Nebraska is beginning to implement Medicaid work requirements, becoming the first state to require certain Medicaid enrollees to work, train or go to school under a rule mandated by congressional Republicans' One Big Beautiful Bill Act. The new system puts poor and working people under a fresh layer of paperwork and surveillance, with coverage now tied to proving compliance to the state.
Who Gets Hit First
Schmeeka Simpson of Omaha, who works as a patient navigator for the American Civil Liberties Union and an administrative assistant at Nebraskans for Peace and also picks up shifts at a Dunkin' shop, said she worries about losing her health coverage even though she has three jobs. Simpson, 46, has relied on Medicaid since her divorce in 2014. None of her employers offers health coverage. She said she lost her government food assistance after technical problems caused her to miss renewing in time, and she worries that similar problems will happen again. She said, "Adding more barriers won't make the program work any better."
Crystal Schroer, 30, who has been on Medicaid since 2022 and unemployed since 2024, said it has been difficult to find work near her home in Kearney, Nebraska, that will allow her to take along her psychiatric service dog, Tarot, who helps her with anxiety. She said, "I am insanely worried," and added, "It's made my depression way worse."
The state says it is trying to make compliance easy, but the burden still falls on enrollees to keep their coverage from being stripped away by administrative failure. Nebraska Medicaid officials say they are trying to make it as easy as possible for enrollees to comply so people do not lose coverage for administrative reasons such as failing to file the proper paperwork. Enrollees with one of thousands of health conditions detailed by the state would be exempt.
The Bureaucratic Trap
Drew Gonshorowski, the state's Medicaid director, said in an early-April news release, "Our top priority is making sure members clearly understand changes to the program and how to maintain their coverage." That is the official language of the apparatus: tell people the rules, then make them prove they deserve care.
In Nebraska, about 70,000 Medicaid enrollees will need to meet the requirement, said Collin Spilinek, a spokesperson for the Nebraska Department of Health and Human Services. About 72% of them probably will not have to do anything to keep their coverage because the state already knows their work or exemption status via state or national databases, Spilinek said. Nebraska and other states plan to tap into various databases, including Medicaid claims information and data controlled by credit rating agencies. Enrollees for whom Nebraska does not have data will be notified and can complete an online form to confirm they meet the new rules.
The Nebraska Medicaid agency is not adding any employees to implement its work requirement. Spilinek said enrollees will be allowed to self-attest that they volunteer, go to school or qualify for exemptions, such as for poor health or caring for a disabled parent, and that supporting documentation such as medical records will not be required. The long list of health conditions that can be considered for the exemption was posted last week by the state and includes many types of cancers and mental health and heart conditions.
Kelsey Arends, senior staff attorney for Nebraska Appleseed, said the state's long list of medical billing codes for conditions that would be exempted is still not long enough and that different levels of illness severity are not included. Several advocacy groups had asked the state to exempt enrollees with specific conditions, including the American Diabetes Association, HIV+Hepatitis Policy Institute and National Bleeding Disorders Foundation. They said losing coverage would mean losing access to medications that keep people healthy and out of the hospital.
Who Pays for the Policy
Health policy analysts, advocates for the poor and health industry groups remain skeptical, fearing thousands of Nebraska Medicaid enrollees will lose coverage and, with it, access to health services and protection from medical debt. Jeremy Nordquist, the president and CEO of the Nebraska Hospital Association, said hospitals also worry that an increase in uninsured patients will hurt their bottom lines. He said, "There is a lot of concern on many different levels." He said many enrollees are unaware of the changes and might not realize they have to act to stay insured.
Andrea Skolkin, the CEO of Omaha-based One World Community Health Centers, said, "We are still concerned about the expanded Medicaid folks losing coverage." About 4,000 of their 52,000 patients are covered under the Medicaid expansion, Skolkin said. She said many enrollees received letters from the state about the work requirement, but she worries many did not understand them. Losing 10% of those patients would mean $500,000 less in revenue for the nonprofit centers, she said. To help patients, they plan to add staff to help people fill out the forms to get and maintain coverage.
Nebraska Appleseed's Arends said, "We remain very concerned about the early implementation." People who lose coverage may have a harder time getting health bills covered if they reenroll in the Medicaid program because the federal law also reduces retroactive eligibility from three months to one month for expansion enrollees. Because many people sign up for Medicaid when seeking care for an emergency and it can take weeks or months to complete enrollment, hospitals are concerned the change will leave them to cover the costs when people lose coverage, Nordquist said.
The bill President Donald Trump signed last July requires the 42 states, along with the District of Columbia, that fully or partially expanded Medicaid under the 2010 Affordable Care Act to implement a work requirement starting in 2027. The full expansion enables adults with incomes of up to 138% of the federal poverty level — amounting to $22,025 for a single person this year — to be eligible for Medicaid. More than 20 million people gained coverage from Medicaid through expansion, according to KFF, and the Congressional Budget Office estimates 4.8 million will become uninsured over the next decade as a result of the work requirement.
Under the law, enrollees must work or volunteer at least 80 hours a month, attend school at least part-time, or participate in job training, or they must prove they qualify for certain exemptions, such as caring for a child 13 or younger or a disabled parent, or having a health condition that prevents employment. The policy is being sold as a path to order, but the record already shows what it does when the paperwork machine gets rolling.
In 2018, Trump's administration became the first to allow states to adopt the policy, but only Arkansas implemented it. In the nine months the policy was in place before a federal judge deemed it unlawful, more than 18,000 people lost coverage, nearly 1 in 4 of those subject to the requirement. Most lost coverage not because they did not meet the requirements but for failing to correctly submit paperwork in time. Georgia has had a work requirement under its partial Medicaid expansion since 2023. Only about 8,000 people signed up for the coverage in its first two years, far fewer than the 25,000 that state officials predicted for the first year alone, and many have been denied benefits because of paperwork issues.
Whether self-attestation will broadly be allowed in other states will depend on CMS rules for work requirements, expected to be set this summer. Centers for Medicare & Medicaid Services Administrator Mehmet Oz said on April 28 outside the National Press Club in Washington, D.C., that he applauds Nebraska for being the first state to begin implementing the work requirements. He acknowledged that the state is still "working out the kinks," and said his hope is "by the end of this year they will get into a more sophisticated place." Only two other states plan to implement the work requirement early: Montana, which plans to launch in July, and Iowa, which plans to go live in December. Many states will be closely watching Nebraska's implementation to see what lessons they can learn ahead of their own launches in January, said Andrea Maresca, a senior principal at Health Management Associates. She said states are better prepared to enact work requirements than they were when Arkansas tried in 2018 because after reconfirming millions of enrollees' eligibility post-COVID, they have more experience using public and private databases to automate the process and more practice communicating with enrollees. Still, she said, "it won't be perfect," and states will have to adapt as they go.