Articles 2A and 2B examined verification and exemption systems – the technical architecture and policy frameworks governing work requirements for 18.5 million people. But architecture doesn’t determine outcomes. Between system design and human impact lies a critical layer: the navigators, case managers, community organizers, advocates, and individuals themselves who translate policy into lived reality.
This human layer isn’t optional infrastructure that well-designed systems can eliminate. It’s essential infrastructure determining whether systems serve their stated purposes or fail predictably. Arkansas built verification systems and exemption processes, but without adequate navigation support, 18,000 people lost coverage in the first seven months. Research found only an estimated 3-4% of those subject to requirements were not working and didn’t qualify for exemptions, yet 25% lost coverage – the problem wasn’t compliance but navigation. Georgia spent between $86.9 million and nearly $100 million on technology but minimal investment in human support – enrollment ranged from 2,344 people in December 2023 to 9,175 in August 2024, far below the projected 100,000 for the first year.
The pattern is consistent: technical systems optimize for average cases and fail at complexity. Human systems handle complexity but don’t scale efficiently. The question isn’t whether states need both – they do. The question is how to build human infrastructure that’s adequate to the challenge, sustainable over time, and empowering rather than just managing compliance.
The Funding Reality: Why States Can’t Rely on Professional Models Alone#
States don’t have the money, workforce, or time to build professional navigation infrastructure adequate to 18.5 million people by December 2026.
Traditional Community Health Worker programs cost $35,000-55,000 annually per FTE including wages, benefits, training, supervision, and administrative support. If one CHW can support 50-75 people navigating work requirements (a generous ratio given complexity), 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. Federal Medicaid administrative matching doesn’t fully cover these costs. Even if funding materialized, the workforce doesn’t exist – there aren’t hundreds of thousands of trained CHWs waiting to be hired. Even if the workforce existed, building hiring, training, and supervision infrastructure at this scale takes years, not months.
This isn’t argument against professional navigation – it’s recognition that professional services alone cannot reach everyone who needs support. States must build layered approaches that combine professional capacity, community volunteer engagement, and Community Inclusive Social Enterprises (CISE) – peer-driven, compensation-generating support that sits between traditional volunteering and formal employment.
The question isn’t whether to supplement professional services with community capacity – states have no choice. The question is whether to acknowledge this reality and intentionally build infrastructure supporting diverse helping roles, or to pretend professional services will suffice and watch people fall through predictable gaps.
A Layered Approach to Human Infrastructure#
Effective human infrastructure combines multiple layers, each serving different functions and populations:
Layer 1: Professional Navigation and Case Management#
Handles most complex cases: appeals, complicated exemptions, multi-system coordination
Capacity: One professional per 200-300 people = 60,000-90,000 served nationally
Cost: $2.7-4 billion annually at $45,000 average per FTE
Function: Expert navigation, training/supervision of peers, escalation backstop
Layer 2: Community Inclusive Social Enterprises (CISE)#
Peers with lived experience receiving compensation ($200-800 monthly) for helping others
Capacity: If 2-3% become CISE providers (370,000-555,000) each supporting 5-10 others = 1.85-5.5 million reached
Cost: $500 million-1.5 billion annually (stipends, micro-grants, credentialing infrastructure)
Function: Initial consultations, ongoing check-ins, practical help, peer support
Critical element: Hours helping others count toward helpers’ own work requirements
Layer 3: Volunteer Community Support#
Faith communities, service organizations, family members, neighbors providing unpaid support
Capacity: If 5-10% engage as volunteers, potentially millions providing occasional help
Cost: $100-300 million annually (training materials, tools, partnerships)
Function: Information sharing, encouragement, occasional practical help, community belonging
Critical element: Medicaid members volunteering to help others receive credit toward own requirements
The power is in integration. Someone might learn about requirements from a church volunteer, get initial consultation from a CISE provider with similar experience, receive ongoing monthly check-ins from that same provider, get escalated to a professional for complex exemption application, then return to CISE provider for continued support. Total cost is a fraction of professional-only service while likely delivering better support through trusted relationships.
For layered approaches to work, states must build connecting infrastructure: referral pathways between layers, training ecosystems adapted to each level, shared knowledge bases, quality networks for peer learning, and differentiated compensation structures (salaries, stipends, volunteer credit).
Navigation as Practice#
Navigation – helping people understand requirements, gather documentation, access exemptions, find opportunities, and maintain coverage – will be the most visible human function in work requirements implementation. But it’s not a single role with standard practices. It’s a set of functions performed by diverse people in varied contexts with different relationships to the populations they serve.
Professional navigators offer consistency and accountability but face inherent tensions: helping people comply with policies they may personally oppose, being funded by systems they may view as harmful, and balancing fidelity to policy requirements with advocacy for individuals whose circumstances don’t fit policy categories. They need training covering not just policy mechanics but trauma-informed approaches, motivational interviewing, cultural competency, and recognition of when system failures require escalation rather than just helping individuals adapt.
