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Medicaid Enrollees With Mental Health Issues Less Likely to Meet Work Rule Thresholds


A new study in Health Affairs comes within a week of a federal ruling that found Medicaid work requirements in Arkansas and Kentucky failed to meet requirements of the 1965 law creating the program.

A study appearing today in Health Affairs finds that Medicaid enrollees with serious mental health issues were less likely than other beneficiaries to work 20 hours a week, the amount needed keep pace with new work rules in some states.

The April issue features research by authors from the University of Kentucky, Johns Hopkins, and Emory University, who used data from the National Survey on Drug Use and Health to find out if adults with serious mental health diagnoses or substance use disorders are more likely to be subject to Medicare work requirements than other adults, and if so, whether they would be able to meet them.

Among enrollees age 18 to 64, those with serious mental health illness were less than half as likely to have worked at least 20 hours in the past week as those without any health condition. Thus, they would be unlikely to meet work requirements that were in place in Arkansas and poised to take effect in Kentucky, 2 states whose work requirements were deemed invalid last week by a federal judge who found they violated the 1965 law that created Medicaid.

Under the Trump administration, HHS has sought to allow states to use Medicaid waivers to “increase employment and promote community engagement,” and the Health Affairs authors note that 15 states have applied for work requirements; 6 have received approval, and 8 were pending at the time the study went to press, with Kentucky’s rules on hold due to a court order.

Work rules have targeted non-elderly adults and exempted pregnant women, full-time students, and people with disabilities on Supplemental Security Income (SSI). While some states exempt those taking part in a substance use treatment program, the authors note that SSI and federal disability programs do not consider SUDs as a contributing factor for disability.

US District Court Judge James Boasberg agreed with arguments that any waiver still had to meet a core requirement that Medicaid serve primarily as a source of health insurance for those with low incomes. Boasberg remanded the Arkansas and Kentucky waivers back to HHS; this is the second time the agency has failed to pass muster in court with Kentucky’s rules.

The authors also examined whether people with behavioral health issues also reported another chronic condition, noted as “other health condition.” The survey included a place for respondents to rate their health on a scale of 1-5 from “poor” to “excellent,” thus allowing the authors to create an indicator of health status for those being diagnosed with more than 1 condition.

Findings showed:

  • An estimated 13.2% of the non-elderly had a serious mental illness, substance use disorder or both.
  • The shares of for Medicaid enrollees who had worked less than 20 hours per week were 16.8% and 18.8%, respectively.
  • Those with both serious mental illness and substance use disorder were significantly more likely to be enrolled in Medicaid (13.8%), compared with 12.1% for serious mental illness only, 10.5% for substance use only, and 8.4% for no health conditions.
  • People with behavioral health conditions were far more likely to report they were disabled for work than those without (38.9% vs 13.7%). They were also less likely to report they were looking for work (31.6% vs 40.8%) or that they were not looking because of child care or housekeeping responsibilities.

“These data tell us that Medicaid enrollees with mental health disorders or substance use disorders are more likely to be affected by new Medicaid work requirements,” senior author Janet Cummings, PhD, associate professor of health policy at Emory University, said in a statement. “If policymakers consider implementing Medicaid work requirements, it is crucial that they also take a hard look at how accessible mental health and substance use treatment are for Medicaid enrollees in their state. Many behavioral health providers do not accept Medicaid, and many enrollees face geographic barriers when trying to access services.”

The policy implications of the Health Affairs findings are clear, the authors said. Some with mental health issues have trouble accessing care, and if that is the case, they are unlikely to be able to find work, at least not at levels to meet new work requirements. Without Medicaid benefits, however, they have little chance of holding down a job.

“Employment is an important goal for many with behavioral health conditions,” the authors noted. “Therefore, if states are going to move forward with work requirements, it is critical that they continue to implement policy changes that encourage the provision of a full continuum of care for people with behavioral health conditions,” noting the great variation in benefit design and coverage levels from state to state.

The authors noted that some evidence-based treatments for substance use disorder that are recommended in clinical guidelines are not included in some state Medicaid programs.


Wen H, Saloner B, Cummings JR. Behavioral and other chronic conditions among adult Medicaid enrollees: implications for work requirements. Health Aff (Millwood). 2019;38(4):660-667. doi:10.1377.hlthaff.2018.05059.

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