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Medicaid Work Requirements Could Erode ACA Coverage Gains

By Jack O'Brien  
   March 28, 2019

A new survey from the Kaiser Family Foundation looks at Medicaid and the Children's Health Insurance Program as states push to implement Medicaid work requirements.

On the same day that a federal judge blocked Medicaid work requirements in Kentucky and Arkansas, the Kaiser Family Foundation (KFF) released its 17th annual survey on Medicaid and the Children's Health Insurance Program, including a look at the potential effects of work requirements on patient eligibility for federal health programs.

KFF found that the ACA has led to robust enrollment in Medicaid through the expansion statute of the landmark law, filling previous coverage gaps for eligible populations. To that end, all states have worked to streamline the enrollment process, even those that did not expand Medicaid under the ACA. 

However, KFF stated that emerging policies, namely the rise of Medicaid work requirements, could "erode coverage gains and enrollment simplifications" that resulted from the ACA. 

"These types of requirements create barriers to coverage and increase administrative burdens and costs for states," the report stated. "As such, they will likely dampen potential coverage gains and lead to coverage losses."

Related: 3 Dos and Don'ts for Hospitals in States With Medicaid Work Requirements

KFF noted that Medicaid work requirements have not previously been approved and carry a significant cost to enact, specifically regarding documentation and administrative efforts.

The survey further stated that work requirements could contribute to increased barriers to coverage for eligible populations, introduce complexities to the enrollment process, or coverage losses.

Since Arkansas implementated Medicaid work requirements six months ago, 18,000 people have lost their Medicaid coverage.

The Commonwealth Fund released its own analysis earlier this month finding that work requirements could cost hospitals between $2.5 billion to $3.7 billion this year in states that have implemented the policies or are aiming to do so.

Related: Medicaid Work Requirements Could Cost Hospitals $3.7B

Medicaid work requirements, which require waiver approvals from CMS, have been achieved in eight states so far, with at least nine other waiver requests still pending.

This number is likely to change in the coming months, KFF noted, as leadership changes in the midterm elections have influenced whether a state is considering moving ahead with the waiver approval process or withdrawing from consideration.

Despite the growing popularity of Medicaid work requirements in some states, they have been the subject of fierce legal opposition by those who argue the waivers ignore Medicaid's primary mission to provide medical assistance.

CMS Administrator Seema Verma has been an ardent defender of Medicaid work requirements, telling the 2018 Medicaid Managed Care Summit in September that "there is dignity and pride that is derived from work" and that financial independence can be achieved through these policies.

Related: New Hampshire's Medicaid Work Requirements Latest to Face Lawsuit

KFF also stated that other factors could lead to continued Medicaid enrollment declines, including process-related issues, decreased outreach and enrollment efforts from the Trump administration, and federal immigration policy changes.

Jack O'Brien is the finance editor at HealthLeaders, a Simplify Compliance brand.


The Kaiser Family Foundation survey states that Medicaid work requirements "create barriers to coverage and increase administrative burdens and costs for states."

The complexities introduced by the policies, which have never been enacted before, could "dampen potential coverage gains."

The survey was released the same day a federal judge struck down Medicaid work requirements in Kentucky and Arkansas.

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