Yesterday, the Centers for Medicare & Medicaid Services (CMS) approved Arkansas’s Medicaid Section 1115 waiver amendment application, making it the third state to impose work requirements on its Medicaid expansion population, in addition to Kentucky and Indiana. Unfortunately, Arkansas’s proposal contains one of the most punitive consequences for individuals who don’t meet the requirement: locking them out of coverage until the following coverage year. Since individuals will be considered out of compliance if they don’t meet the 80-hour per month work requirement for three months or more, Medicaid enrollees have the potential to be locked out of coverage for nine months of the year.

In addition to this severe lockout period, Arkansas’s work requirement involves complex and strict administrative processes, which will likely mean even those who are working or eligible for an exemption are at risk of losing coverage simply for failing to meet paperwork requirements. For example, individuals must report their work activities by the fifth day of each month and are only able to report these activities online. Similarly, individuals who believe they are eligible for an exemption can only report this eligibility through electronic submission. Thus, individuals without easy access to the internet, such as those living in rural areas are disproportionately at risk of failing to comply with the work requirement.

Work requirements are likely to worsen health disparities and health outcomes

Arkansas’s proposal also only provides narrow exemptions. For example, individuals who are in active treatment for drug or alcohol addiction are exempt, but not those who are in other stages of the recovery process. As we’ve written previously, some individuals with substance use disorders have a criminal history directly associated with their untreated addiction and face barriers to employment because of their criminal record. Taking into account the disproportionately punitive approaches to substance use in communities of color through the “War on Drugs,” as well as the discrimination people of color face in the job market, these policies are likely to worsen health disparities for these communities. In addition, barriers to coverage and care can worsen maternal and infant health outcomes. The proposal also does not categorically exempt individuals with disabilities and only exempts those who are medically frail and “medically certified” as having a condition that prevents him or her from complying with the work requirement. As a result, individuals with complex health needs could be at risk of losing coverage.

And while it’s true that certain groups are exempt, all Medicaid expansion enrollees, whether they’re working, not working or exempt, will have the burden of proof of proving their circumstances by submitting the right type of paperwork by the right deadline, and will lose coverage if they don’t.

The waiver also contains other harmful provisions that will likely lead to individuals losing coverage and access to care, including limiting retroactive eligibility for the Medicaid expansion population to 30 days prior to the application date, down from 90 days. Arkansas claims that one of its intended goals for the waiver is to “provide continuity of coverage for individuals,” a goal that can hardly be achieved when individuals are denied retroactive coverage for months in which they were otherwise eligible and can be locked out of coverage for the majority of the calendar year. It’s incredibly hard to see how barring someone from health coverage for nine months will help them stay employed or healthy, particularly since having health coverage is key to staying healthy, and being healthy is necessary for being able to work.

Fortunately, CMS did reject Arkansas’ proposal to rollback income eligibility for Medicaid expansion from 138 percent to 100 percent FPL, which would have caused even more coverage disruption and loss. This likely signifies the approach they will take to any similar proposals in the future. However, with the multitude of harms caused by work requirements, coupled with the severe lockout period and restriction of retroactive eligibility, Medicaid expansion enrollees in Arkansas face a tough road regarding keep their coverage and staying healthy.