Schmeeka Simpson of Omaha juggles three jobs — patient navigator for the ACLU, an administrative assistant at Nebraskans for Peace, and shifts at Dunkin’ — yet she fears losing Medicaid now that Nebraska, on May 1, becomes the first state to enforce a federal rule requiring many Medicaid enrollees to work, train, volunteer, or attend school. The mandate stems from a law signed last July tied to congressional Republicans’ One Big Beautiful Bill Act.
Simpson, 46, has relied on Medicaid since her 2014 divorce. None of her employers provide health insurance. She recalled losing food assistance after missing a renewal because of technical problems and worries similar errors could cost her health coverage. “Adding more barriers won’t make the program work any better,” she said.
Nebraska Medicaid officials say they are trying to minimize administrative barriers that could cause people to lose coverage accidentally. The state has posted a long list of health conditions that qualify for exemptions, saying thousands of codes describe illnesses that would exempt enrollees. Drew Gonshorowski, Nebraska’s Medicaid director, said the agency’s “top priority is making sure members clearly understand changes to the program and how to maintain their coverage.”
Centers for Medicare & Medicaid Services Administrator Mehmet Oz praised Nebraska for being first to implement the requirements but acknowledged the state is “working out the kinks” and expressed hope the system will be more refined by year’s end. Still, health policy analysts, advocates, and providers remain skeptical, warning that thousands could lose coverage and thereby access to care and protection from medical debt.
Hospitals fear a rise in uninsured patients will strain finances, said Jeremy Nordquist, president and CEO of the Nebraska Hospital Association. Many enrollees may not realize they must act to keep coverage, he added.
What the law requires and who it affects
The federal law requires states that fully or partially expanded Medicaid under the Affordable Care Act to impose a work requirement beginning in 2027, though it allowed states to start earlier. Expansion covers adults with incomes up to 138% of the federal poverty level (about $22,025 for a single person this year). KFF reports more than 20 million people gained coverage through expansion. The Congressional Budget Office projects about 4.8 million people could become uninsured over the next decade because of the new work requirement.
Under the rule, enrollees must do at least 80 hours a month of work or volunteering, attend school part-time, or participate in job training. They can also qualify for exemptions — for example, caring for a child 13 or younger, caring for a disabled relative, or having a health condition that prevents work.
Nebraska’s rollout
Nebraska is moving ahead eight months before the federal deadline. The state estimates roughly 70,000 Medicaid expansion enrollees will be subject to the requirement. Collin Spilinek, a spokesperson for Nebraska Health and Human Services, said about 72% of those people probably won’t need to take action because the state already has data showing they meet work or exemption criteria.
To verify compliance, Nebraska plans to use various databases, including Medicaid claims and data from private firms like credit bureaus. For people with no available records, the state will send notices and offer an online form to confirm compliance. Nebraska officials say they will allow self-attestation for volunteering, schooling, or qualifying exemptions and will not require supporting documentation such as medical records.
The state’s decision not to hire extra staff to run the program has raised concerns. “The fact that they say they do not need additional resources raises questions” about whether the system can be implemented smoothly, Nordquist said.
Exemptions and medical frailty
Nebraska posted a detailed list of medical billing codes intended to define who is medically frail and therefore exempt. Advocacy groups say the list still falls short because it doesn’t account for different severity levels of illnesses. Kelsey Arends, senior staff attorney at Nebraska Appleseed, called the early implementation worrisome.
For people like Crystal Schroer, 30, the exemption matters. She’s been on Medicaid since 2022, unemployed since 2024, and struggles to find work near her Kearney home that would allow her psychiatric service dog. “I am insanely worried,” she said. “It’s made my depression way worse.”
Federal officials’ stance and states’ experiences
CMS Administrator Oz told KFF Health News he prefers documentation over self-attestation, saying “we don’t like self-attesting” and that “documentation is critical.” Final CMS rules for work requirements are expected this summer and could influence how broadly self-attestation is allowed.
Advocacy groups including the American Diabetes Association, the HIV+Hepatitis Policy Institute, and the National Bleeding Disorders Foundation urged wider exemptions, warning that coverage loss would mean losing access to essential medications.
This is not the first time work requirements have been tried. The Trump administration allowed states to pursue such policies in 2018; Arkansas implemented a requirement that year, and more than 18,000 people lost coverage in nine months before a judge blocked the policy — many for failing to file paperwork correctly. Georgia’s partial expansion with a work rule, in place since 2023, saw far fewer enrollments than state projections and many denials tied to paperwork issues.
Evidence and concerns
Research indicates many Medicaid adults already work, attend school, or have health limitations. A study in the Annals of Internal Medicine found about one-third of adults at risk under the new rule reported a physical or mental illness or disability. “This is not a case that we have mostly healthy adults choosing not to work,” said Darshali Vyas, a study co-author. The concern is that vulnerable people may not be adequately protected as requirements roll out.
In Nebraska specifically, about two-thirds of expansion enrollees work or attend school, and the state’s unemployment rate is roughly 3%. Still, clinics and community health centers worry. Andrea Skolkin, CEO of One World Community Health Centers in Omaha, said the policy has created uncertainty for providers and patients. About 4,000 of their 52,000 patients are on Medicaid expansion; losing 10% of those patients could cut revenue by around $500,000. Her clinic plans to add staff to help patients complete forms.
Administrative automation and retroactive eligibility
States say they will automate much of the verification process, relying on public and private data sources and lessons learned after pandemic-era eligibility reconfirmations. Andrea Maresca of Health Management Associates said states are better prepared than in 2018 but warned implementation “won’t be perfect” and will require adjustments.
A related change in federal law reduces retroactive eligibility for expansion enrollees from three months to one month, which could make it harder for people to get medical bills covered if coverage lapses and they reenroll later. Hospitals say that could leave them shouldering costs for patients who lose coverage mid-treatment.
Where other states stand
Besides Nebraska, Montana plans an early launch in July and Iowa in December. Many other states will begin implementing work requirements in January as permitted under the federal timeline. Officials and advocates around the country will be watching Nebraska’s rollout closely for lessons and pitfalls.
KFF Health News is the source of much of the reporting on these issues; it is a national newsroom that focuses on health policy and is part of KFF, an independent health policy organization.