Nebraska Becomes First State to Implement Medicaid Work Requirements
On May 1, Nebraska became the first state to require certain Medicaid enrollees to work, train, or attend school, as mandated by the One Big Beautiful Bill Act signed by President Trump. The requirement applies to about 70,000 enrollees in Nebraska's Medicaid expansion program.
What the Requirement Entails
Enrollees must meet one of the following criteria each month:
- Work or volunteer at least 80 hours per month
- Attend school part-time
- Participate in job training
- Qualify for an exemption
Exemptions include caring for a child under 13 or a disabled parent, or having a health condition that prevents employment. The state has posted a long list of medical conditions that qualify for the "medical frailty" exception.
The state plans to use databases to verify work or exemption status for an estimated 72% of enrollees. Those not verified will be notified and can submit an online form. Importantly, enrollees can self-attest to volunteering, schooling, or qualifying for exemptions; supporting documentation such as medical records will not be required. Nebraska is not adding administrative staff to implement the requirement.
Background and Federal Context
The federal law requires states that expanded Medicaid under the Affordable Care Act to implement work requirements starting in 2027, though states have the option to start earlier.
The Congressional Budget Office estimates that 4.8 million people will become uninsured over the next decade due to the requirement.
Previous state experiences offer cautionary tales:
- Arkansas (2018): Implemented a work requirement under a waiver; over 18,000 people lost coverage in nine months, mostly due to paperwork issues.
- Georgia (since 2023): Work requirement under partial expansion has seen about 8,000 enrollees, far fewer than projected.
Official Statements and Concerns
Nebraska Medicaid Director Drew Gonshorowski said the state's top priority is making sure enrollees "understand the changes and how to maintain coverage."
CMS Administrator Mehmet Oz said he applauds Nebraska and hopes the state will "get into a more sophisticated place" by year's end.
Advocacy groups, including Nebraska Appleseed and KFF, have expressed concerns about potential loss of coverage due to paperwork errors and insufficient exemptions.
The Nebraska Hospital Association warned that increased uninsured patients could hurt hospital finances.
Health policy researchers noted that most Medicaid expansion enrollees already work or attend school, and that the population subject to the requirement includes many with health conditions.
Implementation Plans in Other States
- Montana: Plans to launch in July
- Iowa: Plans to launch in December
- Other states: Expected to begin in January 2027
Potential Impact
- Enrollees who lose coverage may face reduced retroactive eligibility (from three months to one month) if they reenroll.
- Hospitals and clinics anticipate financial losses if patients lose coverage.
- Advocacy groups warn that the long list of exempt medical conditions may still miss some severity levels.