In March 2025, the State of Arkansas requested to amend its Arkansas Health and Opportunity for Me Section 1115 Medicaid demonstration waiver by establishing a work requirement for all adults ages 19 to 64 who are covered by qualified health plans through the state’s Medicaid expansion program. The state designed its amendment to reflect lessons from a previous waiver, in which Arkansas implemented a work requirement that resulted in the disenrollment of more than 18,000 adults from the state’s Medicaid expansion program in 2018. Researchers found that this earlier work requirement was associated with an increase in the number of uninsured adults in the age group subject to the requirement, but it did not affect employment.

Under the proposed amendment, the state would take a more personalized approach by using available data to identify enrollees who do not appear to be meeting certain health and economic goals, and then refer them to “success coaches.” These coaches would work with enrollees to develop a personal development plan that requires participation in certain work and community engagement activities, and provide care coordination services to address health-related social needs. Enrollees who do not cooperate with their plan could have their Medicaid coverage suspended for the remainder of the calendar year.

Our Comments

In a public comment letter submitted to the Centers for Medicare & Medicaid Services, Urban Institute researchers summarize evidence from Arkansas’s previous work requirement program and highlight several implementation challenges with the state’s proposed new approach to this policy that would prevent it from achieving its stated objectives:

1. Even with the proposed success coaching and care coordination, it is likely that the new work requirement would terminate coverage for many vulnerable adults based on a subjective decisionmaking process.
2. Coverage losses resulting from work requirements would worsen health outcomes, reduce access to care, and potentially undermine the state’s poverty reduction goals.
3. The success coaching plan would likely be inadequate to lift many beneficiaries out of poverty because it does not include new resources for education and training or address employment barriers among Medicaid enrollees. Additionally, the resources allocated for success coaching suggest that it will be a very low-touch intervention for most enrollees.
4. The proposed evaluation does not have a quasi-experimental design and, as structured, is subject to finding effects on income and transitions to private coverage from the intervention that are biased upward.

Coverage losses under the waiver could have negative health consequences for many adults, including those with chronic health conditions or disabilities, those with mental health and substance use disorders, and parents living with dependent children. The researchers suggest the state would have a greater likelihood of achieving the waiver’s health and economic goals if it were to implement, adequately fund, and evaluate the success coaching and care coordination components of the proposed waiver without suspending coverage of enrollees.