Between system design and human impact lies a critical layer that determines whether verification and exemption architectures serve their stated purposes or fail predictably: the navigators, case managers, community organizers, and individuals who translate policy into lived reality. Arkansas built verification systems and exemption processes but without adequate navigation support, 18,000 people lost coverage as research showed the problem was navigation, not compliance. Georgia spent between $86.9 million and nearly $100 million on technology but minimal investment in human support, enrolling far below projections. The pattern is consistent: technical systems optimize for average cases and fail at complexity. Human systems handle complexity but do not scale efficiently. States need both, and the question is how to build human infrastructure that is adequate to 18.5 million people by December 2026.
The article confronts the funding reality directly. Traditional Community Health Worker programs cost $35,000-55,000 annually per FTE. If one CHW can support 50-75 people navigating work requirements, serving 18.5 million people would require 250,000-370,000 CHWs at a cost of $8.75-20 billion annually. No state budget accommodates this. The workforce does not exist. Even if funding materialized, building hiring, training, and supervision infrastructure at this scale takes years, not months.
The proposed solution is a layered approach combining three tiers of human infrastructure. Layer 1 consists of professional navigation and case management handling the most complex cases: appeals, complicated exemptions, multi-system coordination. At one professional per 200-300 people, this requires 60,000-90,000 workers nationally at $2.7-4 billion annually. Layer 2 introduces Community Inclusive Social Enterprises (CISE), peers with lived experience receiving $200-800 monthly compensation for helping others navigate requirements. If 2-3% of the affected population becomes CISE providers (370,000-555,000 people), each supporting 5-10 others, this reaches 1.85-5.5 million people at $500 million to $1.5 billion annually. Critically, hours spent helping others count toward helpers’ own work requirements. Layer 3 relies on volunteer community support through faith communities, service organizations, and family members providing unpaid assistance, with Medicaid members receiving work requirement credit for volunteering.
The power lies in integration across layers. Someone might learn about requirements from a church volunteer, receive initial consultation from a CISE provider with similar life experience, get escalated to a professional for a complex exemption application, then return to the peer provider for ongoing support. Total cost is a fraction of professional-only service while likely delivering better outcomes through trusted relationships and cultural alignment.
The article identifies the case manager’s dilemma as a defining tension. Navigators help people comply with policies they may personally oppose, funded by systems they may view as harmful, balancing fidelity to policy requirements with advocacy for individuals whose circumstances do not fit policy categories. They need training covering not just policy mechanics but trauma-informed approaches, motivational interviewing, and recognition of when system failures require escalation rather than individual adaptation.
An “exhaustion economy” runs through the entire human infrastructure. Case managers are exhausted. Navigators burn out. Community organizations stretch beyond capacity. Individuals seeking help are exhausted from life circumstances before adding navigation burden. When exhaustion is widespread across people in similar roles facing similar demands, it is systemic, not individual. Systems that require unsustainable human effort are poorly designed systems, and the solution is redesigning systems to require less human effort or providing adequate resources for the effort required.
For state Medicaid directors, the article makes clear that federal requirements specify verification and exemption frameworks but provide minimal guidance on human infrastructure, and the human layer is the component determining whether technical and policy infrastructure actually functions. Directors must budget for human infrastructure proportional to technical system complexity and exemption rigor. For MCO executives, the member struggling with work verification is probably also struggling with medication adherence and appointment attendance, and care coordinators must address all of it simultaneously. For community organization leaders, the article documents their essential yet impossible position: essential because technical systems cannot handle complexity, impossible because funding is inadequate to need and responsibility for system failures they did not cause falls on them.