Person:

Goldman, Anna

In recent years, policymakers have introduced unprecedented changes to Medicaid. 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.1 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.2 However, critics dispute these claims3,4 and warn that the policy could lead to large coverage losses.5 Work requirements have been used previously in programs such as the Supplemental Nutrition Assistance Program and the Temporary Assistance for Needy Families program. Studies of those programs showed that work requirements produced modest, short-term increases in employment but no increases in income.6,7 The effects of work requirements in a health insurance program are unclear. 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.8 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.9 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,10-15 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.

Descriptive studies have suggested that the Affordable Care Act’s (ACA) health insurance Marketplaces improved access to care. However, no quasi-experimental evidence is currently available to support these findings. We use longitudinal survey data to compare previously- uninsured adults to adults who had employer-sponsored insurance (ESI) prior to the ACA, in the income range eligible for subsidized Marketplace coverage (138-400% of poverty). Among the previously-uninsured group, the ACA led to a significant decline in the uninsurance rate (-10.8 percentage points), decreased barriers to medical care, increased use of outpatient services and prescriptions drugs, and increased identification of high blood pressure, compared to a control group with stable ESI. Changes were largest among those with incomes between 138-250% of poverty, who were eligible for the ACA’s cost-sharing reductions. Our quasi-experimental approach provides rigorous new evidence that the ACA’s Marketplaces led to improvements in several important health care outcomes, particularly among lower-income adults.