 Good afternoon, everybody. I hope you have grasped all of the needs and priorities that I need to guide you through this afternoon. Today is a really exciting lunch, because it is the first digital health lunch of this academic year. The digital health lunch is a collaboration between the Berkman Klein Center for Internet and Society and the Petrie Flam Center to bring interesting programming from around Boston about what's going on as people try to use the capabilities of data to really push forward health. We have another event coming up very soon, so I would suggest that you check out our websites. It's available both on the Berkman website, as well as on the Petrie Flam website. So speaking of Berkman and Petrie Flam collaborations, next week on October 24th, we have a big all-day conference looking at drug pricing. We know that the topic of drug pricing has gotten a lot of press, a lot of ink, a lot of words have been spilled on that topic. What makes this day a little bit more interesting is that we are looking at the drug pricing policies, both in the United States, as well as globally, and trying to pinpoint the interaction between those two fields. So please take a look at the Berkman site, the Petrie Flam site, please RSVP, so we know exactly how many brownies to provide over the course of the day, and we hope to see you at many more of our events. So I am Carmel Schachar, the Executive Director of the Petrie Flam Center, so I have a vested interest in getting you to our events. But more importantly, I am a friend of our fantastic speaker today, Rachel Gershen, who is a senior associate at the Center for Health, Law and Economics at UMass Medical School, where she performs legal policy and analysis regarding Medicaid health reform and social services. So her specific areas of work include healthcare affordability, accountable care organizations, long-term supports and services, housing supports, language access and consumer protections. Rachel brings experience advising and representing individuals who receive public benefits, including Medicaid, Medicare, prescription assistance, SSI, and social security. Now, I want to plug Rachel's law school experience, which is how I met her. Rachel is a graduate of this school, HLS, but as well also a graduate of the T.H. Chan Harvard School of Public Health, which back when both Rachel and I were in the JDMPH program was not yet the Chan School of Public Health. I hope that makes you feel old. So if you are a student, particularly a 1L, who is interested in working in public health law, I would suggest that you keep that on your radar and come talk to either myself or Rachel. The JDMPH program is always looking for people really motivated for that. So the last couple of things that I want to plug for you before I hand it over to Rachel is that to be aware that these lunches are webcast live and recorded for posterity. So I hope you got your hair done before you came here. As well as to please continue this conversation, not only in the audience Q and A that we'll be having towards the end of the session, but also to tweet, especially if you're not in the room but you're watching on the webcast, you can tweet us at BKC Harvard, that's Berkman Klein's Twitter handle, or at Petriefarm, which is Petriefarm's Twitter handle. And with that, I won't take up too much more time, but I will ask everybody to give Rachel a warm welcome. Good afternoon, everyone. I had to check the clock. Make sure I had the right time between morning and afternoon. So when Carmela and I were in school together, it was a great class. We were four who did a JD-MPH together. And I have to say throughout my career, having both an MPH and a JD has been really helpful. Working across the boundaries of law and public policy and public health has really enhanced my experience in the world. So as I was mentioning, Carmela and I were together at Harvard Law School and the TH-Tan School of Public Health, and we were a class of four. And throughout my career, having both a master's in public health and a JD has been really helpful to bridge the divide between policy and law and figuring out how to get people accessible, affordable healthcare, and also addressing social determinants of health. So I want to talk a little bit about my organization. I'm part of the University of Massachusetts Medical School, which is centered in Worcester, Massachusetts. I'm part of the Center for Health Law and Economics. We're just up the road on Cambridge Street in Charlestown. And our function is to work with state Medicaid agencies and also with health foundations, providers, other entities to think through several aspects of health policy and health law. I tend to focus on the state's relationship with the federal government, for example, how to be able to draw down funds to fund Medicaid programs. We are often hiring, feel free to check out our website. And I also wanted to mention that we support the medical school in that we essentially act as private health policy consultants. But at any margin goes to the medical school. So that's how we function. So today I'm going to be talking about Medicaid work requirements and disability in the role of digital health. So last month over 4,300 people lost Medicaid in the state of Arkansas due to their work requirements. Under the program, if a person does not meet that 80 hour requirement for either work or volunteer activities, or if they don't meet an exemption, then they are off the program until January of next year. So three months of not reporting, then you get kicked off Medicaid until the first of the next calendar year. And I should also mention, it's