Commentary: As Predicted, Arkansas’ Medicaid Waiver Is Taking Coverage Away From Eligible People
Arkansas’ Medicaid waiver provides direct evidence of the effects of taking away Medicaid coverage for not meeting work requirements. Unfortunately, it corroborates the most pessimistic projections.
Since last June, Arkansas has required some enrollees to document that they work or engage in other work activities (e.g., job training or volunteer work) for at least 80 hours per month, unless they report that they qualify for limited exemptions. Before Arkansas began implementing its policy, we and others predicted that it would lead to large coverage losses, including among beneficiaries who are eligible but get tripped up by red tape, and would not meaningfully increase employment. But since work requirements were unprecedented in Medicaid, we based our initial predictions of the policy’s effects on evidence from other types of eligibility restrictions and from work requirements in other federal programs. Here’s how those predictions stack up against the data.
Over 18,000 Arkansas Medicaid beneficiaries lost coverage in 2018 due to the new requirements —almost 1 in 4 people subject to the new rules. The 18,164 people who lost coverage amounts to over 23 percent of all beneficiaries subject to the policy in 2018, even higher than the 15 percent coverage loss Kentucky projected would result from its waiver by the fifth year and the 6 to 17 percent coverage loss that Kaiser Family Foundation researchers forecasted could result from implementing work requirements nationwide.
The harm to beneficiaries will likely continue to grow this year, as Arkansas begins extending the policy to 45,000 beneficiaries aged 19 to 29 and to people with incomes between 100 and 138 percent of the policy. In 2018, the policy applied to those above 29 but below 50 and to those with incomes below the poverty line.
The number losing coverage exceeds the supposed target population: beneficiaries not working and not eligible for exemptions. Studies estimate that around 4 percent of those subject to the work requirement are not working and do not qualify for exemptions. Yet each month, 8 to 29 percent of those subject to the requirement have failed to report sufficient hours, many of them not reporting any hours. And over 75 percent of those required to report hours who are not automatically exempted by the state have failed to do so each month.
News accounts corroborate that eligible people are losing coverage. For example, one working beneficiary with a chronic condition described losing his Medicaid coverage and then being unable to afford medications, in turn losing his job due to his deteriorating health. Another reported rationing her medication after being unable to navigate the reporting requirement and losing coverage, despite working 25 to 35 hours each week — which equates to well over the monthly minimum.
Arkansas’ web portal has created problems, but challenges for beneficiaries go well beyond it. Many have rightly criticized Arkansas’ decision to initially restrict reporting to an online portal. More than 20 percent of Arkansas beneficiaries lack internet access, and another 20 percent have no broadband access. In addition, Arkansas’ web portal is unavailable from 9 p.m. to 7 a.m. each day, is not mobile friendly, is not accessible for those with certain disabilities, and requires a complex login procedure.
But while Arkansas has now added a phone reporting option, that does not eliminate the hurdles the policy creates for eligible beneficiaries. These include:
- Complex rules creating significant confusion among beneficiaries. Some beneficiaries apparently believed they could maintain their coverage by reporting work hours just once, not realizing they needed to report every month. Also, clients can only count up to 40 hours of job search each month, but several beneficiaries reported over 80 hours of job search for November. These beneficiaries likely thought they were complying as they diligently looked for work and reported their hours but were not actually within the confines of the rigid policy.
- Lack of staff support. The state hasn’t hired additional staff to answer questions or make accommodations for individuals with disabilities. Arkansas Human Services Director Cindy Gillespie justified the lack of additional staff by saying, “If you implement [work requirements] in the old-fashioned way of ‘Come into our county office,’ we would have to hire so many people — and that just doesn’t make sense.” But by not investing in staff and other resources to support enrollees who should be exempt or need help complying with the requirements, Arkansas is creating a bureaucratic maze that is causing many eligible enrollees to lose coverage.
- Insufficient and ineffective outreach. Some beneficiaries never learned about the new rules in the first place. The state conducted much of its outreach through social media and online videos that failed to reach much of the population without access to computers or the internet. And although the state along with health plans, providers, and advocates conducted outreach to educate beneficiaries about the new work requirement, they failed to reach many enrollees due to inaccurate phone numbers in case files.
Arkansas has failed to protect people with disabilities. While the Centers for Medicare and Medicaid Services (CMS) notified states of their responsibility to comply with the Americans with Disabilities Act, we and others warned that protecting people with disabilities would be impossible. Indeed, Arkansas hasn’t adequately explained beneficiaries’ rights under the Act, and it lacks a comprehensive system for providing reasonable modifications to protect people with disabilities, such as modifying the hourly requirement or providing support to help people meet the reporting requirement. Due to the lack of protections and the design of the work requirement itself, individuals with disabilities are losing coverage and may face serious harm as a result.
The data so far appear inconsistent with any meaningful gains in employment as a result of the policy. While many beneficiaries have met the requirement by working, nearly all of those were people were automatically deemed compliant because they were already working before the new rules took effect or because they complied with work requirements under SNAP (formerly food stamps), which were also already in place. Only the group that has to report hours each month faces any new work incentive due to the policy. And of that group, only a few hundred each month have met the requirement by reporting sufficient work hours, the state reports. What’s more, many of them likely would have found jobs anyway.
These data are consistent with focus group interviews showing that the work requirement isn’t changing most beneficiaries’ behavior. Beneficiaries already had enough reasons to work: they need to pay their bills. But they often struggle with unstable work hours, live in rural areas with few jobs, or face other barriers to employment — and the state hasn’t invested any new money in job training programs, services to address barriers, or supports like transportation to help beneficiaries connect to jobs. The Arkansas data are also consistent with evidence that work requirements in other federal programs have had limited effects on employment.
