Work requirements are becoming increasingly common in major public assistance programs, and starting in 2018, several states have received approval from the federal government to require employment or other qualifying ?community engagement activities? to obtain Medicaid coverage. Proponents of work requirements contend that these policies increase beneficiary engagement in work and community activities that may lead to higher incomes and better health. On the other hand, opponents of work requirements suggest that many low-resource households will lose much-needed benefits, without commensurate improvements in employment. More than a dozen states have proposed new Medicaid work requirements in the past year, but there is little rigorous evidence on the effects of these policies in public programs. We propose a randomized controlled trial of work requirements in Virginia, leveraging state support for exempting a portion of Medicaid expansion enrollees from the state's impending work requirements. We will be able to separate the causal impact of enforcing a work requirement from two other new features of Virginia's Medicaid program: additional verification requirements and premiums. Our experimental design will enable us to test for any interactions between work requirements, premiums, and verification requirements. We will study the impacts of each policy on health insurance coverage, access to care, employment, and health outcomes using a mix of administrative data and a new beneficiary survey, and we will oversample several populations of interest, including racial/ethnic minorities and low-income rural residents. In doing so, we will identify the overall policy impacts of these policies, and we will also assess who is most affected by each component to determine the impact of these Medicaid policy changes on racial, ethnic, socioeconomic, and geographic disparities.

Public Health Relevance

More than a dozen states have proposed or plan to implement work requirements in Medicaid, yet evidence on the potential effects of these policies is limited. In 2020, Virginia will begin requiring beneficiaries to participate in at least 80 hours a month of employment or other ?community engagement? activities to maintain coverage. With support from the state's Medicaid agency, we will conduct a randomized controlled trial studying the impacts of this policy on coverage, access to care, employment, and health, with a particular focus on changes in racial/ethnic and geographic disparities in these outcomes.

National Institute of Health (NIH)
National Institute on Minority Health and Health Disparities (NIMHD)
Research Project (R01)
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Special Emphasis Panel (ZRG1)
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Dagher, Rada Kamil
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Harvard University
Public Health & Prev Medicine
Schools of Public Health
United States
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