also for the expansion population. So if you're on traditional Medicaid, it doesn't apply to you. These, this is the first monthly wave in kind of a raft of states who are either asking the federal government for permission around work requirements or already have received permission. So Arkansas and Indiana has been approved by the federal government. Kentucky was also approved, but you might remember there was a court case that has invalidated their approval right now because it did not meet the goals of the Medicaid program, but they are trying again with a new proposal. And there are 10 other states pending asking for work requirements. And New Hampshire is also approved. In August, three people sued the state of Arkansas challenging the state's work requirements. And one of the plaintiffs mentioned in the complaint that she had been unable to work for a year due to medical conditions and that the state of Arkansas told her that that was not enough to meet a disability exemption. So that piqued my interest in what's the process for getting a disability exemption, who's in, who's out, what's the role of digital health in making sure we get this accurate. So how can states ensure that they're exempting all recipients who are unable to work? In the media, when work requirements are mentioned, they're often mentioned in the context of people who are able-bodied in terms of work requirements only apply to people who are able-bodied, who are able to work. How can we be sure that we're exempting all people who are not able-bodied is essentially the question of this talk. So Arkansas, Indiana, New Hampshire, and Kentucky all have what's called agreements between CMS and the state when they get a waiver amendment approved. And part of that agreement says that they will exempt people with disabilities, with medical conditions, caring for people with medical conditions, and a term called medical frailty, which I'll also address throughout this talk. So thinking through the challenge of making sure that we exempt all people who are not able to work according to the 80-hour standard or whatever standard the state puts up. I think it's good to look back at the welfare program because there's similar exemptions that have happened in the welfare program around the welfare-to-work requirements that were put into place in 1996. States had a little bit of flexibility around welfare-to-work. They had to make sure a certain percentage of their welfare population was engaged in work activities, but they could exempt some folks. It didn't help their percentage. They couldn't exempt them out of the percentage, but they could exempt them from their own program requirements. A number of states decided to exempt folks with disabilities, but recent research has shown that despite the exemptions and despite screening many times during the process, people with disabilities were much more likely to be sanctioned on welfare than their able-bodied counterparts. So when thinking about disability determinations, experts will tell you that the process is nuanced, it's complicated, it's time-consuming. I worked for a very brief time as a public-benefits assistance person before law school and then in legal services after law school working on social security. I would work months on a disability claim and that would only be a small portion of a person's attempt to get social security. Takes a long time to determine if somebody is disabled. And states with these Medicaid work requirements that require you to report work or report exemptions within five days of the next month, essentially they have to speed up this process of disability exemption that usually takes months or years to get right to a matter of maybe, I don't know, weeks or months depending on their process. So can states get assistance from digital health? I was thinking through all the digital health tools and how a state might use these tools to focus on people with disabilities and be able to exempt the full population. States use, for example, data matching to make sure that if somebody is determined eligible by another agency that they are determined eligible by Medicaid for the exemption. States also use claim analytics. For example, if we're designing a program in Medicaid that focuses on a certain group of people, maybe people with high risk medical conditions or need of care coordination or care management will often use these types of data analytics to look at, for example, people who have spent at least $10,000 in medical expenses last year or who have certain diagnoses. Maybe these can be helpful. So on one hand, digital health could help identify this population. But on the other hand, there's a risk that using digital health might increase our reliance and mask some of the flaws in the system. For example, folks in the media saying that these requirements only apply to able-bodied folks if they really don't apply only to able-bodied folks. So I constructed this very simplified graph. Over on your left-hand side is able to work, and here I mean able to work according to the standards of the Medicaid agency. In the middle is not able to work, but not yet determined, disabled by an agency, and over on the right is determined, disabled by an agency. So I'm gonna talk about a few examples taken from my experience as a legal services attorney and as a public benefits advisor, thinking through how a person might intersect with disability throughout their life going towards a disability determination or going towards an ability to work. This first example is someone who is able to work at the beginning, but then experiences a pretty sudden and severe disability