Déjà vu: Work Requirements in Medicaid Echo Lessons from SNAP and TANF

By Suzanne Wikle

Last year, Arkansas became the first state to kick people off Medicaid for not meeting work reporting requirements. More than 18,000 Arkansas residents lost their health insurance in just six months before the courts forced Arkansas to stop disenrolling Arkansans. 

A new study published last week in the New England Journal of Medicine confirms what health policy experts and advocates predicted all along. Many eligible people lost their health insurance even though they were working enough to meet the state’s requirements. And many others should have been exempt by the state’s guidelines. In fact, 97 percent of those subject to the policy met the requirement or should have been exempt. 

Furthermore, the study found no significant changes in employment. This is a key point: despite proponents touting their desire to increase employment as the main driver of work requirements, the policy did not lead to greater employment. Rather, it led to a “significant loss of Medicaid coverage and rise in the percentage of uninsured persons.”  

One might think this new research will cause supporters of these disastrous policies to pause and rethink their approach. Call me cynical, but I don’t expect that to happen. We knew from the very beginning these policies would not work because they haven’t worked in other programs. In fact, a spokesperson for the Arkansas Department of Human Services responded to the research by saying that “the best way to get answers……would be to let Arkansas continue what was started and conduct a true evaluation over time.” Just how much time the state thinks it’ll need to prove people aren’t losing health insurance is unclear.

The new research is important because it gives us clear data about what really happened in Arkansas—and what’s likely in other states that implement Medicaid work requirements—but the outcomes here shouldn’t surprise anyone. In fact, they align very well with what’s happened in both the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF).

For more than 20 years, both SNAP and TANF have had work requirements for certain populations, and we know these work requirement policies are not effective in connecting people to long-term jobs. Any improvements in employment outcomes are often temporary. And when people do get hired, the jobs often don’t provide living wages or benefits such as health insurance or paid time off. As the “gig economy” grows and more people are involuntarily working part-time, it becomes even harder for workers paid low wages to climb the economic ladder. This is particularly true for Hispanic and Black workers, who have been hardest hit by the structural shift toward involuntary part-time work.

We also know that work requirements in SNAP and TANF lead to a decrease in enrollment—another key finding of the Arkansas research. The red tape and complexity of work requirements present hurdles that many people simply can’t successfully navigate. We know that for every additional piece of paperwork required it becomes more difficult for someone to successfully apply for and retain SNAP, TANF, or Medicaid. The Arkansas research confirms this—“our findings suggest that work requirements have substantially exacerbated administrative hurdles to maintaining coverage.” 

Someone unfamiliar with the history of work requirements in SNAP and TANF may look at the Arkansas research and conclude that the policy has failed because it produced no increase in employment and a decrease in Medicaid enrollment. I would argue that the policy worked exactly as its designers expected because they knew the SNAP and TANF history. The question now is whether they will be able to keep hiding behind the smoke-and-mirrors argument that they are trying to promote work, rather than attempting to place so many hurdles that it becomes too difficult for people to access a program for which they are eligible.