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June 21, 2019

Medicaid work requirements don't boost employment, new study suggests

Daily Briefing

    After Arkansas implemented Medicaid work requirements, thousands of adults lost their health insurance and unemployment among Medicaid-eligible adults rose, according to a study published Wednesday in New England Journal of Medicine.

    Your cheat sheets for understanding health care's legal landscape


    According to Kaiser Health News, the Trump administration has embraced the idea of applying work or other "community engagement" requirements to state Medicaid programs. The administration and other proponents of the practice argue that the requirements encourage Medicaid beneficiaries to find jobs, which in turn could improve their lives. However, critics of the proposal have said the requirements are contrary to Medicaid's purpose of providing health coverage and could result in coverage losses.

    So far, CMS has approved Medicaid work requirements in nine states, and six other states have pending applications, Kaiser Health News reports.

    Arkansas in June 2018 became the first state to phase in Medicaid work requirements. The state's requirements initially applied to non-disabled individuals ages 30 to 49 enrolled in its Medicaid expansion program, Arkansas Works. Affected individuals were required to work a minimum of 20 hours per week or 80 hours per month, participate in job training programs, or volunteer to remain eligible for Medicaid coverage.

    However, U.S. District Court Judge James Boasberg in May struck down the requirements in Arkansas, as well as similar requirements in Kentucky. Boasberg in his rulings for both cases said the federal government failed to demonstrate how work requirements would advance Medicaid's purpose of providing health coverage.

    Study details

    For the study published Wednesday, Harvard University researchers sought to compare changes in employments rates, uninsured rates, and Medicaid coverage rates among Arkansas residents ages 30 to 49—who were subject to the work requirements—and residents ages 19 to 29 and 50 to 64, who were not yet subject to the state's work requirements. The researchers also sought to compare the outcomes with residents in Kentucky, Louisiana, and Texas, which they used as comparison states.

    To do so, the researchers conducted a phone survey of about 3,000 low-income adults in Arkansas, Kentucky, Louisiana, and Texas between 19 and 64 years of age. The researchers compared those survey results to a previous survey their team conducted in 2016, before Arkansas implemented its Medicaid work requirements.

    Study shows more adults were uninsured, unemployed after work requirements 

    Overall, the researchers found no evidence that the adults who lost coverage after Arkansas implemented the requirements found employment or gained insurance.

    According to the researchers, the employment rate decreased among Arkansas adults ages 30 to 49 who were eligible for Medicaid, declining from 42% in 2016 to less than 39% in 2018. At the same time, the uninsured rate increased from 10.5% to 14.5% among those adults, according to the study. The researchers said their findings were in line with state data showing nearly 17,000 adults were removed from Medicaid between October and December 2018.

    The researchers noted that the work requirements only had a small chance of success, as almost 97% of Arkansas respondents ages 30 to 49 who were eligible for Medicaid were already employed, making them exempt from the requirement.

    As for why so many residents lost coverage, the researchers found that one-third of Arkansas respondents who were subject to the requirements did not know they existed, and 44% were not sure if the requirements applied to them. "Lack of awareness and confusion about the reporting requirements were common, which may explain why thousands of individuals lost coverage," the researchers wrote.


    The study's findings support arguments from experts and advocates that many Medicaid-eligible adults already have jobs, and directly contradicts claims by the administration and state officials that adults who lost coverage found jobs, KHN reports.  

    When asked whether the study results prove that the administration should shut down the work requirements, Benjamin Sommers, co-author of the study and professor of health policy and economics at Harvard, told KHN, "It's time for them to pump the brakes at the very least."

    "Based on our results so far in Arkansas, it doesn't appear that this particular policy is accomplishing its goals," he said, adding, "It does not make sense to keep approving the same waiver without doing anything differently."

    But Arkansas officials said the study results cannot fully demonstrate the effects of the program, because the work requirements were in effect for less than a year because of the judge's ruling. The officials also said the researchers did not look into why adults who lost coverage did not reapply for Medicaid.

    "So you cannot describe this as the robust evaluation … of a demonstration project that truly has national significance," said Amy Webb, a spokesperson for Arkansas' Medicaid program. The best way to measure the effects of the requirements "would be to let Arkansas continue what was started and conduct a true evaluation that follows people over time," Webb said (Galewitz, Kaiser Health News, 6/19; Diamond, "Pulse," Politico, 6/20).

    Where the states stand on Medicaid expansion

    The Supreme Court ruling on the Affordable Care Act (ACA) allowed states to opt of the law's Medicaid expansion, leaving each state's decision to participate in the hands of the nation's governors and state leaders.

    The Daily Briefing editorial teams have been tracking where each state stands on the issue since the ruling, combing through lawmakers' statements, press releases, and media coverage. In this latest iteration of our Medicaid map, we've determined each state's position based on legislative or executive actions to expand coverage to low-income residents using ACA funding.

    Get the Map

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