and fairly quickly receives a disability determination. Each node represents a moment in time, so the more nodes, the longer a process will take. So you'll see here that the person started able to work, they went towards the middle, not able to work, not yet determined, disabled because they're getting their application ready for social security administration, and then finally they're determined, disabled at the end. The red circle in the middle represents the point in time when they find a medical professional who's willing to defend their case, willing to put in the evidence, the diagnosis, all of the medical records required to prove to the social security administration that you are disabled. This example is different. As you can see, there's a lot of nodes representing a long period of time. This person eventually receives a disability determination but only after a long process. And you notice the process from able to work to not able to work, to getting a medical professional to buy in takes some time. This may be because a person has a disease that's difficult to identify, diagnose, get someone on board. It could mean that their condition is gradually deteriorating. And on the other side, from medical professional buy-in to the social security administration determination, that represents the long period of time that it often takes people to get a disability determination. The process, if you may know, if you've worked on social security cases, is typically initial decision, redetermination and appeal, and maybe some other steps after that. At the appeal stage, 40% of people get approved. So this is not a small number of folks who were missed the first or second time around. It's a fairly large number. And if you are at the hearing appeal stage, your average is about 27 months from the turning in of the initial application, which itself takes time to prepare. So this is kind of a typical process for people who've been eventually determined disabled. In this next example is a person who's able to work and stays able to work even though they have disabilities. I just wanted to have the full range, or not the full, but an example of the full range, the diverse lives of people with disabilities. Not everyone with a disability cannot work. That said, that person might still experience barriers, like disability discrimination. They might experience transportation barriers or other things in the way of being able to work. The second to final example is somebody who kind of is on the edge of ability to work. So they may be able to work one month, but not the next. When I was doing public benefits assistance, my clients who were experiencing issues with mental health or substance use sometimes felt into this category where they could work for one month, but it just took a toll on them, so they had to take a break for a while. And you can imagine this does not meet the work application process, like just because they're able to work those three months doesn't mean they're gonna immediately be able to apply, get a job and start getting paid and start meeting the requirements of the state. And also notice there's no red circle. So they haven't been determined by a medical professional disabled enough to go after Social Security. They're kind of right on that line. And then finally, this person was able to work, became disabled and did not get a medical professional buy-in and did not get a determination. So some folks stay in this middle area for a long time. And I think this middle area represents the highest risk for people who might be missed by a state trying to exempt people with disabilities. And it's the place where I'm gonna focus on when working through some digital health tools. So just wanna mention, this is not representative of everyone with disabilities. There's a lot of nuance here. There's a lot of intersectionality here. For example, women often experience medical conditions that aren't well researched in the scientific community and that can take a long time to get a diagnosed by diagnosis by a medical professional. Even if you're able to work, you may not be able to get your application in on time, find a job free of disability discrimination in the hiring process and be able to work immediately. For folks who are homeless, for example, it's been shown that it's harder for them to get onto disability than other populations. For folks who have substance use disorders or folks who do not have enough hours or don't have low enough income, all these little factors that Social Security looks at in addition to disability, they may not bother applying because they know they're not eligible for other reasons. So now I'm gonna turn to data matches. So this is kind of the first cut to try to find people with disabilities in the context of a Medicaid work requirement program. So states already use data matches a lot. Arkansas data matched against SNAP work and disability exemptions and it also, through its medical frailty exemption, also data matched through the Social Security administration process. So there is some data match going on. States could expand it, for example, some welfare states data match to veterans affairs and there's a lot of different agencies and programs that determine disabilities. So if we look at the green, is that green? At the green box, this is my representation of kind of the portion of the population who would be covered by a data match and you see it's all the way over on the right. It's not covering folks who are in the disability application process. It's not covering folks who are trying to get a medical professional on board. It's not covering folks who