What Happened When Arkansas Tied Medicaid to Work Hours in 2018

The website was the first problem. Starting in the summer of 2018, tens of thousands of Arkansans who received health coverage through the state's Medicaid expansion were told they would have to log on to a state portal every month and enter the hours they had worked, volunteered or spent in job training. They had to do it by the fifth of the following month. At first there was no option to report by phone or in person. The portal went down for maintenance overnight. Many of the people affected did not have reliable internet at home, and many had never heard of the portal at all. Arkansas was the first state in the country to actually enforce a work requirement in Medicaid, and within months the numbers came in. Over 18,000 people had lost their coverage. Then a federal judge stopped the program, and researchers went looking for the jobs the rule had been supposed to produce.

In short: Arkansas ran the first Medicaid work requirement in American history from mid-2018 until a federal court halted it in March 2019. More than 18,000 people lost coverage, most of them for failing to report rather than for failing to work, and independent research found no meaningful rise in employment. With a national version of the rule now written into the 2025 budget law, Arkansas's short experiment is the closest thing the country has to a preview.

A conservative state's unusual expansion

To understand the Arkansas experiment, start with how unusual Arkansas's Medicaid expansion was in the first place. In 2013, a Republican-controlled legislature and a Democratic governor, Mike Beebe, agreed to accept the ACA's expansion, but with a twist. Instead of putting newly eligible adults into traditional Medicaid, the state would use federal Medicaid money to buy them private insurance plans on the new marketplace. The arrangement was called the private option. It let conservative legislators say they were expanding private coverage rather than a government program, and it brought more than two hundred thousand low-income Arkansans into coverage.

After Asa Hutchinson, a Republican, became governor in 2015, he kept the expansion but renamed it Arkansas Works and sought to add conditions. When the Trump administration announced in January 2018 that it would, for the first time, approve state requests to require work or community engagement as a condition of Medicaid, Arkansas was ready. Federal officials approved its plan that March.

The letter that opened the door

The legal route Arkansas used is worth a moment, because it explains the court fight that came later. Medicaid law lets the Secretary of Health and Human Services waive certain federal requirements for state experiments, known as demonstration projects, that the Secretary judges likely to promote the program's objectives. For decades, administrations of both parties had used those waivers for things like managed care or new ways of delivering services. None had approved a work requirement; the Obama administration had turned such requests down.

In January 2018, the federal Medicaid agency sent a letter to state Medicaid directors announcing a new policy: it would consider proposals to make work or community engagement a condition of coverage for working-age adults who were not disabled. Several states applied. Kentucky's approval came first, in January, but a court blocked it before it took effect. That left Arkansas as the state where the idea would actually be tested on real people.

How the rule worked

The Arkansas rule applied, at first, to expansion enrollees aged 30 through 49; the state planned to extend it to younger adults later. Those people were required to spend 80 hours a month working, looking for work, in job training, in school or volunteering, unless they were exempt.

The exemptions included people with a disability or medical condition preventing work, people caring for a dependent child, pregnant women, people already meeting work rules in food assistance, students and others. The state used its own data to identify many people as exempt or as already working enough, so a large share of enrollees did not have to report anything.

The rest had to report. They had to create an online account and enter their hours or claim an exemption each month. If someone failed to meet the requirement for any three months in a calendar year, their coverage ended, and they could not re-enroll until the following year.

That penalty structure matters. Missing a report did not cost a person one month of coverage. Three missed months, whether in a row or scattered across the year, cost them the rest of the year.

The losses

The state began terminating coverage in September 2018, for people who had failed to meet the requirement for three months since it started. By the end of the year, more than 18,000 people had lost coverage.

State figures showed something else. In each month, only a small share of the people who were required to report actually logged on and reported qualifying hours. Some of those who did not report may have been working enough and simply did not know they had to say so. Some may have qualified for an exemption they did not know about. Some were probably not working. The data the state collected could not distinguish among them, which was part of the problem.

Arkansas later added the ability to report by phone, in response to complaints. By then, many people had already lost coverage.

What the researchers found

A team of researchers led by Benjamin Sommers of the Harvard T.H. Chan School of Public Health surveyed low-income adults in Arkansas and in comparison states that did not impose work requirements. Their findings, published in the New England Journal of Medicine in 2019, were stark.

First, coverage fell. Among adults in the targeted age group, the share with Medicaid dropped and the share without any insurance rose compared with the comparison states.

Second, employment did not rise. The researchers found no significant change in employment among the targeted group after the requirement started.

Third, the people who lost coverage were mostly people who should not have. The study found that the vast majority of people in the targeted group already met the work requirement or should have qualified for an exemption. Confusion was widespread; many people surveyed did not know whether the requirement applied to them, or did not know it existed at all.

Follow-up research by the same team found that people who lost coverage reported problems with medical debt and with delaying care and medications because of cost.

In short, the policy removed people from coverage without achieving its stated goal. The mechanism was not that people refused to work. It was that the reporting system filtered people by their ability to navigate it.

