Shocking news — work requirements don’t work

Benjamin Sommers** and others published an important study with a completely expected result on Wednesday in the New England Journal of Medicine.  They surveyed Arkansas to evaluate what was happening with employment and insurance coverage as a result of the state’s decision to implement work requirements for Medicaid:

We conducted a telephone survey to compare changes in outcomes before and after implementation of the work requirements in Arkansas among persons 30 to 49 years of age, as compared with Arkansans 19 to 29 years of age and those 50 to 64 years of age (who were not subject to the requirement in 2018) and with adults in three comparison states — Kentucky, Louisiana, and Texas. ….

Our study had three primary outcomes: the percentage of respondents with Medicaid, the percentage of respondents who were uninsured, and the percentage of respondents reporting any employment. Secondary outcomes were the number of hours worked per week, the percentage of respondents satisfying any category of community engagement requirement (described below), the percentage of respondents with employer-sponsored insurance, and two measures of access to care — the percentages of respondents having a personal physician and reporting any cost-related delays in care….

estimate of changes in the percentage of respondents who were not insured was an increase of 7.1 percentage points (95% CI, 0.5 to 13.6; P=0.04).

Uninsurance rates increased more for the work requirement cohort than other cohorts.  This is not an unexpected result.  Almost every pre-waiver approval analysis projected significant enrollment drops due to increased paperwork friction.  The amount of friction would be a function of how user friendly the roll-out and implementation was; it was not a particularly user friendly process as the reporting system was online only with limited professional office hour availability that made reporting extremely difficult and unlikely for people who did not have reliable internet or worked jobs that did not neatly map to a 9-5 assumption.

Overall, more than 92% of the respondents in all four groups — and nearly 97% of the respondents 30 to 49 years of age in Arkansas — were already meeting the community engagement requirement or should have been exempt before the policy took effect.

Work requirements are targeted at an incredibly small cohort of people who might be able to work but don’t.  This is very wide spread pain to sort out the “deserving” vs “undeserving” working poor.

Employment declined from 42.4% to 38.9% among Arkansans 30 to 49 years of age, a change of −3.5 percentage points. The three comparison groups had similar decreases, ranging from −2.9 to −5.7 percentage points.

And work requirements did absolutely nothing for employment.

None of this is particularly surprising.  It is good that we have very firm evidence of the obvious as this type of evidence raises the bar in future litigation against arbitrary and capricious waiver approvals.  The current federal district court judge who is overseeing lawsuits against work requirements has held that work is not a fundamental purpose of Medicaid.  If the study had shown absolutely minimal to no net coverage loss as people shifted to exchange or employer sponsored insurance and significant income gains, then the administration’s argument that this was an evidence based experiment with plausible real gains could hold some water.  Instead, this study shows that work requirements are fundamentally paperwork requirements that culls enrollment without producing employment effects.




** DOI: 10.1056/NEJMsr1901772


22 replies
  1. 1
    Baud says:

    Uninsurance rates increased more for the work requirement cohort than other cohorts. 

    Sounds like they work as they are intended to.

  2. 2
    MomSense says:

    The goal of work requirements is to shame poor people and to cause harm. In those ways, work requirements are very effective.

  3. 3
    Another Scott says:

    @Baud: Yup.

    These policies are “virtue signaling” and have nothing to do with making the system work better.

    It’s unfortunate that researchers have to spend time debunking stuff like this because sensible people know what’s what, and it won’t affect the policies as long as the Teabaggers are in power. Yeah, it needs to be debunked but it’s another example of how monstrous people drive the conversation and the coverage.

    Not to go off on a tangent so early, but I was pleasantly surprised that the House’s hearings on reparations seemed to get more coverage than McConnell’s pre-emptive comments the day before that were intended to shut that whole thing down. I was especially pleased that TNC was called to testify and apparently did very, very well in presenting his case (as one would have expected).

    Vote the monsters out!!

    Thanks David.


  4. 4
    OzarkHillbilly says:

    @Baud: Beat me to it.