are going in and out with the ability to work or other processes. So it's a pretty small portion. And the consequences of Medicaid loss can be pretty big. Access to healthcare, access to financial protection, access to employment and access to disability determinations. I'm gonna focus on this last one because it shows how it's related to how you get a disability determination in the first place. Let's say for the first, going back to this example, as someone who takes a long time to get a disability determination, they're kind of stuck in a catch 22. Let's say that their doctor has told them that you really can't work 80 hours a month. That's just not good for your health. So you decide not to work and you lose Medicaid. This yellow splat indicates a break in the process towards getting disability determination because if you don't have Medicaid, then you might not be able to get access to a medical professional, to put together your medical record, to submit and get a disability determination. When I was a social security disability attorney and when I worked in public benefits, I really was grateful when a person had Medicaid or another public health insurance or health insurance in general because it meant such a big difference in trying to get their case together. On the other hand, let's say they decide to work and make those require and be able to keep Medicaid, keep going to the doctor, keep building their case. Well, then they run a danger of what's called substantial gainful activity. The Social Security Administration, when they determine whether a person is determined disabled or not disabled, they look at the work you do. They look at the volunteer work you do. And if they think that you're doing substantial gainful activity, then that's a sign that you're not really disabled enough for cash assistance. So we see here that the standard for Social Security is really high. And if you work, if you don't work, you can be in a catch 22 in a Medicaid work requirement situation. So here's another thought. Maybe in addition to having a data match for disability determinations, we do a data match for disability applications. Welfare states have done this, a few of them, especially trying to get TANF-eligible folks from welfare TANF to SSI Supplemental Security Income, which is one of the Social Security Disability Benefits. They've decided to exempt people who are in the process of applying for SSI because that gets them out of this catch 22 of deciding whether to work or not and either not being able to get medical records together or getting dinged for a substantial gainful activity. So you see, that helps a little bit. It goes past to where I imagine disability applications start, but it's still missing a lot of people. It's missing people who don't have a medical professional on board and it's missing folks who don't meet this or strong disability standard and therefore aren't going through the process of applying for disability. So thinking about who is not applying for SSA benefits. If you do applications, then you mitigate the substantial gainful activity issue, but you're still leaving some folks out because if they lose their Medicaid, then that is still a problem with the link between getting a medical professional on board, getting all the medical records together and submitting a strong application. So let's think through claim analytics. So I've worked on a number of projects where we've used claims analytics to focus on a particular population. For example, we want to help folks who have behavioral health conditions and people with behavioral health conditions are known to have a lot worse physical health. So we might focus on people with behavioral health conditions with high rates of physical health expenditures to try to integrate those services and help get the outcomes better and the expenditures down. So that's one example of you need to claim analytics. You can use a diagnosis, you can use a dollar amount for claims analytics. Also when thinking about risk adjustment, which is the process of paying managed care agencies more if they have higher acuity folks. So to make sure that managed care doesn't try to just skim the most healthy people on and try to disenroll all the unhealthy folks one way and also to be fair to managed care organizations who focus on populations that are more complex and higher acuity. One way to do that is to risk adjust, paying more for folks who have higher acuity. We've also started in the field of risk adjusting for social determinants of health, which my colleague Arlene Ash has been working on for the last few years. So that's another process, right? Where claims analytics is identifying people with high acuity or with disability. Maybe these processes could be used to help identify people with disabilities in the context of Medicaid work requirements. This is my very guesstimate of what a claims analytic procedure might do that it'll cover some people, but not all. And there's a few issues with this. There's time delay in claims analysis, making sure you have a person with the most recent claims is important when doing this. There's also claims are pretty course predictor at times, especially around risk adjustment. For example, somebody may be disabled, they may have depression and not be able to get out of bed in the morning and not have a lot of medical expenses because they're not going to the doctor. They're still high acuity but they're not getting help. So it's not showing up in the claims. Another example is diagnosis. But diagnosis doesn't talk about functional status. And here we see where states try to do a disability assumption. This