“Community engagement requirements are not some subversive attempt to just kick people off of Medicaid.”

“But we also will not draw rash conclusions after only a few months of data and information.”

—Seema Verma, head of the Centers for Medicare and Medicaid Services (Sept. 2018)

In 2018, Arkansas became the first state to implement Medicaid work reporting requirements. Now, following a full year of operation, the “data and information” out of that state has illuminated very troublesome results for those who have pushed for work reporting requirements.

In a study published on June 19 in the New England Journal of Medicine, Benjamin Sommers, M.D., and his colleagues at the Harvard T.H. Chan School of Public Health evaluate the effects of work requirements in Arkansas. The researchers find not only that work reporting requirements did not improve employment and community engagement among the targeted population, but also that work requirements led to ballooning of the uninsured rate.

Arkansas work reporting requirements apply to all Arkansans enrolled in Medicaid who are 30 to 49 years of age and who do not qualify for an exemption such as disability or pregnancy. The state requires these Arkansans to participate in at least 80 hours per month of work or community engagement (vocational training, general equivalence diploma preparation or community service).

Between October and December 2018, Arkansas disenrolled 17,000 people from Medicaid, and those who lost coverage overwhelmingly became uninsured. The researchers found after work reporting requirements were implemented the uninsured rate in the age group rose from 10.5% (2016) to 14.5% (2018).

The study did not find work reporting requirements made any significant changes in employment status, hours worked or community engagement. Employment actually declined in the age group, similar to trends in states used for comparison.

Along with a sharp increase in the number of people who are uninsured, the lack of observed employment effect was predicted by critics of Medicaid work reporting requirements. Past states who instituted work reporting requirements saw little to no growth in employment. Additionally, 96.7% of low-income adults 30 to 49 years of age were already meeting employment requirements or fell under exemption criteria, meaning only 3.3% of the targeted income-age group could have even been influenced by new employment incentives. After work reporting requirements, more—not fewer—adults 30 to 49 years of age did not meet employment or community engagement requirements (3.9%). “There are just not that many people [enrolled in Medicaid] who aren’t working but could,” Sommers explained to KHN.

The study also confirmed something we’ve long suspected – much of the coverage loss from work reporting requirements comes from the burden of having to complete the reporting in the first place.

Medicaid recipients lost coverage after three months of noncompliance or nonsubmission in monthly online reports to the state. Fewer than half of those warned to submit these reports did so regularly. Those who did not cited the reason as lacking Internet access (32.3%) or confusion about reporting (17.8%). 40.4% of these respondents wrongly believed they were not meeting the reporting requirements. With only 1,500 having reenrolled as of March, many who inadvertently lost coverage are still unaccounted for.

Given the grim results in Arkansas, one may assume a lack of interest in work reporting requirements from other states. Instead, proponents have continued pursuing the policy with seven approved waivers including work requirements, seven pending waivers that include work reporting requirements and many more states publicly staking interest in the provision.

Despite an abysmal legacy of work reporting requirement provisions for past safety net programs, conservative lawmakers and Trump administration officials have continued to contend that they can work for Medicaid. CMS and the Trump administration continue to allow and even promote harmful Medicaid provisions, including work reporting requirements, drug testing, and per capita caps. Now, the results are in — thousands have been forced off health coverage with employment unchanged.

Whether or not work reporting requirements were originally a “subversive attempt to just kick people off of Medicaid,” their effects are now clear. This study, combined with Judge James E. Boasberg’s decision in March to halt the implementation of work reporting requirements in Arkansas and Kentucky, sends a strong message that since Medicaid’s purpose is to provide health coverage, policies and costly bureaucracy that cause losses of coverage can in no way promote its purpose.

Blog Author: Max Weiss, Intern, Together For Medicaid