The court case

Advocates for enrollees sued the federal government, arguing that the Secretary of Health and Human Services had approved Arkansas's plan without properly considering its effect on coverage, which they said was a central purpose of the Medicaid Act. A similar lawsuit had already stopped Kentucky's planned work requirement in 2018, before it took effect.

On March 27, 2019, Judge James Boasberg of the federal district court in Washington, D.C., vacated the federal approval of Arkansas's program and, the same day, a renewed approval of Kentucky's. He held that the Secretary had failed to consider adequately whether the programs would help or hurt Medicaid's core objective of providing medical coverage to people who need it. The Arkansas requirement stopped.

The federal government appealed. In February 2020, a unanimous three-judge panel of the U.S. Court of Appeals for the D.C. Circuit affirmed the ruling. The Supreme Court agreed to take up the issue, but after the Biden administration took office and began withdrawing the approvals of work requirement programs, the case was set aside without a decision on the merits.

The court rulings were about administrative law: whether the federal government had followed the Medicaid statute in approving waivers. They did not say Congress could never impose work requirements. In 2025, Congress did exactly that by passing the requirement into law directly, which removes the question the courts had decided.

The best argument for what Arkansas tried

It would be unfair to treat Arkansas's leaders as if they set out to strip people of coverage. Governor Hutchinson and others argued that the requirement was meant to connect people to work and job training, to lift them out of poverty, and to make the program more sustainable and more acceptable to the taxpayers who fund it. They pointed out that the state had expanded coverage when many conservative states refused, and that conditions were part of keeping political support for the expansion alive.

That last point is real. In a state where many legislators were skeptical of the ACA, adding conditions may have been the price of keeping the expansion at all. Progressives should be honest that political sustainability is a legitimate concern.

But the purpose of a policy is not the same as its effect. The Arkansas data showed that the requirement did not move people into work, and that the coverage losses fell mostly on people who already worked or should have been exempt. If the aim was to connect people to jobs, the reporting system was a poor tool for the job. If the aim was savings, the savings came from people losing care, not from people finding work.

There is also a deeper question about the premise. Most adults covered by Medicaid who can work already do, often in jobs that offer no health insurance. Their hours are often irregular and not under their control. A rule built on the assumption that the main problem is unwillingness to work aims at a problem that is mostly not there.

What Arkansas tells the rest of the country

The 2025 budget law requires every state with the ACA expansion to impose a work requirement on expansion adults by January 1, 2027, unless the federal government grants an extension for good-faith efforts. The federal rule has a broader set of exemptions than Arkansas used, requires states to use available data to verify compliance where possible, and gives people a 30-day window to fix problems after a notice. Those design choices are partly lessons from Arkansas.

But the core structure is similar: 80 hours a month, documented, with coverage lost for failure to document. That means the most important variable will be administration. States that check data aggressively, exempt people without demanding paperwork when the law allows it, send clear notices in plain language and pay community groups to help will see fewer people lose coverage for reasons that have nothing to do with work. States that do the minimum will see something closer to Arkansas.

Arkansas also offers a quieter lesson. The people who lost coverage did not show up in the headlines as names. They were a few lines in monthly state reports. Many of them were working at fast-food counters, poultry plants and warehouses, or caring for relatives, and found out they had lost coverage only when they went to fill a prescription. Their experience is the best evidence the country has, and it should be on the table in every state capitol in 2026.

The people behind the count

One more detail is worth carrying away from 2018. The reporting rule assumed that low-income workers would have stable internet, a working email address, predictable hours and the time to log in each month. The people the rule was aimed at were the least likely to have any of those things. A requirement designed by people with desk jobs and smartphones landed on people with neither.

That is not a partisan point. Republican and Democratic administrators alike have learned, often painfully, that the hardest part of any public program is getting it to the people it is meant for. A policy that ignores that fact will produce the result Arkansas got, whatever its intentions.

What you can do

The national work requirement starts soon, and states are making the decisions now that will decide whether the Arkansas pattern repeats.

• Find out how your state plans to run the requirement. Ask your state legislators and governor's office whether your state will rely on data matching, what notices will look like and how exemptions will be approved. The representatives lookup gives you your state lawmakers and members of Congress, with contact details and their recent votes.
• Share accurate information with people who could be affected. Many Arkansans lost coverage because they did not know the rule applied to them. The safety net topic page collects reporting on the new Medicaid rules and how states are carrying them out.
• Put the federal rules on the record. Federal agencies will issue guidance and regulations defining exemptions and verification. The comment page shows which federal rules are open for comment, with the nearest closing dates first, sorted by issue, and explains how to submit a comment.
• Volunteer or give to groups that help people report. Legal aid offices, community health centres and food banks will be on the front line. Look them up by state in the organizations directory.
• Follow the legal fights. Lawsuits over how states carry out the requirement are likely. The Court Watch page follows Supreme Court opinions with the Court's own summaries, its emergency docket and Senate votes on judges.