happened in some welfare states where they would use diagnosis to try to figure out who has a disability. You can't tell from a person's diagnosis whether or not they're able to work. The social security process looks much more at what you can functionally do. Your activities of daily living, your activities of work, looking at your age, what your experiences are. Are you a lawyer or not? And matching it to the employment workforce and the jobs available. It's a much more nuanced approach than kind of some big data health look would do. So here I wanted to talk about one particular consequence of Medicaid loss and that's loss of access to employment. So if we think of what Medicaid does is it helps people get better in some cases. And in those cases, if a person is not able to work, sometimes they're allowed to work after. This is a recent evaluation done of the Ohio Medicaid agency. And it showed that of people who are employed, 83% of people said that Medicaid helped them get back to work. This is an evaluation of the expansion population. So the same kind of population as Arkansas and other work requirement states. And then among unemployed, unemployed enrollees, it's still 60% to make it easier to look for work. And that kind of follows a logical pathway, right? If you are disabled and not receiving medical care, just logically, it's probably gonna be harder for you to find work, get a job, retain a job, get medical benefits. When I was a public benefits advisor, I would see this pattern again and again where a person would be employed. They would get sick, they would try to work as hard as possible, as long as possible, but eventually they would lose their job, they would lose their health insurance with this. This was before the Affordable Care Act, so they didn't have a lot of options. So they would either be low income enough to apply to Medicaid or they would try their luck on the individual market, which with preexisting coverage was not very helpful. So people were stuck, and I think Medicaid expansion was in part in response to that stuckness of people in this country when we have employment tied to health insurance so closely and your health status influences your employment status. I think it's important to have a safety net that also doesn't rely on your employment status or else you still get that stuckness. So this is an illustration of the person in and out of the ability to work and if they don't have Medicaid, they're not able to get back. And finally, thinking about this person who has remained disabled but not able to get a medical professional online, maybe because their condition takes a long time to figure out or they just have a loss of access to healthcare, not being on Medicaid is not gonna help them get back to work. So going analog. What happens when people self-report, process for analyzing the self-report and who bears the burden of uncertainty. So this is what I know about the Arkansas process. Let me flip so I can get these numbers right. So in August 55, people applied for an exemption. So a very small portion, 45 got it. When you're applying for a work exemption, you click on disability as a barrier to work, but it doesn't define disability and I have to have a caveat here. I didn't reach out to the state of Arkansas, I just took some of their training videos to see how it would work in the system. So they may have fixed this. And then on the next page, you have to click under penalty of perjury that you're saying that you're disabled. So who bears the burden here of determining the standard of disability that they're applying. After you click on disability, Arkansas says that it'll send you a letter about how to proceed. So there's not a lot of information yet about the process, how they're planning on doing this disability determination for people who self-report. And thinking about the risk of this. Who bears the burden of uncertainty around who gets to be determined disabled and who doesn't I think is important to think about because if your risk is losing Medicaid or working, that's a hard choice to make if you're disabled. And some other data in Arkansas and 19,000 people were found to be working according to their state records. So they didn't have to report. 7,000 were matched under SNAP work or disability requirements or disability exemptions. And 6,000 were matched under medically frail, which is it's a term used in federal law to make sure that states who are expanding Medicaid have the medically frail keep traditional Medicaid. And definitions differ by state. In Kentucky, for example, if you're homeless, you can be medically frail. For Arkansas, they did a data match against social security determinations. They used claims and algorithms to determine who would be medically frail for that purpose. And they used a questionnaire where they asked, are you unable to work even part-time? Which you'll notice doesn't meet that standard of 80 hours a week. You can say that I'm able to work part-time but still not meet that standard. And I think the medically frail gets close. It's identifying a portion of the population who were already identified beforehand. But it doesn't ask the exact same question. So again, we're missing people. We're missing people who've become more disabled since the last time they took the medically frail questionnaire. We're missing people who may not meet that medically frail ambiguous standard but can't be able to work. So just another point in uncertainty. I heard Sarah Cliff talk a few months ago on a podcast and she mentioned somebody she met in Kentucky who had vertigo, was unable to work, and that person didn't know