  5. 5
  6. 6

    @Baud: I am shocked, shocked I tell you, that there is gambling going on here

  7. 7
    gvg says:

    @Another Scott: Sensible people don’t always or even usually rise above their culture and tiny child upbringing. The protestant work ethic is really deeply ingrained in our culture and even serious lifelong liberals really spend a lot of time obsessing about people who could work and don’t and it leads to less helpful actions. Homeless people panhandling for money who aren’t really homeless or who can’t save enough when employed are a particular peeve of my parents for instance.

  8. 8
    Another Scott says:

    In other news about attempts to circumvent the law, GovExec:

    Acting Office of Personnel Management Director Margaret Weichert recently gave Congress an ultimatum: approve the Trump administration’s proposal to merge OPM with the General Services Administration, or she will furlough, and potentially lay off, 150 agency employees.

    According to a briefing document obtained by Government Executive, unless lawmakers make a commitment by June 30 to greenlight the controversial plan to send most of OPM’s operations to GSA, OPM will begin to take the steps required to issue furloughs to career agency employees beginning Oct. 1. A reduction in force could come as early as 30 days after that. The details of the plan were first reported by The Washington Post.

    The crux of the issue, according to OPM, is that once the agency’s security clearance processes are transferred to the Defense Department, it will face a nearly $70 million budget shortfall. After a number of savings efforts are undertaken, OPM still would face a $23.3 million gap in fiscal 2020, which equates to roughly 150 full time employee positions in the agency’s Title 5 policy and oversight workforce.

    However, the House Appropriations Committee has already advanced a spending bill for fiscal 2020 that increases spending for OPM by $43.4 million over current funding levels, nearly double what is needed to cover the budget shortfall. That legislation also blocks the administration from moving forward with its plan to merge OPM and GSA.


    Rep. Gerry Connolly, D-Va., chairman of the House Oversight and Reform Committee’s Subcommittee on Government Operations, blasted the news of furlough threats as an attempt by the Trump administration to bully lawmakers.

    “This announcement from OPM flies in the face of testimony the administration gave to our subcommittee,” he said. “Director Weichert made it clear that this merger proposal was not ready for prime time. After realizing they were not going to prevail on the merits of the proposal, the Trump administration is taking 150 federal employees hostage unless we consent to a plan that has no rationale and is nothing more than a political gambit to give the White House control of our longstanding merit-based civil service system.”

    Rep. Jennifer Wexton, D-Va., said the furlough threats are the latest in a series of actions taken at the expense of federal workers.

    “This administration has demonstrated an unprecedented level of outright hostility to our federal workforce,” Wexton said. “These confrontational—and unwarranted—actions will inflict lasting and permanent damage to our government’s ability to function.”


    Gerry and Jennifer are right. This isn’t about saving money, this isn’t about the Anti-Deficiency Act. This is a power grab by Donnie to try to have direct control over all federal employees.



    The only plausible rationale still remaining is the move of OPM’s policymaking function into the White House. Apparently Trump really, really wants direct control over personnel policies, and he’s willing to go to the mats over this. But is that a good idea? If another president had suggested it, I might shrug and figure it’s just part of the steady centralization of executive power in the White House. Trump, however, has made it pretty clear that he doesn’t like it when he’s not allowed to hire and fire whoever he wants, whenever he wants. More control over civil service policy might be just the ticket to eliminating anyone who might get in his way.

    We have a Civil Service for a reason – to make sure the government is run – at an operational level – by civilians who are professional and not primarily guided by politics. Donnie would destroy that. The House is right to fight him on it.

    As with the work requirements stuff, it’s virtue signaling with a nefarious actual intent.

    We need to vote the monsters out!!


  9. 9
    Ohio Mom says:

    @gvg: Your parents made the same mistake as most people do, looking down at the poor as their adversaries instead of up at the 1% of the 1%. Of course the ultra wealthy are hidden from us, by their design, and the panhandlers are by definition in our faces.

    A long time ago I realized that since this economic system of ours actually requires there be a pool of poor people, we middle-class people should be extremely grateful that the impoverished are filling this role, else it might fall to us.