Embedded helpers – social workers, healthcare navigators, benefits counselors already in other roles – add navigation to existing responsibilities. They often have advantages of deeper relationships and better understanding of individual circumstances, but face severe capacity constraints. They need simple guidance on where to find information, who to contact with questions, and what resources exist for complex cases – not comprehensive training on all policy details.
Peer navigators bring credibility professionals can’t match – they’ve lived the experience, faced the same barriers, learned the workarounds. They work well where trust in government systems is low or where cultural and linguistic barriers exist. But peer navigation requires support to be sustainable: stipends or recognition programs, training materials, drop-in support sessions, and pathways to professional navigation positions for those who want them.
The Case Manager’s Dilemma#
Case managers in social services, healthcare, workforce development, and other systems will inevitably become work requirements implementers whether that’s formally part of their role or not. This creates profound tensions for people whose professional identity centers on supporting vulnerable populations.
Compliance vs. Advocacy#
A case manager’s client is at 45 hours mid-month with chronic health conditions that might qualify for medical exemption. The case manager faces competing obligations: help the client find additional work hours to meet requirements, help them apply for exemption, or advocate that the requirements themselves are inappropriate for someone in their circumstances.
Each choice reflects different assumptions about the case manager’s role. Helping find work hours treats work requirements as legitimate policy to support compliance with. Helping apply for exemption acknowledges requirements but seeks appropriate accommodation. Advocating against requirements positions the case manager as challenger to the policy framework.
This tension intensifies when case managers believe requirements harm the people they serve. Helping someone comply with a policy you think is destructive feels like complicity. But refusing to help because you oppose the policy harms the individual who still faces consequences of non-compliance. The choice isn’t between compromised values and pure resistance – it’s between different forms of complicity and different strategies for harm reduction.
Documentation Burdens and Professional Ethics#
Case managers will be asked to provide documentation supporting exemption claims, verifying activities, and explaining individual circumstances. This documentation work takes time away from direct service. It also positions case managers as gatekeepers whose assessments determine coverage.
When a healthcare case manager documents that a patient can’t meet work requirements due to disability, they’re making a judgment that affects that person’s access to healthcare. The ethical frameworks case managers rely on don’t cleanly resolve these dilemmas. Client advocacy suggests documenting generously to ensure people maintain coverage. Professional integrity suggests documenting accurately even if that means some clients lose coverage. Organizational accountability suggests following organizational guidelines even if those conflict with client interests.
The Exhaustion Factor#
Case managers already have overwhelming caseloads. Adding work requirements navigation, documentation, and advocacy doesn’t reduce other responsibilities – it compounds them. The predictable result is burnout, compassion fatigue, and eventual exodus from the field.
Preventing case manager burnout requires more than individual self-care – it requires systemic changes. Reasonable caseloads. Administrative support for documentation tasks. Clear protocols for complex situations. Permission to escalate policy problems rather than just managing their individual consequences. Recognition that case managers can’t simultaneously implement work requirements flawlessly and maintain their core service missions without additional capacity.
Community Organizations as Infrastructure#
Faith-based organizations, nonprofits, mutual aid networks, and grassroots groups will be essential infrastructure for work requirements implementation. But their participation isn’t guaranteed, and their capacity isn’t infinite.
The Collaboration vs. Resistance Question#
Community organizations must decide whether to help people comply with work requirements – becoming part of implementation infrastructure – or to resist requirements through organizing, advocacy, and support for non-compliance.
Arguments for collaboration: People need help now. Refusing to provide navigation support because you oppose the policy doesn’t hurt the policy, it hurts the individuals who lose coverage. Organizations have missions to serve vulnerable populations. Work requirements exist whether organizations support them or not. Better to help people navigate successfully than to let them fail on principle.
Arguments for resistance: Helping people comply makes the system work better, extending its life and legitimizing it. Organizations become government contractors implementing policies they view as harmful. Resistance through documentation of failures, legal challenges, and political organizing is the path to eventual policy change. Focusing on individual compliance distracts from systemic change.
Many organizations will attempt both – providing individual navigation support while simultaneously advocating for policy change. This “both/and” approach requires careful internal communication so staff and volunteers understand the organization’s position and don’t burn out from cognitive dissonance.
Capacity and Sustainability#
Even organizations willing to support work requirements implementation face capacity constraints. Churches already running food pantries now add credentialing for volunteer coordinators. Nonprofits already providing case management now handle work requirements questions alongside housing, food, and healthcare navigation.
State contracts to fund navigation services help but create dependency and constraint. Organizations funded to provide navigation must deliver defined services, report specified metrics, and maintain funder relationships. Mission drift becomes real risk – organizations gradually become work requirements implementers rather than community institutions that happen to help with work requirements.