on the eve of Medicaid work requirements whether she would be disabled or not. There was, as far as she knows, she didn't know the standard or the process for being able to apply and be determined disabled or not by the state. And again, this comes with a lot of caveats. I haven't done extensive reporter-like research into what these standards or processes are. They might have gotten better. They may have a process that's only available to Medicaid recipients. So this kind of leads me to the question. Are Medicaid work requirements worth it? What are we willing to trade off to get a Medicaid work requirement? One recent article in JAMA did an analysis of SIP data throughout SIPP data throughout the nation to see who would be eligible for a work exemption or meet the work requirements. And they found that only about 0.3 to 5.4% of recipients either don't meet an exemption category or don't meet work requirements. That's a pretty small portion of your Medicaid population. On top of that, those researchers used that higher social security standard, eligible for SSI. So that's not even looking at the middle ground and looking at the number of people who would be eligible. So thinking through, you're looking for a needle in a haystack. Medicaid itself is a work support, so you might be cutting off that process where somebody gets better and gets back to work. And you have a potential for disrupting the disability determination process in general. So thank you so much for listening to my talk. I really look forward to answering questions and getting into discussion and hearing what you think about whether you think my thoughts are right or are missing the base. Thank you so much. Excellent. So thank you, Rachel. We're gonna keep her up here for questions and Dan is running around with the microphone. So if you have a question, raise your hand. But I will take moderator's prerogative to kick it off. Excellent. So it seems to me there's kind of two themes we're talking about here. The fact that our data systems are imperfect for measuring what we want to measure and then whether we should have Medicaid work requirements at all. Could you envision a situation in which we could improve our data collection systems to the point where you would find work requirements to be workable? Please excuse the pun. No, I'm not sure. I've spent a lot of time over the last few months thinking through this. And I would love to hear opinions about where I might be wrong here, but the Social Security Administration has been doing this for a number of years since the 70s and they haven't come up with a faster, cleaner process. And they are underfunded on the technology side, but I think there's an incentive to try to find a better way to find people who are disabled through some sort of big data match. And I just haven't seen it yet, but maybe I'm wrong. There's also a whole raft of other criticisms against Medicaid work requirements that I didn't get into around people with part-time work and different aspects of working while you're low income. But for this particular question of is there a technological way in the future to identify people with disabilities? I'm not seeing it yet. All right, audience questions? The issue of people's ability to work being a factor in whether they can get the assistance. And this happened in California. My question is how widespread is this? A friend who had been seriously injured in a car accident tried to go back to work and was unable to do it. And she was judged ineligible for assistance because she had gone back to work. And is this a widespread problem? Yes. And I think it's important to think of the Social Security Administration and the Social Security Fellowship. She described the situation a long time ago. So can you say for sure which government agency was and could welcome social security? Of course, of course. I think that in my experience of doing benefit help with folks, there's just a lot of people who meet the middle. And with America's work ethic, honestly, people I meet are trying to get back to work. That was when their life made sense for a lot of them. I wanna be careful about how I talk about this because there's a range of experiences you can be not working and happy. Work does not equal happiness. But I think in our culture, that's definitely the message that your work is your worth. And I think there's a lot of strong headwinds or tailwinds, whatever it is, towards a person finding work despite barriers they might experience. So the gentleman in the white shirt. Hi, great. Thanks for coming and having the talking. A lot of the framing for the process being so long and problematic seems to be about an issue of bureaucratic capacity. But other disciplines will often talk about specifically welfare requirements and work requirements as a matter of politics or a matter of putting up barriers to keep enrollments low. So to the extent that, in your mind, how much of this is a problem of capacity versus a problem of politics? And to the extent that politics is involved at all, is there any concern that increasing digital capacity will just promote, let's call them reformers, to circumvent those systems in new ways and then putting up even more barriers in ways that we haven't conceived of yet? So I might go on a bit of a rant here. Please. When we think about how America treats public benefits, access to basic housing, food, medical care, often people are put into two groups, deserving poor and undeserving poor. And we've spent a lot of time debating whether you're deserving or not. There are something like 200 categories in Vermont Medicaid to determine whether you meet