Last June, Arkansas became the first state in the country ever to require a portion of its Medicaid recipients to report enough work, volunteer, or school hours each month in order to keep their health coverage. Since imposing that requirement, more than 18,000 people have lost their health insurance.
But those coverage losses are about to come to an abrupt halt. On Wednesday, federal Judge James E. Boasberg blocked Arkansas’s work-requirement program and also ruled against a proposed work requirement in Kentucky that had already been halted under a previous court order. As in the earlier ruling on Kentucky, Boasberg argued that when the Trump administration signed off on the work requirements these states had proposed, it hadn’t “adequately considered whether the program ‘would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid.’” The ruling “underscores…the notion that Medicaid was specifically created to provide health care coverage for low-income populations,” says Marquita Little Numan, president of the Urban League of the State of Arkansas. “The work requirements are really counter to the intended purpose and why Congress created the Medicaid program to begin with.”
The judge did not stay his decision, which means the ruling will have an immediate impact on the low-income people in the state who rely on Medicaid for health care. “As of now, there are no work requirements,” says Kevin de Liban, a staff attorney at Legal Aid of Arkansas who represented the Arkansas plaintiffs in the case before Boasberg. No other Medicaid recipients in the state will lose their coverage for failing to comply with the requirement—the state was set to terminate coverage for another round of people who were out of compliance on April 1—and those who already lost their coverage will be eligible to re-enroll. All Medicaid recipients in the state “can be sure that, at least for the time being, they’re going to have health coverage when they wake up next week or next month and be able to get the medical care they need to life a full life,” de Liban noted. “That’s a beautiful thing.”
Still, the impact of the state’s having imposed the work requirement, even now that it’s been struck down, is significant. The 18,000 recipients who lost coverage must reapply to get back into the Medicaid program. Many may not be aware that they can or, if they are, know how. Legal Aid of Arkansas will work to help this population regain their coverage, but reaching this population is a significant challenge. In December, when the people kicked off the program in 2018 were eligible to re-enroll, fewer than 1,000 had done so.
And there’s still potential for political fallout in the state. When funding the state’s Medicaid expansion, the legislature made clear that a work requirement was the price to be paid. This ruling comes as the legislature is again considering whether to maintain funding for Medicaid expansion. The state Senate approved the needed funding on Wednesday, before the ruling was issued; now the funding bill heads to the house, where it needs a three-quarters majority to pass.
If state lawmakers decide to roll back the expansion, the shock to the state’s health-care delivery system will be enormous. With so many more people covered under expansion, the state’s health-care infrastructure has transformed. Community health-care providers no longer get money to cover uncompensated care, because most residents now have health insurance. “The whole notion of a charity care system for people who were uninsured or underinsured, that’s completely changed,” said Numan. The state hasn’t had a single rural hospital close since the expansion in 2010, unlike all of its neighboring states that didn’t expand the program. Before the work requirement, the state had significantly reduced the number of uninsured people. Those trends could reverse if the legislature terminates Medicaid expansion.
Despite the massive disruption Arkansas’s work requirement caused, 14 other states have submitted requests to the Department of Health and Human Services seeking to impose their own work requirements on Medicaid. This ruling should be even more reason for them to think twice. “I still hope that Arkansas is a cautionary tale for those other states,” Numan argues. “There is no effective, good way of implementing this type of work program.… People who need health care are definitely going to lose access.”
The state could appeal the ruling, keeping its attempt to impose work requirement alive. If so, de Liban will be back in court. “We know that the work requirements are illegal, and we also know from Arkansas’s experience that they’ve caused devastating harm to tens of thousands of people,” de Liban said. “We stood by [our clients] thus far, we plan on standing by them as long as necessary.”