The most sustainable model is hybrid: state funding for core navigation capacity, foundation support for advocacy work, earned revenue from fee-for-service where possible, and volunteer engagement for community-driven support. Diversified funding protects organizational autonomy while providing stability.
Trust and Credibility#
Organizations known for advocacy and support of low-income communities can leverage existing trust. Organizations without established community relationships will struggle regardless of technical capacity. A well-funded navigation program run by an organization the community doesn’t know will be less effective than a resource-strapped program run by a trusted community institution.
This creates equity concerns. Well-resourced communities with strong institutional infrastructure can provide navigation capacity. Under-resourced communities already lacking institutional support won’t suddenly develop it for work requirements. The result is predictable: geographic variation in effective access despite identical state policies.
Community-Centered Micro-entrepreneurship#
Beyond traditional employment and formal volunteer structures lies a third pathway: Community Inclusive Social Enterprises (CISE) that transform compliance into community capacity building. This approach recognizes that many people subject to work requirements have skills, knowledge, and experience that their communities need – but these assets operate outside formal labor markets.
The CISE Model#
What if communities could define their own needs and credential their own experts to meet them? What if someone who successfully navigated work requirements while managing diabetes could be compensated for helping others do the same? What if someone who figured out how to balance multiple part-time jobs with childcare could earn income teaching others those strategies?
This is the CISE model: small-scale, peer-to-peer services that meet community needs while providing income that satisfies work requirements. It’s not traditional employment with employers paying wages. It’s not volunteering – people receive compensation. It’s a third category that combines economic activity with community mutual aid.
Maria successfully navigates work requirements while working three jobs and raising her nephew. Other women in her church face similar challenges and ask for help. Maria becomes a credentialed CISE provider – not employed by an organization but operating as an independent microenterprise. She charges $20 for an initial consultation and $10 monthly for ongoing support. This income and hours count toward her own work requirements while providing useful service. She helps five people, generating $150 monthly and 15-20 hours counting toward her requirements.
Volunteering Credit for Peer Support#
Not everyone wants or needs income from helping others – some people simply want to support their communities while meeting work requirements. States should create clear pathways for Medicaid members to receive work requirement credit for volunteer peer support activities: navigation assistance, documentation support, exemption advocacy, peer education, and community organizing.
Someone might spend 20 hours monthly as paid CISE provider and 10 hours as volunteer peer supporter, reaching their 80-hour requirement entirely through helping others navigate the same systems they’re navigating. This transforms work requirements from individual burden into community organizing opportunity.
The Infrastructure Requirements#
For community micro-entrepreneurship to work at scale, several infrastructure pieces must exist:
Credential recognition: States or community organizations credential peer experts – not professional licensing, just verification of successful navigation and basic training
Payment mechanisms: Community currencies, time banking, micro-grants, or sliding-scale fees enabling exchange when cash is constrained
Liability protection: Clear guidelines about what peer navigators can and cannot do
Quality mechanisms: Training, mentorship, feedback systems ensuring quality without burdensome credentialing
Connection to formal services: Warm handoffs to professionals for situations beyond peer capacity
The model extends beyond navigation to any community need where lived experience creates expertise: disability accommodation consulting, skill sharing networks, community care cooperatives, documentation services. The income is usually modest ($50-200 monthly) but meaningful for someone already working near the 80-hour threshold. It’s also dignified work – being paid for expertise rather than charity.
The Matching Infrastructure#
For peer micro-entrepreneurship to scale, communities need ways to match people who need help with people who can provide it. This requires lightweight marketplace infrastructure – simple apps or websites where seekers post needs, providers post offerings, and the system suggests matches based on lived experience, language, geography, availability, and service type.
Not everyone will use digital platforms. Community centers, churches, libraries, and gathering places can facilitate matching through physical bulletin boards, regular matching events, or trusted community members who know both who needs help and who can provide it. The key is documenting hours in ways that satisfy work requirements while respecting community economic practices.
Effective matching considers multiple dimensions: health conditions, family structures, employment contexts, geographic contexts, cultural and linguistic contexts, trauma and adversity. The more dimensions of shared experience, the more effective the support. Trust forms more readily when someone seeking help sees that a potential helper has navigated similar circumstances.
Individual Agency and Self-Advocacy#
Amid discussion of systems and support services, it’s easy to lose sight of individual agency. People subject to work requirements aren’t passive recipients of services – they’re active agents making decisions, developing strategies, and advocating for themselves.
The most basic form of self-advocacy is understanding requirements, exemptions, and processes. People who know they can apply for caregiving exemptions, that volunteer hours count, or that they can dispute incorrect denials have power that those who don’t know these things lack. States can improve information equity through plain-language materials in multiple languages, community information sessions, partnerships with trusted messengers, and proactive notification.