that certain category to be deserving of Medicaid. And that's both a function of federal law and of state law determining whether you pick certain options for populations. And all the rhetoric that is around deserving and undeserving poor, it adds to a bloated bureaucracy in the eligibility world. And that bloated bureaucracy blunts our ability to use the tool of public benefits to address societal problems, right? Like if we weren't so concerned in spending a lot of administrative resources to determine if someone is actually disabled or not or actually working or not, think of how much easier it would be to apply and to apply those funds to the people who really need it. I mean, in there, there's still some administration around targeting certain folks who need it most. But for example, in social security, if you're working, your paycheck is dinged against your benefit. And for SSI, it's determined, I think based on the day you get your paycheck, on SSDI, it's based on the day you earn it or something like that. It's so complex to try to intersect with public benefits and become eligible and stay eligible that I think if we work on lessening the divisive rhetoric, we might actually get less bloated bureaucracy. Yeah, I think you had a slide which showed data matches and several categories. One of them is the SNAP program. So I may be, I'm not knowledgeable enough about this, but the SNAP program is food stamps. Yes. So what exactly is being matched? I mean, these are not people, these are people, basically poor people. Food stamps has work requirements now. Oh, okay. And they have disability exemptions for those work requirements. Sorry, I wasn't clear. I'm just visiting on campus today in Popton. But I'm glad I did. I'm what you call a lay minister in the church in Tucson, Arizona. And we helped the ministers out and we're assigned people, it's all confidential. Now, what if I'm thinking to myself, what if I have a woman, let's say it's a woman who maybe qualifies for a lot of these benefits. I don't know anything what the state of Arizona requires. Would it be who made to start investigating so it could work? Because it looks like a lot of work, a lot of time. And I'd like to help someone, but there's gonna be a lot to know, isn't there? You know, I applaud the impulse to help people. I have found helping people find benefits is my favorite thing to do. It's like the big puzzle. I've been doing it since I was 22, just out of college. And the reason I became a lawyer was the closest I could get. This is before Affordable Care Act navigators. There wasn't really a job description for what I was doing. So my advice to you is to check out the state's Medicare advice place. It's either called SHINE or SHIBA. There's some, or SHIP, I think that's the federal term. And what they are, it's a group of volunteers. You get about 40 hours of training from your state's insurance department. It's how I first learned the difference between Medicaid and Medicare. And people call in and ask questions about Medicare. And you can help them navigate the process. For example, getting help with your Medicare premiums. You can get help if you are eligible under some Medicaid programs that are very underutilized. If you don't get Medicare Part B in time, you could be paying a penalty for the rest of your life. So there's some very particular points in Medicare benefits that you can have a positive income effect on some low-income folks. That's where I would encourage you to go. I think. Hi, this is sort of like an opposite of whatever you've been saying. Yeah, sure. What do you do about all the fraud you're seeing around you? For example, I live, we moved just recently to a senior complex. And most of those people look to me really fine. They're going, watching ball games, et cetera. And they're all getting disability. And I said, people like us who worked all our lives, we've got to sit and live on our pensions. And these guys are having a great time. So how come all these people qualify? And how come there are lawyers out there who fill out the forms for them? That's a great question. Thank you. And it's a sentiment I hear a lot. I think it's a very common sentiment. Why are people who are getting disability benefits getting that they seem to be fine? They seem to be able-bodied. Why am I paying for their income? And I think this is tough, right? In this environment of divisive language and just kind of looking at someone and thinking that they should be working, there's a lot of people with invisible disabilities, especially in the mental health space. There's a lot of people, for example, who may or may not use a wheelchair some of the time to help them get around and not others. And just because you're not in a wheelchair doesn't mean you're not disabled. And the social security process is so long and so such a high standard. I would ask more questions before assuming that they're not eligible. And I would also think about when we're designing public benefit systems, a lot of times if you become eligible for let's say social security disability, there's a very strong incentive to not go back to work even if you're able because you could lose your benefits. You could become in debt. I had clients who were 40, $70,000 in debt to the Social Security Administration because even though they reported their hours, Social Security didn't write it down right. And they levied it against them years later. So you only have to hear a few of those stories before becoming very cautious about moving from one, if you're thinking about my diagram that I showed for 20 slides, one category to the other because it can be pretty hard