The Issue

In 2018, Arkansas became the first state to implement work requirements in Medicaid. These rules specify that adults must spend a certain number of hours working or on another activity, like school or job-training, or lose their Medicaid coverage. For their new study in the New England Journal of Medicine, Commonwealth Fund–supported researchers led by Benjamin Sommers, M.D., of the Harvard T.H. Chan School of Public Health examined how insurance coverage and employment changed in the early aftermath of Arkansas’s work requirements. The analysis compared 30-to-49-year-olds, the group that was subject to the state’s new requirements, with younger (ages 19 to 29) and older (ages 50 to 64) adults, who were not. It also looked at outcomes for adults in three comparison states: Kentucky, Louisiana, and Texas.

17,000 Number of adults who were removed from Medicaid between October and December 2018 in Arkansas after the state implemented work requirements in its Medicaid program

What the Study Found

  • After Arkansas implemented work requirements, the share of 30-to-49-year-old Arkansans with Medicaid or marketplace coverage fell from 70.5 percent in 2016 to 63.7 percent in 2018, a decline of 6.8 percentage points. Coverage rates for other age groups in Arkansas and for non-Arkansas residents showed smaller changes, ranging from an increase of 3.9 percentage points to a decrease of 1.3 points.
  • The uninsured rate in the 30-to-49 group increased from 10.5 percent in 2016 to 14.5 percent in 2018, with smaller or no changes in the other groups. Employer coverage for this group increased slightly, from 10.6 percent to 12.2 percent, but was within the survey’s margin of error.
  • Employment declined from 2017 to 2018, and self-reported disability increased. Employment declined from 42.4 percent to 38.9 percent among 30-to-49-year-old Arkansans, a drop of 3.5 percentage points. Employment rates in the other comparison groups experienced a similar decline. There were no significant changes in hours worked in Arkansas either.
  • Many Medicaid beneficiaries were not aware of the work requirements or were confused about them, with 33 percent of adults ages 30 to 49 who had Medicaid or marketplace coverage reporting they had not heard anything about the policy. And nearly half the target population was unsure whether the requirements applied to them.

The Big Picture

The first six months of Arkansas’s work requirements resulted in a significant loss of Medicaid coverage and a significant rise in uninsured rates, indicating that many people who lost Medicaid coverage did not obtain other health coverage. Researchers found no significant changes in employment associated with the work requirements. Most people who were targeted by the policy had already met the work requirement or should have been exempt. In addition, Medicaid beneficiaries were unaware of the policy or confused about how to report their status to the state. According to the authors, these findings suggest that “bureaucratic obstacles played a large role in coverage losses under the policy.”

The Bottom Line

The first six months of Arkansas’s Medicaid work requirements resulted in a loss of health care coverage and failed to increase employment rates.