By Benjamin D. Sommers, M.D., Ph.D., Anna L. Goldman, M.D., M.P.A., M.P.H., Robert J. Blendon, Sc.D., E. John Orav, Ph.D., and Arnold M. Epstein, M.D.
The New England Journal of Medicine, June 19, 2019
As of April 2019, nine states have received approval by means of a federal waiver to implement work requirements in Medicaid, and six have applications pending. According to the Centers for Medicare and Medicaid Services, work requirements — also known as community engagement requirements — may promote better health and help beneficiaries escape poverty. However, critics dispute these claims and warn that the policy could lead to large coverage losses.
In June 2018, Arkansas became the first state to implement work requirements in Medicaid. Medicaid beneficiaries 30 to 49 years of age were notified by the state (by mail and informational fliers) that they were required to work 80 hours per month, participate in another qualifying community engagement activity such as job training or community service, or meet criteria for an exemption such as pregnancy or disability. Three months of noncompliance or nonsubmission of monthly online reports within a year led to removal from Medicaid. By December, nearly 17,000 adults were notified by mail that they had been removed from Medicaid. In March 2019, a federal judge halted the program owing to concerns about its effect on coverage. Although several analyses have predicted various results of Medicaid work requirements, data from independent assessments since the policy took effect have been limited. Our objective was to assess early changes in insurance coverage and employment after implementation of the work requirements in Arkansas.
From the Discussion
Using a timely survey involving low-income adults in Arkansas and three comparison states, 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. 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% of the target population appeared to meet the requirements or qualify for an exemption.
Our results show that this loss of Medicaid coverage was accompanied by a significant increase in the percentage of adults who were uninsured, indicating that many persons who were removed from Medicaid did not obtain other coverage.
Although Medicaid has always struggled with high turnover owing in part to legally required annual eligibility redeterminations, our findings suggest that work requirements have substantially exacerbated administrative hurdles to maintaining coverage.
In conclusion, in its first 6 months, work requirements in Arkansas were associated with a significant loss of Medicaid coverage and rise in the percentage of uninsured persons. We found no significant changes in employment associated with the policy, and more than 95% of persons who were targeted by the policy already met the requirement or should have been exempt. Many Medicaid beneficiaries were unaware of the policy or were confused about how to report their status to the state, which suggests that bureaucratic obstacles played a large role in coverage losses under the policy.
By Don McCanne, M.D.
Should there ever be a circumstance in which individuals are deliberately deprived of appropriate health care? There are certainly financial barriers to care, but shouldn’t public policies be designed to remove those barriers? Yet several states are deliberately attempting to erect financial barriers to care for low-income individuals who fail to meet work or community service requirements for Medicaid.
Arkansas led the way and has shown us that Medicaid work requirements caused thousands to lose their Medicaid coverage as the number of adults who were uninsured increased. Further, there were no significant changes in employment suggesting that this policy did not achieve its intended goal. Also the program increases the administrative burden even though health care in the U.S. is already unique for its wasteful administrative excesses. Hopefully, we will not learn what the long-term results of this policy would be since it has been halted by a federal judge, though the Trump administration is appealing the decision.
What is most perplexing is that it seems that our public policies should be designed to enable everyone to receive appropriate health care when they need it, yet they are not. When our public stewards establish or perpetuate policies that impair access to care, then it seems that we should dismiss them and bring in people who actually do care about the health of the nation.
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