The implementation of Arkansas' Medicaid work requirement coincided with a significant decrease in health insurance coverage among low-income residents and appeared to have no effect on the number who were employed, according to a study published Wednesday in the New England Journal of Medicine.
Conducted by researchers with the Harvard School of Public Health, and Brigham and Women's Hospital in Boston, the study used information from cellphone and landline phone surveys to compare health insurance coverage and employment among low-income Arkansans before and after the work requirement took effect in June of last year.
The study also compared the experience of Arkansas residents with those of Kentucky, Louisiana and Texas, which did not have Medicaid work requirements.
The study findings didn't change Arkansas officials' support for the work requirement, which was suspended by a federal judge in March. A spokesman for Gov. Asa Hutchinson cited other data that show that the requirement had the desired effect of getting Medicaid recipients working.
The Boston researchers found that among Arkansans who were potentially subject to the work requirement based on their ages and income levels, the percentage who lacked health insurance increased from 10.5% to 14.5% from late 2016 to late 2018, while the percentage of uninsured among residents surveyed in the three other states remained the same, at 16.2%.
Over the same period, the percentage of the same Arkansans who reported being covered by Medicaid or plans offered through healthcare.gov dropped from 70.5% to 63.7%. That compared with practically unchanged levels in such coverage in the other states, from 59% to 60.4%.
Meanwhile, the percentage of Arkansans potentially subject to the requirement who worked at least 20 hours a week fell from 42.4% to 38.9%.
That change was not considered statistically significant, however, when compared with a drop in the rate of similarly employed people, from 45.2% to 39.5%, in the other states.
"So far in Arkansas, we're seeing significant harm in terms of lost coverage, without any of the desired benefit of more people working," Harvard School of Public Health professor Benjamin Sommers, the study's lead author, said in a news release.
The Commonwealth Fund, a New York City-based research organization that helped fund the study, described the survey in the release as the first independent look at the work requirement, the first to ever be implemented for a state Medicaid program.
From June 2018 through January, 18,164 Arkansans lost coverage because of noncompliance with the work requirement.
The requirement was rescinded in March, after a federal judge in Washington, D.C., ruled that President Donald Trump's administration exceeded its authority when it approved it and a similar requirement in Kentucky that had not yet gone into effect.
The Trump administration and the two states have appealed the judge's ruling to the U.S. Court of Appeals for the District of Columbia Circuit.
Hutchinson has championed the work requirement as a way to encourage low-income Arkansans to become employed and take responsibility for their health care.
Hutchinson spokesman J.R. Davis noted that the study examined less than a year's worth of results. He contended that other evidence is more favorable.
For instance, he said the records indicate that nearly 15,000 Arkansans subject to the requirement started new jobs from June 2018 through April. That number includes enrollees who were already employed and changed from one job to another.
"The numbers that we've seen indicate that people are working," Davis said.
He also said that only about 4,000 enrollees who lost coverage because of the requirement have re-enrolled, even though all 18,000-plus were eligible to do so on Jan. 1.
Some of those who didn't re-enroll may have found other coverage, such as through a spouse's plan, moved out of the state or no longer qualify based on their income, he said.
Kevin De Liban, an attorney for Legal Aid of Arkansas, said the study confirms what advocates for the poor predicted would happen and saw after the requirement took effect.
The Jonesboro-based group is one of three organizations that filed the lawsuit that led to the requirement being thrown out.
"We've been saying all along that this does nothing to improve the lives of beneficiaries and their prospects for earning more money," De Liban said. "It's simply a punitive policy that results in widespread loss of coverage."
The requirement was phased in last year and in January for enrollees ages 30-49, and was in the process of being added for those ages 19-29 at the time of U.S. District Judge James Boasberg's ruling.
It applied to participants in Arkansas Works, which covers people who became eligible for Medicaid when the state expanded it in 2014 to cover people with incomes of up to 138 percent of the poverty level. That income cutoff is $17,236 for an individual or $35,535 for a family of four.
More than 239,000 people were enrolled in the program as of June 1. Most receive the coverage through private plans, with the Medicaid program paying most or all of the premium.
To meet the requirement, enrollees had to spend 80 hours a month on work or other qualifying activity, such as volunteering, and report what they did using a state website or over the phone.
Those who failed to meet the requirement for three months during a year were kicked off the program and barred from re-enrolling for the rest of the year.
The study found that the percentage of the Arkansans potentially subject to the work requirement who reported having employer-sponsored coverage increased from 10.6% to 12.2% from 2016 to 2018. During the same period, the percentage with other coverage increased from 8.3% to 9.5%. But those increases were not considered statistically significant when compared with changes in the other states.
In those states, the combined percentage with employer-sponsored coverage fell from 15.8% to 13.4%, and the percentage with other coverage increased from 9% to 10%.
Besides enrollees who were working at least 20 hours a week, the study found that nearly all other Arkansas respondents ages 30-49 reported circumstances, such as being disabled, that would qualify for exemptions or reported a combined 20 hours a week of work and other qualifying activities, such as volunteering or looking for employment.
From 2017 to 2018, the percentage of Arkansans whose responses indicated that they were exempt or in compliance with the requirement fell from 96.7% in 2017 to 96.1% in 2018, a decrease that was not considered statistically significant.
At the same time, the study found that 32.9% of respondents who reported having coverage through Medicaid or healthcare.gov had not heard about the work requirement, and 44.2% with such coverage or who were uninsured were unsure whether the requirement did or would apply to them.
The study combined coverage through Medicaid or healthcare.gov plans into a single category since some of the same plans offered through the federal website are used to provide Arkansas Works coverage.
"Lack of awareness and confusion about the reporting requirement were common, which may explain why thousands of persons lost coverage even though more than 95 percent of the target population appeared to meet the requirement or qualify for an exemption," the study's authors wrote.
The study was based on responses from 3,004 residents in Arkansas and the three other states from Nov. 8, 2018, through Dec. 30, 2018, and 2,951 residents surveyed in November and December 2016 for previous surveys.
Like Arkansas, Kentucky expanded Medicaid in 2014. Louisiana expanded its program in 2016. Texas has not expanded its Medicaid program.
Changes in coverage were assessed by comparing the 2016 and 2018 surveys, while employment changes were measured by asking respondents to the 2018 survey about their job status that year and in the previous year.
Sommers and some of the study's other authors have used surveys to track the effect of Medicaid expansion in Arkansas and other states since 2014 on the health of low-income residents.
Arkansas Human Services Department spokesman Amy Webb said in an email that the latest study "does not provide a meaningful or thorough evaluation of the Arkansas Medicaid demonstration project."
Although the study found no effect from the work requirement on two measures of access to health care, Webb said it "does not provide information about the health status of individuals or how they view the importance of insurance."
She said some measures reported in the study were based on a subset of fewer than 50 respondents.
"The best way to get answers to everyone's questions about the impact of work and community engagement requirements would be to let Arkansas continue what was started and conduct a true evaluation that follows people over time," Webb said.
A Section on 06/20/2019