Shadowy figures against a wall with various types of jobs written on it
Illustration courtesy of Pixabay and Gerd Altmann

A new study on the impact of Arkansas’ Medicaid work requirement serves as a cautionary tale for other states considering implementing such policies.

That’s according to the lead author, Dr. Benjamin D. Sommers, of the Harvard T.H. Chan School of Public Health.

Sommers and fellow researchers found that the work requirement, which was put in place last year and is now tied up in court, was associated with significant losses in health insurance coverage but no significant change in employment during the first six months of the policy.

“A lot of the people who lost Medicaid ended up uninsured,” said Sommers, a professor of health policy and economics with Chan and the Harvard Medical School.

The researchers also found that many people were unaware of the policy or unsure whether it applied to them.

“Lack of awareness and confusion about the reporting requirements were common, which may explain why thousands of persons lost coverage even though more than 95 percent of the target population appeared to meet the requirements or qualify for an exemption,” according to the study published this month in the New England Journal of Medicine.

The findings are “an indication that we ought to pause and slow down and look at how we’re implementing” Medicaid work requirements, Sommers said. “…We need to figure out what can states do differently. How can they reduce the chance that people get caught up in red tape?”

The results of the study are detailed in a special report, “Medicaid Work Requirements – Results from the First Year in Arkansas.” Last June, that state became the first one in the country to institute a Medicaid work requirement.

Kentucky HEALTH logoThe rule is of interest in Kentucky because Gov. Matt Bevin’s administration has been trying to implement a similar policy as part of a proposed Medicaid overhaul known as Kentucky HEALTH.

In March, a U.S. District Court judge vacated the federal approval of the program for a second time, prompting appeals by the state and federal governments that have yet to be resolved.

The same judge, James Boasberg, ruled against Arkansas’ policy on the same day as Kentucky’s. But the Arkansas policy was in effect long enough to be the subject of the Harvard study and for about 18,000 people to lose their Medicaid coverage.

The Arkansas work requirement — which was being phased in, starting with people ages 30-49 last year — required eligible individuals to complete (and report) 80 hours a month of work, or to do other qualifying activities, in order to keep their benefits.

“When you think about who the work requirements might influence and whose behavior can you change, what we found was that about 40% were already working, another 40% had a disability and couldn’t work, and then there’s still another 10 or 15% who are meeting some of the other categories, either they’re in school or they’re taking care of a child or they’re doing job training,” Sommers said. “So there really was a very small number — only about 5% — who weren’t working but potentially could.

“So if you think about why the policy didn’t succeed in boosting employment, one of the most obvious explanations is just that there weren’t many people who were persuadable” he added. “Most of the people who could work already were and the ones who weren’t working really couldn’t.”

But there was a problem with reporting. “Most of the people who were subject to this didn’t report anything if you look at the state statistics,” Sommers said. “And in our study, again, you know, one out of three didn’t even know about it, and then of those who knew about it and had been told to report … to the state, only half were doing so.”

The Kentucky Cabinet for Health and Family Services, which questions the thoroughness of the study, said it has tried hard to get the word out about Kentucky HEALTH, conducting field interviews, holding forums, posting online and through social media, and to address potential obstacles to reporting.

“The state has gone to great lengths to assure that all reporting can be done from mobile devices, has worked to make sure the screens are easy to navigate and understand, and has designed the computer program to automatically exempt most people who qualify for an exemption,” the Cabinet said in an email Wednesday.

For the Arkansas study, a telephone survey of more than 3,000 low-income adults was conducted in late 2018. About half were from Arkansas and the rest were from a trio of comparison states: Kentucky, Louisiana and Texas. Researchers also used baseline data, involving nearly 3,000 people, from 2016.

The idea was to “compare changes in outcomes before and after implementation of the work requirements in Arkansas among persons 30 to 49 years of age, as compared with Arkansans 19 to 29 years of age and those 50 to 64 years of age (who were not subject to the requirement in 2018) and with adults in three comparison states,” according to the study.

Among 30- to 49-year-olds Arkansans — the policy’s target group — the share of people with Medicaid or Affordable Care Act marketplace coverage declined by nearly 7%, from 70.5% in 2016 to 63.7% in 2018. Meanwhile, groups not affected by the policy experienced smaller or no changes in Medicaid, Sommers said.

Also, the percentage of uninsured in the target group rose to 14.5% in 2018 from 10.5% in 2016, according to the study. But there was a slight increase in the percentage of people with employer-sponsored insurance.

“What we found in the study was that there was a significant increase in the number of people without insurance in the target age group and that there was no change, meanwhile, in employment or the other qualifying community engagement activities, and so we don’t see … the evidence that the policy was having its intended goal of getting people to work,” Sommers said.

Also, many people seemed to be stymied by red tape and misinformation, he said.

“One-third of persons who were subject to the policy had not heard anything about it, and 44% of the target population was unsure whether the requirements applied to them,” according to the study. “Levels of awareness were worse among persons with less education and among adults 19 to 29 years of age, who became subject to the Arkansas requirements in January 2019.”

Lack of internet access was also a barrier, although in late December 2018 Arkansas added a telephone option for people to do their reporting, according to the study.

Jason Dunn
Jason Dunn, policy analyst | Courtesy of Kentucky Voices for Health

Jason Dunn, a policy analyst for Kentucky Voices for Health, doesn’t think the study results bode well for Kentucky.

“We do believe this is what Kentucky is facing if the Kentucky HEALTH waiver is allowed to go forward,” Dunn said via email. “There are many barriers to complying with mandatory work reporting requirements. Without the assistance of case management and supports like transportation, it will set many up for failure.”

Dunn also fears that Medicaid beneficiaries will encounter technology problems if Kentucky HEALTH’s work requirement ever goes into effect.

“We’ve heard many concerns regarding the complexity of signing in to and using the Citizen Connect portal,” he said. “It’s currently being used for the SNAP (Supplemental Nutrition Assistance Program) work reporting requirement, and over 20,000 people subject to the SNAP work requirement have been disqualified. … The method of reporting hours is very similar and uses the same Citizen Connect reporting system.”

The Kentucky Cabinet for Health and Family Services said the state has several advantages as it aims to implement Kentucky HEALTH, including “an aggressive outreach campaign,” “strategic partners who are committed to the program’s success,” and a commitment “to being flexible and proactive in its effort to improve the health of Kentuckians.”

The cabinet also stressed that “the Harvard study does not tell the whole story.”

“Arkansas officials have said the study is not a thorough evaluation, partly because it is based on less than a year’s worth of data, but also because it relies solely on self-report surveys of beneficiaries,” the cabinet said. “It also did not address the fact that most individuals who lost coverage did not re-enroll in January 2019 when they were again eligible.”

This article has been updated to correct the middle initial of Dr. Sommers.

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Darla Carter
Darla Carter is a hometown girl who recently joined the staff of Insider Louisville to mostly cover health. She previously served as a longtime health and fitness writer for The Courier-Journal, where she also worked for the Metro, Neighborhoods and Features departments. Prior to that, the award-winning journalist wrote for newspapers elsewhere in Kentucky and Tennessee, covering a range of topics, from education to courts. She's a graduate of Western Kentucky University, where she studied journalism and philosophy, and is the proud mom of two young children.