In June 2018, Arkansas imposed work requirements as a condition of eligibility on beneficiaries of the state’s Medicaid expansion program, called Arkansas Works. Adults between the ages of 30 and 49 with incomes up to 138 percent of the federal poverty level had to report 80 hours a month of work or community engagement activities to the Arkansas Department of Human Services or risk losing their health coverage. For those not exempt from the requirement, failure to complete and report sufficient work activity for three months during a calendar year resulted in disenrollment from Arkansas Works for the remainder of the year. By December 30, 2018, more than 18,000 beneficiaries were disenrolled from the program.

To learn more about the implementation and implications of Arkansas’s Medicaid work requirement, we visited Little Rock for two days and interviewed a wide range of stakeholders—including state Medicaid and Department of Workforce Services officials, health care providers, health plans, consumer advocates, and policy researchers—and held two focus groups with people who were either currently enrolled in Arkansas Works or had been enrolled but lost coverage after not complying with the state’s work requirements, meaning they either did not or could not report the requisite work or community engagement hours.

We found that focus groups participants, and even many system stakeholders, did not clearly understand the rules of the work requirements and that structural barriers and administrative challenges further inhibited compliance. As a result of state outreach efforts that some people we interviewed described as “robust,” all focus group participants reported having heard of the work requirements. Yet, the majority either didn’t understand the requirements or thought the requirements didn’t apply to them. Furthermore, most stakeholders believed that state outreach efforts—which relied heavily on traditional mail and phone calls—did not reach many Arkansas Works beneficiaries.

Stakeholders praised the Department of Human Services’ effort to conduct data matches to proactively identify the roughly two-thirds of Arkansas Works beneficiaries who were exempt from reporting. But both key informants and focus group participants agreed that the state’s primarily online system to report work and community engagement activities was poorly designed and presented many difficulties that caused consumers a lot of frustration. Further, though the Department of Workforce Services was positioned to help beneficiaries transition to employment, people we interviewed reported that beneficiaries had difficulty accessing employment and training services and that knowledge of those services was not widespread. Some focus group participants said that challenges related to confusion, poor access to a computer and the internet, and difficulty using the online reporting system caused them to lose Medicaid coverage, and losing Medicaid affected their ability to obtain needed care. Many participants who were disenrolled from Medicaid for not reporting the requisite work or community engagement hours, or for being unable to report such activity, only found out when they tried to seek medical care or fill a prescription at a pharmacy; they all claimed they had not received notices from the state. Losses of coverage also appear to hold implications for health care systems; for example, public health care providers, hospitals, and Medicaid health plans all expressed concern over increases in “self-pay” and charity care (i.e., uninsured) patients and decreases in coverage.

Though the federal courts have yet to determine the fundamental legality of Medicaid work requirements, key informants and focus group participants identified several lessons learned and potential strategies to address the challenges surrounding Arkansas’s Medicaid work requirements—strategies that could help reduce coverage losses and promote individuals’ ability to work—including expanding the scope, depth, and intensity of community-based outreach and education efforts; expanding and simplifying the means and methods available for reporting work and community engagement activities; and increasing funding for work support agencies and infrastructure