regarding HMP enrollees' ability to report compliance with work requirements owing to barriers with internet access, telephone access, language challenges, and computer literacy. Conclusions and Relevance In this qualitative analysis of health navigators in Michigan, respondents reported overall positive feedback about many of the implementation and communication strategies, including human-centered design, automatic exemptions, and use of state administrative data to assess whether beneficiaries were in compliance with the policy; however, barriers to reporting remained for enrollees. The findings suggest that state agencies should seek to reduce administrative barriers and apply a human-centered design approach to alleviate risk of unnecessary loss of Medicaid benefits.