Study Links AR Medicaid Work Requirements to Coverage Losses

Arkansas’s decline in Medicaid coverage has been linked to the state’s implementation of a work requirement for Medicaid enrollees between 30 and 49 years old, according to a study approved by Harvard T.H. Chan School of Public Health.

Arkansas is one of nine states to receive a Section 1115 federal waiver to apply Medicaid work requirements. In 2018, it became the first state to enact the measure.

Researchers conducted the study from November 8 to December 30, 2018, concluding approximately three months before a federal judge ended the work mandate due concerns over coverage outcomes.

Under the new regulation, Medicaid beneficiaries age 30 to 49 were required to spend at least 80 hours a month doing one of the following activities: employment, job search, job training, or community service. Enrollees would be removed from Medicaid after three months of refusal or inability to comply.

The state extended exemptions to full-time students, caregivers of child or household member, and those in substance abuse treatment programs.

Survey respondents were divided into three groups: those ages 19 to 29, 30 to 49, and those 50 to 64 years old who were eligible for Medicaid or the ACA marketplace. The study also drew statistics from control states Kentucky, Louisiana, and Texas.

For Arkansas residents who fell underneath the Medicaid work requirement, 95 percent either met the requirements or qualified for an exemption.

In the study, coverage dropped from 70.5 percent to 63.7 percent between 2016 and 2018, respectively. By December, 17,000 enrollees lost Medicaid coverage.

The number of uninsured in the bracket affected by the waiver rose from 10.5 percent to 14.5 percent. Employer-insured respondents increased by 1.6 percent.

When compared with control states—Kentucky, Louisiana, and Texas, none of which have Medicaid work requirements but which were in the highest poverty quartile nationally like Arkansas—13.2 percent more 30- to 49-year-old Arkansas residents lost their marketplace or Medicaid coverage than in the other states.

Among Arkansas Medicaid or ACA marketplace members, 32.9 percent in the 30 to 49 age range had not heard about the new mandate and half were unsure whether they fell under those requirements.

Over 40 percent of Medicaid enrollees had not submitted their work or community engagement hours believing they had not met the requirement. Based on these enrollees’ other survey answers, however, all 22 of them had met the requirement. Of the remaining non-compliant individuals, 32.3 percent did not respond due to lack of internet access and 17.8 percent because of confusion about the process.

“We found that implementation of the first-ever work requirements in Medicaid in 2018 was associated with significant losses in health insurance coverage in the initial 6 months of the policy but no significant change in employment,” the Arkansas study concluded.

The report also mentioned that the losses in Medicaid coverage were not followed by a rise in employer-insured individuals or significant changes in employment.

“Although our confidence intervals are wide enough that policy-relevant changes cannot be ruled out,” the researchers add, “nearly everyone who was targeted by the policy already met the requirements, so there was little margin for the program to increase community engagement.”

They note that in December 2018 a telephone reporting option was added, as an alternative to internet reporting. Also, due to the amount of confusion surrounding rule, it is impossible to ascertain whether the loss of coverage could be due to income variance, renewal incompletion, or other variables as opposed to failure to meet the work requirements.

Separate research mirrors these findings, particularly findings related to beneficiaries’ ability to submit their work or community engagement hours. Research from the Kaiser Family Foundation predicted that these factors would impede the waiver’s success.

In June 2018, while the waiver was still in effect, KFF reported on the impacts of Medicaid work requirements and potential challenges expanded Medicaid programs may face. The study noted that, nationwide, one in three Medicaid adults under age 65 have never used a computer. In addition, 28 percent do not use the internet and 41 percent never use email, though this encompasses all ages up until 65.

Over six out of ten Medicaid adults nationwide are working and one out of ten non-Supplemental Security Income beneficiaries works multiple jobs.

According to the KFF study, six percent of Medicaid non-exempt adults are not working.