Will Evaluations of Medicaid 1115 Demonstrations That Restrict Eligibility Tell Policymakers What They Need to Know?

Issue: With thousands in Arkansas losing their Medicaid benefits under the state's work-requirement demonstration, the importance of evaluating such experiments could not be clearer. In Stewart v. Azar, the court concluded that the purpose of Section 1115 demonstrations such as Arkansas's is to promote Medicaid's objective of insuring the poor; evaluations of these demonstrations, as required by law, inform policymakers whether this objective is being achieved. Goal: To examine the quality of evaluation designs for demonstrations that test Medicaid eligibility and coverage restrictions. Methods: Comparison of state evaluation designs against issues identified in Medicaid impact research. Key Findings and Conclusions: Evaluation designs for 1115 demonstrations that restrict Medicaid eligibility and coverage either are lacking or contain flaws that limit their policy utility. No federally approved evaluation designs for Medicaid work and community-engagement demonstrations are yet available, and the Centers for Medicare and Medicaid Services has not issued evaluation guidance to states. Evaluations thus lag well behind demonstration implementation, meaning important impact information is being lost. Eligibility restrictions attached to some approved Medicaid expansion demonstrations remain unevaluated. Moreover, evaluations are not sustained long enough to measure critical effects; systematic evaluation of communitywide impact is lacking; and comparisons to states with no Medicaid restrictions are missing. Without robust evaluation, the core purpose of Section 1115 is lost.