Nebraska First State to Implement Medicaid Work Requirements Under GOP Bill

Nebraska on Friday became the first state to implement Medicaid work requirements under the One Big Beautiful Bill Act, sparking concerns from health policy analysts, advocates for the poor, and health industry groups who fear thousands of enrollees will lose coverage and, with it, their access to health services and protection from medical debt.

About 70,000 Nebraska Medicaid expansion enrollees will need to meet the requirement, which mandates working, training, or attending school at least 80 hours monthly, said Collin Spilinek, a spokesperson for the Nebraska Department of Health and Human Services. About 72% of them probably won't 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.

The requirement applies to adults with incomes up to 138% of the federal poverty level — $22,025 for a single person this year — who gained coverage through Medicaid expansion under the 2010 Affordable Care Act. More than 20 million people gained coverage through expansion, according to KFF.

"Adding more barriers won't make the program work any better," said Schmeeka Simpson, 46, of Omaha, who works three jobs — as a patient navigator for the American Civil Liberties Union, an administrative assistant at Nebraskans for Peace, and picking up shifts at a Dunkin' shop. Still, even with three jobs, she worries about losing her Medicaid coverage, which she has relied on since her divorce in 2014. None of her employers offer health coverage.

In a brief interview with KFF Health News on April 28 outside the National Press Club in Washington, D.C., Centers for Medicare & Medicaid Services Administrator Mehmet Oz said 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," adding that his hope is "by the end of this year they will get into a more sophisticated place."

Hospitals also worry an increase in uninsured patients will hurt their bottom lines, said Jeremy Nordquist, the president and CEO of the Nebraska Hospital Association. "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, he said.

The Congressional Budget Office estimates 4.8 million people will become uninsured over the next decade as a result of the work requirement. A recent study in the Annals of Internal Medicine found about one-third of adults at risk of losing coverage under the new work requirement reported that they have 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 and health policy researcher at Beth Israel Deaconess Medical Center in Boston. "It's a vulnerable group, and I am not sure there are clear protections as we begin to roll out work requirements."

The law gives states the option to launch their programs early. Montana plans to launch in July and Iowa in December. All 42 expansion states must implement work requirements by January 2027.

"The fact that they say they do not need additional resources raises questions" as to whether "they will be able to pull this off without future headaches," Nordquist said. The Nebraska Medicaid agency is not adding any employees to implement its work requirement.

To help patients, One World Community Health Centers plans to add staff to help people fill out the forms to get and maintain coverage. About 4,000 of their 52,000 patients are covered under the Medicaid expansion, said Andrea Skolkin, the CEO of the Omaha-based clinic. Losing 10% of those patients would mean $500,000 less in revenue, she said.

"We are still concerned about the expanded Medicaid folks losing coverage," Skolkin said. "It's an unsettling time for our clinic and their patients."