By Abigail Abrams
March 29, 2019

After Casey Copeland got sober, he started turning his life around. The 37-year-old Arkansas resident began volunteering at homelessness and addiction recovery organizations near Little Rock to gain experience to become a drug and alcohol counselor. And he signed up for Medicaid.

“When you get hooked on drugs like I did, you lose everything,” Copeland says. “But now that you’ve got [Medicaid] you can go take care of yourself, and if there’s something wrong with you, it can be caught earlier because you’re more willing to go to the doctor.”

But in late January, Copeland unexpectedly received a letter saying his health insurance was canceled. The reason? He had failed to properly document the hours he spent volunteering and searching for work in January. Under an Arkansas policy approved by the Trump Administration, he would be cut off from the state-and-federal health insurance program for a year.

Earlier this week, a federal judge struck down the Arkansas requirements, along with a similar program in Kentucky. But the push to add work requirements to Medicaid isn’t going away. The judge, an Obama appointee, ruled only that the Department of Health and Human Services had been too hasty in its approval, a procedural problem that could be fixed. And the Trump Administration has vowed to push ahead, with at least six states waiting to get the OK for similar requirements.

If successful, the proposals would be the most consequential changes to Medicaid in years, turning what has historically been considered a safety net for the poorest Americans into a more selective and limited program in certain states.

Conservative supporters of the changes argue that they will help push the unemployed toward self-sufficiency by requiring that they work, volunteer, attend school or search for a job for a certain number of hours each month in order to continue receiving health care benefits. The logic was memorably summed up by former Speaker Paul Ryan when he proposed similar changes to food stamps and housing assistance in 2012: “We don’t want to turn the safety net into a hammock that lulls able-bodied people to lives of dependency and complacency.”

But it’s something of a reversal for Trump, who campaigned on the idea that — unlike traditional Republicans — he would protect social welfare programs like Medicare, Medicaid and Social Security. “I’m not going to cut Social Security like every other Republican and I’m not going to cut Medicare or Medicaid,” he told the conservative Daily Signal in 2015.

Since taking office, Trump has reversed course, proposing federal budgets that would cut hundreds of billions of dollars from Medicaid funding, endorsing a Republican health care alternative to Obamacare that would dramatically reduce spending on Medicaid and supporting work requirements that have thinned the rolls in some states.

For Copeland, the loss of health insurance came as a surprise. In order to gain the experience he would need to get a full-time job as a drug and alcohol counselor, he was working the equivalent of three part-time jobs, all on a volunteer basis, and trying to find paid work. He thought he figured out how to report his volunteer hours under the work requirement system last fall, but when he got busy and missed reporting some hours in January, he did not expect to get cut off.

“Boom, I got hit with the termination,” he says. “I didn’t see it coming.”

Medicaid had allowed him to get treatment for high blood pressure, low testosterone and sleep apnea. He rushed to cancel a doctor’s appointment before he was charged out of pocket and realized he had to give back the CPAP machine that treats his sleep apnea. Doctors had told him to use it to prepare for surgery to fix his nose, which he has broken multiple times. Without it, Copeland knew not only would the quality of his sleep deteriorate, but also that his nose would swell again and the surgery would have to wait.

After multiple trips to his county Department of Human Services office, Copeland was told he was still eligible for Medicaid but that it could take up to 30 days for his coverage to be restored. The judge’s order, issued since then, means he’ll probably be able to remain on the program for the time being.

But critics of the Trump Administration policy argue that Copeland’s experience shows that work requirements can fall short of their stated goals, hurting recipients who were trying to find work already and adding a layer of bureaucratic uncertainty to the program.

Since Medicaid was introduced in 1965, it had largely been viewed as offering health insurance for poor Americans, not as a general welfare program, according to Sara Rosenbaum, a health policy professor at George Washington University. Even when President Bill Clinton overhauled welfare in 1996 and and introduced Temporary Assistance for Needy Families with work requirements amid concerns about welfare dependency, the changes did not touch Medicaid.

But when the Affordable Care Act expanded Medicaid to cover working-age, nondisabled, low-income adults in 2014, Rosenbaum says, that spurred many politicians to look at the program more skeptically.

“The irony is the reason that was done is because so many poor adults work and don’t get employer benefits but don’t have enough money to get private insurance,” she says. “That has somehow now become perverted into ‘we shouldn’t have all these poor adults on Medicaid’ with this implicit message that they don’t work.”

About 60% of adults on Medicaid already work, according to an analysis from the nonpartisan Kaiser Family Foundation, and most of those not working cite reasons such as taking care of a family member, attending school, retirement or being too sick to work.

Arkansas was the first state to implement work requirements, and similar programs are in place in Indiana and New Hampshire. Kentucky, Arizona, Michigan, Ohio, Wisconsin and Utah also had their work requirements approved by the Trump Administration, and states eagerly waiting on approval include Alabama, Mississippi, Oklahoma, South Dakota, Tennessee, and Virginia.

Most of these Republican-led states seem to be pressing ahead with their plans, but challenges to work requirements are starting to pick up steam. Michigan’s new Democratic governor is looking into changing the program her GOP predecessor set up and a group of Medicaid recipients recently sued New Hampshire over its work requirements. After the Arkansas and Kentucky ruling this week, similar bills stalled in the Idaho and Iowa legislatures.

Adrian McGonigal, a 40-year-old in Pea Ridge, Ark., is one of the residents who sued his state over its rules. He worked at a food-service company last year when the requirements started, but did not understand he needed to keep logging work hours each month, he said in the lawsuit. When he went to pick up prescriptions in October, he learned his Medicaid was gone and he could not afford his medicine. His health took a turn for the worse, and when he had to miss work, the suit says his employer fired him for the absences.

