The Democratic Party of Arkansas responded Monday to a recent report on the growing number of uninsured children in the state, calling on the state’s Republican leaders to address the issue.

The Georgetown University Center for Children and Families report found that the number of uninsured children increased from 30,000 to 33,000 in 2017, bumping the children’s uninsured rate from 4 percent to 4.4 percent. The uptick represents the first time that the state saw an increase in 20 years, since the enactment of ArKids First in 1997.

Democratic Party of Arkansas Chair Michael John Gray issued the following response:

Protecting and caring for our children is one of the most fundamental responsibilities of governing. It is painful to know that our children’s well being is increasingly put at risk by efforts to weaken access to healthcare. Often times these limits on our health care plans, like a work requirement, are well-intended. Unfortunately, we now know that the real victims of these restrictions are children. Our healthcare policy must be designed to help families, not hurt them. We know that taking away healthcare hurts our families, our hospitals, and our economy. Arkansas needs to take steps to strengthen its healthcare system, not weaken it.

Arkansas was not alone: Nationwide, an estimated 3.9 million children were without health insurance in 2017, representing an increase of around 276,000 children from the prior year, the first significant increase in a decade. Arkansas remains below the national average in the children’s uninsured rate.

Why did this happen? The report suggested that efforts to undermine the Affordable Care Act and other health coverage programs, both nationally and at the state level, may have contributed to the increase. It also sited anti-immigrant rhetoric and policies that may have scared parents away from signing up their kids.

Parents who have coverage themselves are more likely to have coverage for their children. Researchers have long noted that when policymakers expand the number of people who are eligible for coverage, those who were already eligible are more likely to sign up too, because they are more likely to learn about options. This is called the “woodwork effect” or the “welcome mat effect.” The report suggested that the actions of the Trump administration or attempts to cut the Medicaid rolls by red-state governors have created something like the reverse — “an ‘unwelcome mat’ effect where families are unaware of their options or deterred from seeking coverage” — leading to a reduction in the number of insured children.

Rich Huddleston, executive director at Arkansas Advocates for Children and Families, argued that the state’s new Medicaid expansion “work requirement” might indirectly exacerbate the problem. The requirement began this year, after the Georgetown study data was collected. It requires certain beneficiaries to report “work activities” via a burdensome digital paperwork bureaucracy; if they fail to comply or get lost in the shuffle, they are kicked off their health insurance. The program has been a disaster, leading to mass confusion and booting more than 12,000 Arkansans off their health insurance, including people who have a job, with no evidence that it has achieved its purported aim of encouraging people to work. The requirement only applies to adults, and parents with dependent children are exempt. But Huddleston believes that the “unwelcome mat” effect described above may be activated by the state’s policy of purging the rolls.

While work requirements get the headlines, I’d actually point to another factor as a bigger source of worry in terms of the children’s uninsured rate: The state’s various efforts to tighten eligibility and enrollment procedures, which have been a bureaucratic trainwreck — at times in violation of federal law — under the Hutchinson administration. Tens of thousands of Arkansans, including families and children, have been purged from the Medicaid rolls by a confusing and poorly managed process. Unwelcome mat indeed.