Estimating Effects Using National Survey Data
Report Publish Date: March 23, 2025
This journal article examines the effects of an Arkansas policy requiring adults ages 30 to 49 to work or engage in other approved activities in order to keep their Medicaid benefits.
Arkansas’ work requirements increased the percentage of people without insurance (from 22.6% to 29.9%) and did not boost employment.
“Our finding that coverage impacts were concentrated among adults without internet access reinforces qualitative evidence that this group faces particular difficulty navigating systems for reporting work activities that primarily rely on web-based portals,” the authors write.
Proponents of work requirements for people on Medicaid say they want to increase employment. But past studies have found that most Medicaid recipients are working, in school, or unable to work and that work requirements increase the number of people without insurance without boosting employment.
The authors of this study wanted to add to the body of evidence about work requirements by examining the effects of a short-lived policy in Arkansas and comparing it to other states.
The authors used American Community Survey data and “difference-in-differences" analysis to compare affected adults in Arkansas to similar adults in other states that have expanded their Medicaid programs.
“Implementation of Arkansas' work requirements policy was associated with an increase in uninsurance among the targeted age group and no significant change in employment or work effort.”
Anuj Gangopadhyaya, Loyola University, and Michael Karpman, Urban Institute
The authors say their findings suggest that putting in place national work requirements like those rolled out for a short period in Arkansas would lead to "lower Medicaid enrollment and an increase in the number of uninsured adults.”
Objective: We examine the health insurance coverage and employment effects of an Arkansas Medicaid waiver establishing work requirements for adults with Medicaid.
Study Setting and Design: Using 2016–2019 data from the American Community Survey, we assessed the effects of a Section 1115 waiver requiring adults ages 30–49 in Arkansas to work or participate in community engagement activities for 80h per month to maintain Medicaid benefits. A difference-in-differences analysis compared changes in coverage and employment among likely nonexempt adults in Arkansas with peers in other Medicaid expansion states. We focused on changes between the 2016–2017 pretreatment and 2018–2019 posttreatment periods, using randomization inference (RI) for statistical inference.
Data Sources and Analytic Sample: Our study population included adults ages 30–49 likely nonexempt from the policy re- siding in Arkansas and other Medicaid expansion states. We focused on adults with incomes below 300% of the federal poverty level (FPL), with heterogeneity tests for those below 100% FPL, who were most exposed to the policy. We repeated our analysis for unaffected age groups (19–29 and 50–64) and potentially exempt groups (e.g., parents with dependent children) as placebo tests.
Principal Findings: From 2016 to 2019, the share of uninsured adults ages 30–49 in Arkansas increased from 22.6% to 29.9%. Work requirements were associated with a 4.4 percentage-point increase (RI p = 0.04) in uninsurance, concentrated among those with incomes below 100% FPL (7.4 percentage points) (RI p=0.05). This occurred alongside a decline in reported Medicaid/ private nongroup coverage and no significant change in employer coverage. No coverage impacts were observed for unaffected or exempt groups. The association between work requirements and employment among the affected age group (−0.7 points) (RI p = 0.62) was negative, small, and statistically insignificant.
Conclusions: Implementation of Arkansas' work requirements policy was associated with an increase in uninsurance among the targeted age group and no significant change in employment or work effort.
Health Services Research, 2025; 0:e14624; https://doi.org/10.1111/1475-6773.14624
Trends in health insurance coverage by state and age group, 2012–2019. Health insurance coverage is reported at the time of the survey.
Trends in employment by state and age group, 2012–2019.
This study and report was conducted and created by the following people.