People will develop creative strategies for meeting requirements that policy designers didn’t anticipate. If caregiving doesn’t count but volunteering does, maybe the parent collective becomes a formal nonprofit where parents “volunteer” to care for each other’s children. These workarounds exist in gray areas – not fraudulent but instrumental compliance focused on meeting documentation requirements rather than the spirit of promoting employment. Their prevalence indicates whether requirements align with reality.
Some individuals will engage in organized advocacy – testifying at hearings, participating in litigation, joining organizing campaigns, sharing stories with media. Organizations can support this by providing logistical support, training, connection to legal advocates, and privacy protection – ensuring decision-makers encounter the human consequences of their choices.
Building Trust Across Power Differences#
Effective human infrastructure requires trust between people with vastly different power and resources. Trust requires transparency about what helpers can and cannot do, respecting autonomy and expertise (“What times could you realistically work?” not “You should look for a second-shift job”), culturally responsive practice that adapts to cultural contexts rather than expecting populations to adapt to standard approaches, and acknowledging power imbalances while working to mitigate them.
Some organizations experiment with peer-to-peer structures where people with lived experience are integrated into service delivery rather than cordoned off as “clients.” Former clients become peer navigators. Service users participate in organizational governance. People currently navigating work requirements advise on how to improve support services. These approaches partially equalize power while bringing valuable expertise to service design.
When Systems Fail: Escalation and Advocacy#
Even well-designed systems with adequate human support will fail for some people. The human layer must include escalation pathways for when front-line navigation isn’t sufficient.
Internal escalation means moving from direct service staff to supervisors, from line staff to policy experts, from individual problem-solving to systemic issue identification. This requires clear protocols so staff know when and how to escalate, permission to escalate without being seen as failing, and capacity to respond to escalations.
External advocacy – legal challenges, media attention, political pressure, agency complaints – becomes necessary when internal processes fail. Legal aid organizations play critical roles but are chronically under-resourced. Media advocacy creates political pressure but requires people willing to share personal stories publicly. Legislative advocacy requires navigating political processes and maintaining relationships with decision-makers.
One critical function of the human layer is documenting how work requirements function. Individual stories matter, but so do patterns. How many people are denied exemptions they should receive? How long does exemption processing take? What barriers do specific populations face? This documentation supports individual appeals, creates evidence for policy advocacy, informs litigation, and enables continuous improvement.
The Exhaustion Economy#
A theme running through all human infrastructure is exhaustion. Case managers are exhausted. Navigators burn out. Community organizations stretch beyond capacity. Individuals seeking help are exhausted from life circumstances before adding navigation burden.
Work requirements create an exhaustion economy where the labor of maintaining coverage falls on people and organizations least able to shoulder additional burden. This isn’t accident – it’s inherent to policies that create administrative barriers as rationing mechanisms.
When exhaustion is widespread across people in similar roles facing similar demands, it’s systemic not individual. Systems that require unsustainable human effort are poorly designed systems. The solution isn’t expecting individuals to develop better coping mechanisms – it’s redesigning systems to require less human effort or providing adequate resources for the human effort required.
Sustainable human infrastructure requires realistic workloads, adequate compensation, administrative support, supervision and debriefing opportunities, and recognition that this work is difficult. For individuals navigating requirements, sustainability means systems simple enough to navigate without extensive support, grace periods when life circumstances prevent compliance, and acknowledgment that maintaining coverage while working, caregiving, and managing health conditions is legitimately difficult.
What Success Looks Like#
Successful human infrastructure isn’t measured by compliance rates alone – it’s measured by whether people experience support systems as helpful.
People should encounter information when they need it, in formats they can access, from sources they trust. They should receive help that respects their autonomy and expertise. They should find that when they ask for help, someone responds with knowledge and caring. They should experience system navigation as challenging but manageable rather than overwhelming.
Navigators and case managers should feel their work is valued, their expertise respected, and their workloads sustainable. They should have resources to address problems they encounter rather than just managing their consequences. They should experience support from supervisors and organizations when situations are difficult.
Community organizations should maintain their missions and autonomy while helping people navigate work requirements. They should have funding adequate to capacity needed. They should be able to advocate for policy change while providing individual support without those activities being seen as conflicting.
The measure of success is whether the human layer enables people to navigate work requirements without losing the healthcare coverage they need and depend on. That’s the standard against which the next 10 months of human infrastructure building should be judged.
This completes the implementation trilogy focused on state choices. Articles 2A (verification systems), 2B (exemption systems), and 2C (human infrastructure) together provide comprehensive perspectives for states and organizations building work requirements implementation capacity.
Next in this series: What health insurers can do – turning enrollment volatility into care continuity when work requirements make coverage conditional
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