In June 2018, Arkansas became the first state to implement work requirements in Medicaid. Adults aged 30-49 years were notified that they were required to work 80 hours a month, participate in another qualifying “community engagement” activity, or meet criteria for an exemption. By December, nearly 17,000 adults were notified that they had been removed from Medicaid, and in March 2019, a federal judge halted the program due to concerns about its impact on coverage. Benjamin D. Sommers, Anna L. Goldman, Robert J. Blendon, E. John Orav, and Arnold M. Epstein provide the first independent assessment of early changes in beneficiary coverage and employment after the work requirements went into effect in this New England Journal of Medicine paper.


The research team conducted a telephone survey to compare changes in outcomes before and after implementation and compared to populations that were not subject to work requirements (both in Arkansas, and three other comparison states).

They found:

  • Arkansas’s work requirements were associated with a significant loss of Medicaid coverage and rise in uninsured rates, indicating that many individuals did not obtain other coverage after losing Medicaid coverage.
  • There were no significant changes in employment; more than 95 percent of individuals targeted by the policy already met the requirement or should have been exempt.
  • One-third of individuals subject to the policy had not heard anything about it, and 44 percent were unsure whether the requirements applied to them.

Implications for Policy and Practice

In the last several years, new approaches have been tested across the Medicaid program, including requiring work as a condition of coverage. As of April 2019, nine states have received approval from the federal government to implement work requirements in Medicaid, and six more are waiting to receive a decision on their proposals. Proponents of these requirements suggest they may improve health and help low-income adults rise out of poverty, but critics warn that that many beneficiaries could lose their health insurance. Until now, the effects of work requirements on health insurance coverage were largely unknown.

Overall, Arkansas’s implementation of the nation’s first work requirements in Medicaid was associated with significant losses of coverage but no significant change in employment. A lack of awareness and confusion about the reporting requirements may explain why thousands of individuals lost coverage even though more than 95 percent appeared to meet the requirements or qualify for an exemption. Addressing the administrative burdens and communications challenges will be paramount for other states looking to implement work requirements for Medicaid. The findings also suggest that without additional resources or support for finding jobs, the policy may not succeed in increasing employment. Ongoing evaluation will be necessary to track the long-term effects of losing coverage for the thousands of adults in Arkansas affected by the policy.

Related Evidence

  • Published September 8, 2020

    Arkansas implemented Medicaid work requirements in June of 2018. To maintain coverage in the state, adults ages 30-49 were required to work 20 hours a week, participate in “community engagement” activities, or qualify for an exemption. By April 2019, when a federal judge halted the policy, more than 18,000 adults had lost coverage. As an update to research published in 2018, Benjamin D. Sommers, Lucy Chen, Robert J. Blendon, E. John Orav, and Arnold M. Epstein analyzed the policy effects before, during, and after implementation in this Health Affairs brief.

    View Evidence