to go back. So I would just encourage you not to make assumptions about a person's ability to work just like you can't tell in claims or diagnosis or data matches, you can't necessarily tell by looking at them. Any other question? I'm wondering if the system makes it easier for the employers to not provide health insurance. Does the system make it easier for employers to not provide health insurance because you have a work requirement but it seems like there's assumption that okay, they'll still have the Medicaid even though they're working. So the employer doesn't have to do anything. Is that right? Now you're calling me out on what an employer's requirements are now under the Affordable Care Act. I don't remember if it's still delayed or not. Do you know? I can't help you on your design. So there is a federal requirement that may or may not be in place for employers of a certain number of employees to offer health insurance. There's also requirements in the state of Massachusetts for employers of a certain number of employees to offer health insurance. And I think the research that's been done at least in Massachusetts is that the existence of Medicaid has not dramatically decreased the number of people with employer-sponsored health insurance. Here, I don't think it affects their obligation as an employer. I think in general, when we reduce the robustness of our safety net, it may pull people into more desperate circumstances in terms of work conditions. So thinking about it as a labor issue. Sometimes labor is a little bit not aligned with kind of cash low income benefits. But if you think about it in terms of if there's people who aren't getting benefits because they're not working, so they have to work. That means that employers don't have to offer as rich set of benefit packages because there's more people trying to get into the labor force. So there's some interesting questions to ask there. You described these different categories of people, some people who get determination quickly, others take long time, others bounce back and forth. And so I'm wondering has there been research to try to determine how many people are in each of those groups which would inform, potentially inform the policy? I would love to get funding for such research. Let me know if you know any of the resources. This was, and thank you so much for inviting me to come. This was, I wanted to pick a topic I hadn't known a lot about before to use the fact that I have to stand up in front of a bunch of people and talk about it as an impetus to learn it fast. So thank you for being my first try and talking about so. I think we have a question over here. Yeah, when I signed up for Medicare, it seemed like their website was just unfathomable to a person of average intelligence. And do you think that this is much of an issue for the people that you are talking about for trying to get onto such programs? So Arkansas, and I keep talking Arkansas, I don't mean to pick on them. They're just the only state that's implemented the program so far, work requirements. So their website, it used to be that you had to use the website to record your work requirements. Advocates, this is an advocate, but Kaiser Family Foundation has some great briefs about how hard it is to navigate, the get an account, get on, and report your work requirements. Arkansas is one of the least connected states in the United States. And at one point, I don't know if this is true anymore, but the actual website to report your work requirements was only open during business hours. The website shut down after business hours. So Arkansas also offered, they had to promise to offer reasonable modifications to the application process. So that might be another avenue. If for example, you have a disabled client that even if you can't, one avenue is to say, hey, you need to make this reporting process easier or even reduce the number of hours for me. There are some other obligations, not just wholeheartedly fully exempting people with disabilities, there's some other obligations as well. And I think the website might be a prime target for those obligations. Later they said you could call, but there was issues with calling as well, so. Thank you so much for your wonderful, wonderful presentation. I wanted to know if you think the disparity in the data analysis perspective, do you feel like the problem is simply from a policy standpoint of implementing it or is it also a technological standpoint where if you had better programming or more funding or more sort of the technology aspect of pushing that, would that also help increase the problem? I think I go back to the Social Security Administration who's had to determine whether a person is disabled or not since the 70s and it's still a really long process and really they have thousands and thousands of employees working on this. It's just really intense and I think it's also indicative of the nature of how we experience life, health, our bodies, disability, is different than the black and white nature of public benefits eligibility. So any more questions? I know that class is about to start for the people on class schedules, but we want to give you guys the chance to pick Rachel's brain as thoroughly as possible. So, no, okay. Oh, do I see in the back maybe this corner's a tentative hand? Nope, okay. Going, going, gone, I will say. Let's give Rachel a big round of applause. And thank you guys for coming. Please explore the rest of our digital lunch series as well as there's an event tomorrow looking at vaccines and then as I mentioned the drug pricing event next week that we hope we see all of you guys at. Have a good day.