Nebraska became the first state to implement Medicaid work requirements Friday, requiring certain enrollees to work, train or attend school under rules mandated by congressional Republicans' One Big Beautiful Bill Act, marking a significant shift in federal welfare policy designed to encourage self-sufficiency and reduce long-term dependency on government assistance.
The state is requiring about 70,000 Medicaid enrollees to meet the requirement, according to Collin Spilinek, a spokesperson for the Nebraska Department of Health and Human Services. 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.
Streamlined Compliance Process
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. About 72% of affected enrollees 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. 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."
Enrollees for whom Nebraska does not have data will be notified and can complete an online form to confirm they meet the new rules. 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 Nebraska Medicaid agency is not adding any employees to implement its work requirement, demonstrating an effort to minimize administrative costs associated with the new policy.
Federal Support and Timeline
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."
Oz told KFF Health News that "we don't like self-attesting" and that "documentation is critical," suggesting federal rules for work requirements expected this summer may require more stringent verification processes than Nebraska's current approach.
The bill President Donald Trump signed less than one year ago 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 next year. 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.
Concerns About Coverage Loss
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. The Congressional Budget Office estimates 4.8 million will become uninsured over the next decade as a result of the work requirement.
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.
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, "Adding more barriers won't make the program work any better."
Medical Exemptions and Implementation Challenges
Enrollees with one of thousands of health conditions detailed by the state would be exempt. 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. Arends said, "We remain very concerned about the early implementation."
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.
Historical Context and Other States
Adding a work requirement to Medicaid has been a priority for Trump since his first term. In the eighth year, his 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 its third year. 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.
In Nebraska, about two-thirds of Medicaid expansion enrollees work or attend school, according to KFF, and Nebraska's unemployment rate is 3%, one of the lowest in the nation.
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.
Provider Impact
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. 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.
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.
Maresca said states are better prepared to enact work requirements than they were when Arkansas tried in the eighth year 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.
Why This Matters:
Nebraska's implementation represents a fundamental test of whether work requirements can encourage self-sufficiency without creating excessive administrative burdens that result in eligible individuals losing coverage. The policy reflects a longstanding conservative principle that able-bodied adults should contribute through work or training in exchange for government benefits, promoting personal responsibility and reducing taxpayer costs. However, the fiscal impact extends beyond potential savings, as hospitals face revenue losses from increased uninsured patients, potentially shifting costs to private payers and taxpayers through uncompensated care. The state's decision to implement the requirement without adding staff demonstrates fiscal discipline, though the effectiveness of database automation and self-attestation will determine whether administrative efficiency can be achieved without coverage disruptions. With 41 other states required to implement similar requirements next year, Nebraska's experience will provide critical data on whether work requirements can be structured to promote employment while maintaining access to care for those genuinely unable to work.