Abstract
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 80 h 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 residing 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.