Arkansas’s governor has noted that it’s plan is limited in scope and says it should be reasonable to require people to get jobs in a state with a low 3.8% unemployment rate. While Medicaid covers close to 1 million people in Arkansas, the work requirement in February only applied to about 116,000 nondisabled, working-age adults who are covered under the state’s Medicaid expansion. The state’s Department of Human Services exempted the majority of these people from having to document their work for reasons such as having a dependent child, attending school full time or making above a certain income threshold.

However, advocates for poor residents say all these factors mean the work requirements applied largely to some of the state’s most vulnerable people: those who make less than the income cutoff of $736 per month, or 65% of the federal poverty line.

“The people who are unemployed in this job market are the people who are the least employable,” said Rev. Paul Atkins, who runs a weekly movie and dinner night for the homeless and has helped a number of people report their work hours since June. “They’ve had substandard education, difficulties with family life, drug addiction, mental health issues, or all of the above.”

At Jericho Way, a day shelter for homeless people in Little Rock, director Mandy Davis says her clients want to work.

“These are people who need consistent health care access,” Davis says of the Medicaid recipients her center helps. Finding out they could lose their health care “sucks all hope from someone who received hope by thinking they could access housing and change their situation.”

The threat of losing Medicaid coverage has also meant that Jericho Way staff could not focus as much on helping people find jobs. The center has had to raise extra money to cover more prescriptions for their clients, Davis said, and case workers often could not move forward with employment plans if people were sick or worried they were about to lose health care.

Part of the issue has been that Arkansas was figuring out some aspects of its program as it went along. Seema Verma, Trump’s Medicaid chief, has said she wants to make it easier for states to experiment with Medicaid.

Experimentation in Arkansas meant when the work requirement was first introduced, enrollees could only report their work activities through a complicated online portal, which closes between 9 p.m and 7 a.m every day, or ask a “registered reporter” such as an insurance agent to log their hours for them. A phone reporting option was added in December after advocates raised concerns. While people could use kiosks at county Department of Human Services offices to report their hours, the department did not hire extra staff to help enrollees navigate the program.

When Copeland first tried to report his volunteer hours last year, he could not figure out how to create an account and had to wait until he could call someone he knew at a local insurance agency to walk him through the process. “I worked in the insurance business for years, so I feel like I was usually pretty good at [navigating computer systems]. But it was so confusing the way you had to go about doing it,” he recalls.

He was far from the only one to experience computer issues. Critics of the program say internet reporting can be tough in Arkansas, considering it ranks 50th in the nation for broadband access and nearly one third of those likely to be subject to the work requirement have no home or mobile internet access, according to a recent Urban Institute study. The problem is further compounded by low literacy rates and increasing homelessness in the state, meaning many people lack basics such as cell phones, transportation or consistent housing.

All of that explains why one of the most common problems with the Medicaid work requirement was that people didn’t even know about it, according to advocates. Cindy Gillespie, director of the Arkansas DHS, says her agency’s outreach has included letters, phone calls and emails to Medicaid enrollees, as well as a paid advertising campaign. “DHS and our partners have worked very hard to educate people on what they need to do,” she told TIME.

But that effort can’t reach people who move homes frequently, or don’t have an email address or have run out of minutes on their cell phone. Atkins says many homeless or nearly homeless people in Little Rock use his church as their mailing address — but most people he talked to in the last 10 months were not aware the requirements existed.

“We get tons of mail for people we haven’t seen in years,” he says. “They’re around, I see them around town or at another homeless service location. But they might not remember to check in with their mail. So there are things they are missing.”

Tomiko Townley, the advocacy director for the Arkansas Hunger Relief Alliance, says her job normally involves helping people around the state apply for food stamps. But since the Medicaid work requirement was introduced last year, people have approached her “desperate” for help figuring out what to do about their health care. She notes that even for those who have stable homes, many live in rural areas where there are few jobs close by and transportation options are scarce. Employment can often be seasonal or might offer inconsistent hours, she says, which can make it hard to bank on meeting a work requirement.

“It’s so cut and dry and black and white, and the people we work with are in the gray,” Townley said. “They are human beings who have lives that are unpredictable.”

These factors all added up to a very small number of people actually reporting hours they worked in the first 10 months of Arkansas’s work requirement. In February, fewer than two in 10 people who were not exempt from reporting their work hours logged into the system to do so, according to state data.

Arkansas officials have also touted the number of Medicaid expansion recipients who found new jobs (more than 11,000 since last June) as evidence their program was working. But these number only show new hires, not whether people later left those jobs, whether the jobs gave them benefits or whether they were motivated to get them by the requirements.

Gillespie said in an email before the latest ruling that she knows it’s important to “continually monitor” the program and to see where adjustments are needed. But overall she said that most people had been meeting the requirements and that the program had seen success.

“Since we implemented the work and community engagement requirement, thousands of people in the program have also accessed services at the Department of Workforce Services that will help them meet the goal of the program. Those are all positives and the direction we’d like to see the program continue to go,” she said.

For Copeland, the work requirement did not serve as a motivating force in his job search. He doesn’t think it’s inherently wrong for the government to want people to work if they’re getting assistance, he says, but the way the program has been implemented has not worked. “I’m more productive than I’ve been in a long time,” he notes, and that didn’t stop him from losing his health care.

“I would give somebody a chance,” he says. “They signed me up [for the Medicaid expansion] when I was coming out of prison. You don’t just come out of prison with a car and a bank account and internet. It’s a process.”

Write to Abigail Abrams at abigail.abrams@time.com.

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