Column: Confirmed--Medicaid work rules are a health disaster for the poor and don’t produce jobs

Arkansas Gov. Asa Hutchinson is responsible for a Medicaid work rule that cost thousands of his constituents their health coverage.
(Brian Chilson / Associated Press)
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Ever since Arkansas implemented its first-in-the-nation work requirements for Medicaid in June 2018, the state has functioned as a laboratory for the concept of placing unnecessary obstacles in the way of low-income people seeking health coverage.

The experiment consistently has shown that the policy is catastrophic for the target population’s health coverage. A new study confirms that finding and adds another insight: Medicaid work rules do nothing to increase employment.

The study was produced by a team led by Benjamin D. Sommers of the Harvard School of Public Health and published this week in the New England Journal of Medicine. It was based on a survey of roughly 6,000 residents of Arkansas and other nearby states (for comparison).


In its first 6 months, work requirements in Arkansas were associated with a significant loss of Medicaid coverage.

— Sommers, et. al.

The core finding was that in the group targeted by the first phase of the Arkansas policy — those aged 30 to 49 — coverage from Medicaid and Affordable Care Act marketplace plans declined precipitously. The results indicate that Medicaid enrollment fell by a stunning 12 percentage points. The percentage of uninsured respondents in the 30-49 age cohort rose to 14.5% in 2018 from 10.5% in 2016, “with smaller or no changes in the other groups,” according to the study.

As for the work aspect of the policy, Sommers et. al. say they “did not find any significant change in employment...or in the related secondary outcomes of hours worked.”

To put it bluntly, the study found that “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.”

The loss of insurance coverage is a phenomenon that had been noted by other researchers and official state statistics, which showed that 17,000 Arkansans had been thrown off Medicaid by December. That was enough to unnerve a federal judge, who in March ordered the policy suspended.

It should go without saying that a sharp drop in Medicaid enrollment with no increase in employment is the way a work policy would function in the Bizarro world, to quote Jerry Seinfeld. But the ever-expanding empirical evidence did nothing to move Arkansas policymakers before the judge stepped in.


Nor have the figures or the judge’s ruling — he also blocked a Medicaid work rule scheduled to start in Kentucky — moved healthcare officials at the federal level. Trump’s Department of Health and Human Services, which consistently has moved to narrow healthcare options for low-income Americans, has approved work requirements for Medicaid in seven states, with applications pending from seven more (not counting the two states blocked by the judge).

The Arkansas rule required Medicaid enrollees to show 80 hours per month of employment, job search, job training, or community service. Pregnant women, the disabled, students, and a few other categories were exempt. The work hour reports had to be made online, even thought the reporting website has been out of order for long stretches and many enrollees don’t have adequate internet access.

Among the key flaws of the policy is that 95% of Medicaid enrollees already work or participate in activities that met the necessary threshold or are exempt, which means the ability of the rule to materially affect employment is close to nil.

As others have previously found, one of the major problems of the Arkansas scheme — leaving aside its fundamental malevolence — was that a high percentage of the target population didn’t know about it or didn’t understand the rules. The Sommers study confirmed that, finding that one-third of the target population “had not heard anything about it, and 44% of the target population was unsure whether the requirements applied to them.”

Awareness was worse among those with lower educational levels and adults 19-29 years old, who were made subject to the rules in January. “Our findings suggest that work requirements have substantially exacerbated administrative hurdles to maintaining coverage,” the study says.


Arkansas government officials have blamed Medicaid enrollees themselves for failing to meet the program’s reporting rules. Some “simply chose not to comply,” Gov. Asa Hutchinson said last year. “Personal responsibility is important.”

But that’s gaslighting. The Arkansas program, like Kentucky’s or those of the other applying states, is not about “personal responsibility.” It’s about paring the Medicaid rolls on the principle that anyone needing public assistance must be undeserving.

These rules are nothing but an assault on healthcare for our neediest residents, gussied up as clarion calls to “personal responsibility.” But perhaps it’s wrong to say they don’t work as designed. They throw people off Medicaid, which is exactly what the designers have in mind.

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