Benjamin Sommers** and others published an important study with a completely expected result on Wednesday in the New England Journal of Medicine. They surveyed Arkansas to evaluate what was happening with employment and insurance coverage as a result of the state’s decision to implement work requirements for Medicaid:
We conducted a telephone survey 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 — Kentucky, Louisiana, and Texas. ….
Our study had three primary outcomes: the percentage of respondents with Medicaid, the percentage of respondents who were uninsured, and the percentage of respondents reporting any employment. Secondary outcomes were the number of hours worked per week, the percentage of respondents satisfying any category of community engagement requirement (described below), the percentage of respondents with employer-sponsored insurance, and two measures of access to care — the percentages of respondents having a personal physician and reporting any cost-related delays in care….
estimate of changes in the percentage of respondents who were not insured was an increase of 7.1 percentage points (95% CI, 0.5 to 13.6; P=0.04).
Uninsurance rates increased more for the work requirement cohort than other cohorts. This is not an unexpected result. Almost every pre-waiver approval analysis projected significant enrollment drops due to increased paperwork friction. The amount of friction would be a function of how user friendly the roll-out and implementation was; it was not a particularly user friendly process as the reporting system was online only with limited professional office hour availability that made reporting extremely difficult and unlikely for people who did not have reliable internet or worked jobs that did not neatly map to a 9-5 assumption.
Overall, more than 92% of the respondents in all four groups — and nearly 97% of the respondents 30 to 49 years of age in Arkansas — were already meeting the community engagement requirement or should have been exempt before the policy took effect.
Work requirements are targeted at an incredibly small cohort of people who might be able to work but don’t. This is very wide spread pain to sort out the “deserving” vs “undeserving” working poor.
Employment declined from 42.4% to 38.9% among Arkansans 30 to 49 years of age, a change of −3.5 percentage points. The three comparison groups had similar decreases, ranging from −2.9 to −5.7 percentage points.
And work requirements did absolutely nothing for employment.
None of this is particularly surprising. It is good that we have very firm evidence of the obvious as this type of evidence raises the bar in future litigation against arbitrary and capricious waiver approvals. The current federal district court judge who is overseeing lawsuits against work requirements has held that work is not a fundamental purpose of Medicaid. If the study had shown absolutely minimal to no net coverage loss as people shifted to exchange or employer sponsored insurance and significant income gains, then the administration’s argument that this was an evidence based experiment with plausible real gains could hold some water. Instead, this study shows that work requirements are fundamentally paperwork requirements that culls enrollment without producing employment effects.
** DOI: 10.1056/NEJMsr1901772