Few beneficiaries who lost coverage have re-enrolled this year. Individuals who lost coverage last year could have re-enrolled effective January 1, but only about 1,400 of the more than 18,000 who lost coverage have done so. Most of those who lost coverage — many of whom did not even know they were subject to the work requirement — are likely unaware that they are again eligible or may struggle to navigate the application and verification process. Or, knowing that the state will likely end their coverage again after three months of non-compliance with the requirement, some residents may be waiting to enroll until a later time when they need coverage more.
Arkansas’s experience should serve as a warning to other states about the human toll of taking coverage away from people who can’t meet rigid work requirements. No matter how they’re implemented, all work requirements will have unintended and harmful consequences — most notably, taking coverage away from people who are already working or should be exempt. These fundamentally flawed policies can’t be fixed.
 Jennifer Wagner and Judith Solomon, “States’ Complex Medicaid Waivers Will Create Costly Bureaucracy and Harm Eligible Beneficiaries,” Center on Budget and Policy Priorities, May 23, 2018, https://www.cbpp.org/research/health/states-complex-medicaid-waivers-will-create-costly-bureaucracy-and-harm-eligible; Hannah Katch, Jennifer Wagner, and Aviva Aron-Dine, “Taking Medicaid Coverage Away From People Not Meeting Work Requirements Will Reduce Low-Income Families’ Access to Care and Worsen Health Outcomes,” Center on Budget and Policy Priorities, updated August 13, 2018, https://www.cbpp.org/research/health/taking-medicaid-coverage-away-from-people-not-meeting-work-requirements-will-reduce.
 For data availability reasons, we calculate coverage loss as the total cases terminated as of January (18,164) as a portion of the cases subject to the work requirement in September (after all four groups were phased in) plus the number of cases terminated effective September 1. This calculation approximates the reduction in January enrollment, compared to a counterfactual in which the work requirement had not been implemented. (Both the numerator and denominator likely include some people who would have left the program by January even absent the work requirement.) Kentucky HEALTH §115 Demonstration Modification Request, Commonwealth of Kentucky, July 3, 2017, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ky/ky-health-pa2.pdf; Rachel Garfield, Robin Rudowitz, and MaryBeth Musumeci, “Implications of a Medicaid Work Requirement: National Estimates of Potential Coverage Losses,” Kaiser Family Foundation, June 27, 2018, https://www.kff.org/medicaid/issue-brief/implications-of-a-medicaid-work-requirement-national-estimates-of-potential-coverage-losses/.
 Anuj Gangopadhyaya et al., “Medicaid Work Requirements in Arkansas,” Urban Institute, May 24, 2018, https://www.urban.org/research/publication/medicaid-work-requirements-arkansas.
 “With new work requirement, thousands lose Medicaid coverage in Arkansas,” PBS News Hour, November 19, 2018, https://www.pbs.org/newshour/show/with-new-work-requirement-thousands-lose-medicaid-coverage-in-arkansas; Benjamin Hardy, “Locked out of Medicaid — Arkansas’s work requirement strips insurance from thousands of working people,” Arkansas Times, November 19, 2018, https://www.arktimes.com/arkansas/when-arkansas-works-doesnt/Content?oid=25890378.
 Anuj Gangopadhyaya et al., “Under Medicaid work requirements, limited internet access in Arkansas may put coverage at risk,” Urban Institute, October 29, 2018, https://www.urban.org/urban-wire/under-medicaid-work-requirements-limited-internet-access-arkansas-may-put-coverage-risk. Data are for non-elderly, non-disabled Medicaid recipients aged 19-49, the population subject to the work requirement.
 Benjamin Hardy, “Medicaid advocate criticizes Arkansas Works’ email-only reporting for work requirements,” Arkansas Times, April 28, 2018, https://www.arktimes.com/ArkansasBlog/archives/2018/04/28/medicaid-advocate-criticizes-arkansas-works-email-only-reporting-for-work-requirements.
 MaryBeth Musumeci, Robin Rudowitz, and Cornelia Hall, “An Early Look at Implementation of Medicaid Work Requirements in Arkansas,” Kaiser Family Foundation, October 2018, http://files.kff.org/attachment/Issue-Brief-An-Early-Look-at-Implementation-of-Medicaid-Work-Requirements-in-Arkansas.
 “Taking Away Medicaid for Not Meeting Work Requirements Harms People with Disabilities,” Center on Budget and Policy Priorities, updated December 10, 2018, https://www.cbpp.org/sites/default/files/atoms/files/1-26-18health.pdf.
 Anna Bailey and Judith Solomon, “Medicaid Work Requirements Don’t Protect People With Disabilities,” Center on Budget and Policy Priorities, November 14, 2018, https://www.cbpp.org/research/health/medicaid-work-requirements-dont-protect-people-with-disabilities.
 Arkansas Department of Human Services, ARWorks Reports, https://humanservices.arkansas.gov/newsroom/toolkits.
 MaryBeth Musumeci, Robin Rudowitz, and Barbara Lyons, “Medicaid Work Requirements in Arkansas: Experience and Perspectives of Enrollees” Kaiser Family Foundation, December 18, 2018, https://www.kff.org/medicaid/issue-brief/medicaid-work-requirements-in-arkansas-experience-and-perspectives-of-enrollees/.
 LaDonna Pavetti, “TANF Studies Show Work Requirement Proposals for Other Programs Would Harm Millions, Do Little to Increase Work,” Center on Budget and Policy Priorities, November 13, 2018, https://www.cbpp.org/research/family-income-support/tanf-studies-show-work-requirement-proposals-for-other-programs-would.
 Judith Solomon, “Medicaid Work Requirements Can’t Be Fixed,” Center on Budget and Policy Priorities, January 10, 2019, https://www.cbpp.org/research/health/medicaid-work-requirements-cant-be-fixed.