Coverage losses in Arkansas following implementation of Medicaid work requirements

Thousands of adults in Arkansas lost insurance coverage in the first six months after Medicaid work requirements were implemented, with no change in employment, according to a new study from Harvard T.H. Chan School of Public Health. The study is the first quantitative evidence on the nation's first-ever work requirements in Medicaid, which started in Arkansas in June 2018.

"The idea of work requirements is to get people into new jobs and private insurance. But in our study that didn't happen," said Benjamin Sommers, lead author of the study and professor of health policy and economics. "We didn't find any employment changes and instead we see Medicaid coverage rates dropping and more people without health insurance—usually because the process itself was confusing or beneficiaries didn't even know about the new requirements."

The study will be published online June 19, 2019 in the New England Journal of Medicine.

The researchers conducted a telephone survey in late 2018 among low-income citizens ages 19-64. About half the respondents were from Arkansas, the others were from comparison states—Kentucky, Louisiana, and Texas—that had not implemented work requirements.

The researchers found that the policy was associated with significant reductions in insurance coverage for the 30-49 year olds targeted by the policy, but not among individuals in other states not subject to the rules. While the state itself reported that the policy led to 18,000 adults leaving Medicaid in late 2018, it wasn't clear what had happened to them, and defenders of the program have argued that most probably got coverage through new jobs. The study showed that a large portion of this group had not gained other coverage and had become uninsured.

In addition, more than 95% of the low-income individuals in Arkansas subject to the policy were already meeting the work requirements (either working 80 hours a month or participating in a community engagement activity such as job training) or should have been able to gain an exemption (based on disability, childcare, or other factors). But one third of this group hadn't even heard of the requirements (particularly among those with less than a high school degree), and only half were reporting the required information online to the state in order to keep their coverage, primarily due to confusion about the process or lack of internet access. This suggests that many lost coverage due to confusion and red tape, said Sommers.

"Many more states are considering work requirements, and the Trump administration has been eager to support that effort. With these sorts of broad social policy changes, it's really important to have evidence afterwards to see whether they're working as intended. Based on our results so far in Arkansas, it doesn't appear that this particular policy is accomplishing its goals," said Sommers.