On May 1 Nebraska became the first state to begin enforcing a new federal rule that requires many Medicaid expansion enrollees to work, train, volunteer, or attend school — a change that has left beneficiaries, providers and advocates alarmed.
Schmeeka Simpson of Omaha, 46, juggles three jobs — patient navigator for the ACLU, administrative assistant at Nebraskans for Peace, and shifts at Dunkin’ — yet worries she could still lose Medicaid. Simpson has depended on the program since her 2014 divorce; none of her jobs offer health insurance. She recalls losing food assistance after a renewal error and fears similar administrative problems could cost her coverage. “Adding more barriers won’t make the program work any better,” she said.
The requirement stems from a law passed last July tied to congressional Republicans’ One Big Beautiful Bill Act. Though federal rules give states until 2027 to impose such conditions on Medicaid expansion populations, Nebraska moved ahead early. The state estimates roughly 70,000 expansion enrollees will be subject to the rule.
What the rule requires and who it affects
The federal rule targets adults covered by Medicaid expansion — people with incomes up to 138% of the federal poverty level (about $22,025 for a single person this year). Under the requirement, enrollees must complete at least 80 hours a month of work or volunteering, attend school part-time, or participate in job training. Some people will qualify for exemptions, including caregivers of a child 13 or younger, those caring for a disabled relative, or people with health conditions that make work infeasible.
The Congressional Budget Office has projected that the new work requirement could make about 4.8 million people uninsured over the next decade. Research also finds many Medicaid adults already work, study, or have health limitations: a study in the Annals of Internal Medicine found roughly one-third of adults at risk under the rule reported a physical or mental illness or disability.
How Nebraska is rolling it out
Nebraska officials say they are trying to limit unnecessary administrative hurdles. The state posted a lengthy list of medical billing codes intended to identify people who are medically frail and therefore exempt, and officials say thousands of codes describe conditions that would qualify. Collin Spilinek, a spokesperson for Nebraska Health and Human Services, said about 72% of people subject to the rule probably will not need to take any action because the state already has data indicating they meet work or exemption criteria.
To verify compliance, Nebraska plans to rely on a variety of data sources, including Medicaid claims and information from private firms such as credit reporting companies. For enrollees with no available records, the state will send notices and provide an online form to report work, volunteering, schooling, or claim an exemption. Nebraska will allow self-attestation for many activities and says it will not require supporting documentation like medical records.
That decision — and the state’s choice not to hire additional staff to run the program — has raised concerns. Hospitals and community providers worry that automation and data-matching could miss people or produce errors, leading to coverage losses for individuals who do meet the rules but fail to document it properly. Jeremy Nordquist, president and CEO of the Nebraska Hospital Association, said hospitals fear a rise in uninsured patients that would strain finances and that many enrollees may not realize they must take action to keep coverage.
Clinical and advocacy concerns
Advocates and clinicians have criticized the approach, arguing the long list of billing codes may not reflect illness severity and that relying on data matches and self-attestation could leave vulnerable people unprotected. Kelsey Arends, senior staff attorney at Nebraska Appleseed, called the early implementation worrisome.
People with mental health conditions or caregiving responsibilities say the rule is already taking a toll. Crystal Schroer, 30, who has been on Medicaid since 2022 and is unemployed, said the uncertainty has worsened her depression; she struggles to find work near her Kearney home that would accommodate her psychiatric service dog.
Federal stance and lessons from other states
Centers for Medicare & Medicaid Services Administrator Mehmet Oz praised Nebraska for moving first but acknowledged the state is “working out the kinks” and said he expects refinements. Oz has also signaled a preference for documentation over broad self-attestation; final CMS guidance on work requirements is expected this summer and could affect how states handle proof.
Advocacy organizations — including the American Diabetes Association, the HIV+Hepatitis Policy Institute, and the National Bleeding Disorders Foundation — are urging broader exemptions, warning that losing Medicaid can mean losing essential medications and protection from medical bills.
This is not the first time states have tried similar policies. During the Trump administration, Arkansas implemented Medicaid work requirements in 2018; more than 18,000 people lost coverage in nine months before a judge blocked the program, with many terminations tied to paperwork failures. Georgia’s more limited program, in place since 2023, produced lower-than-expected enrollment numbers and many denials linked to administrative issues.
Practical impacts and related changes
Community health centers report immediate fallout. Andrea Skolkin, CEO of One World Community Health Centers in Omaha, said roughly 4,000 of the clinic system’s 52,000 patients are on Medicaid expansion; losing even 10% of those patients could mean an estimated $500,000 revenue loss. Clinics are hiring staff to help patients complete forms and navigate the new rules.
States say they have learned from past efforts and pandemic-era eligibility renewals and will automate much of verification. But experts caution implementation will not be perfect and will require adjustments. A separate federal change shortening retroactive eligibility for expansion enrollees from three months to one month adds another layer of risk: if coverage lapses, patients may have less protection for bills incurred before a new enrollment takes effect, potentially increasing uncompensated care costs for hospitals.
What’s next
Besides Nebraska, Montana plans an early launch in July and Iowa in December; many other states are scheduled to begin implementing work requirements in January under the federal timeline. Policymakers, providers and advocates across the country will be watching Nebraska’s rollout for lessons and pitfalls as the broader rollout proceeds.
Much of the detailed reporting on these developments has been produced by KFF Health News, a newsroom focused on health policy. As states begin enforcing these requirements, the central questions remain whether systems will avoid administrative errors, adequately protect people with health limits or caregiving duties, and prevent large numbers of people from losing coverage unintentionally.