    They deserve the various sorts of welfare our paltry social service net provides for their public service.

    Is that too cynical?

  10. 10
    Ohio Mom says:

    @Another Scott: I don’t pay attention to all the various plans our candidates are proposing, but I sure hope among them they have detailed blueprints for repairing the administrative state in short order.

    I’m not expecting them to make these plans part of their stump speeches because I don’t imagine most voters would find them inspiring. But it will be one of the most critical tasks for the next Democratic administration.

  11. 11
    laura says:

    Work requirements have only, ever and all been about cruelty and denying those people access to the social safety net. The cruelty is the point. It’s the banality of evil because it provides cover for the discriminatory purpose. It presumes the recipients can work, ignores that many are already working, ignores the role of care giving as work, ignores the sheer lack of jobs available, infers laziness and willfully blinds the state to the reality of the need.

  12. 12
    ruemara says:

    If only work requirements came with hiring requirements, so jobs creators were forced to make the work that is required. Funny how no one thinks it through.

  13. 13
    Kent says:

    Wasn’t it Michigan where they tried to make the work requirements racist as well?

    By exempting upstate rural white counties from the requirement but imposing it on urban black areas using some sort of county-wide unemployment metric?

    As long as you only hurt the “right” people….

    Anyone know whatever came of that proposal?

  14. 14
    Felanius Kootea says:

    @Baud: This. The GOP has perfected the art of producing reasonable-sounding (to those who aren’t paying attention) but malicious requirements intended to cause harm. And they keep getting away with it.

  15. 15
    gvg says:

    @laura: Not really. Both have always known the Rich greedheads were their real enemy and of most people. It comes from early childhood culture and it’s often religion based. “good” people work. Even many rich people work hard. The poor, who often have health reasons including mental, for not holding a job, often don’t meet the social rules of good. It’s Calvinism and Puritanism. Mom has Calvinist relatives.
    The mentally ill often seem lazy too, and they have often not enough hope to bother with ideas for saving. Not to mention that some people are poor because they aren’t that bright which our society often acts like they could change if they just had some will power. My parents still vote for safety nets and mercy, mind you. Its just work requirements seem OK to even a lot of liberals.

  16. 16
    Another Scott says:

    @Kent: Citylab talks about the proposal. It’s not all sweetness and light for rural counties, but cities would be affected more.

    Arkansas and Kentucky work requirements were blocked in federal court, but that court doesn’t have jurisdiction in Michigan. I haven’t seen anything about court action on MI’s plan.

    HTH a little.


  17. 17
    J R in WV says:

    @Another Scott:

    We have a Civil Service for a reason – to make sure the government is run – at an operational level – by civilians who are professional and not primarily guided by politics. Donnie would destroy that. The House is right to fight him on it.

    He wants to buy and sell federal jobs, to become King in truth!

    Worse than almost anything these unAmerican monsters have come up with so far!! Nothing is too bad for these folks to dream up. Ignorant fools in charge of everything. How long would things continue to work at all? These guys won’t be able to pave the roads, let alone run a high-tech program like NASA or the military!!

    How enjoyable do they think being rulers of a junkyard with sewage problems will be???

    ETA fix blockquote…

  18. 18
    TenguPhule says:

    @J R in WV:

    How enjoyable do they think being rulers of a junkyard with sewage problems will be???

    Remember, they’re the sparrow on a curtain rod party. As long as the liberals don’t have a sparrow, they’re perfectly fine with everything going to hell.

  19. 19

    Is there a non-subscription link to the full paper?

  20. 20
    Miss Bianca says:

    @gvg: I must be weird, then, because I don’t obsess about it – except to get furiously angry at the people who impose all kinds of fucking conditions, from work to drug-testing, on poor people needing family assistance, unemployment, Medicaid, or other government benefits. FUCK OFF, you holier-than-thou assholes!

  21. 21

    @battlebornecon: e-mail me and I will send you a copy.

  22. 22
    Jado says:


    Don’t forget increasing profits for participating corporations and providing job security for patronage jobs like “Director of Making Sure THOSE People Do as They Are Told.”

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