Schmeeka Simpson of Omaha works as a patient navigator for the American Civil Liberties Union, an administrative assistant at Nebraskans for Peace, and picks up shifts at a Dunkin’ shop.
Still, even with three jobs, she worries about losing her health coverage when Nebraska, on May 1, becomes the first state to require certain Medicaid enrollees to work, train, or go to school under a rule mandated by congressional Republicans’ One Big Beautiful Bill Act.
Simpson, 46, has relied on Medicaid since her divorce in 2014. None of her employers offers health coverage. She said she lost her government food assistance after technical problems caused her to miss a renewal deadline, and she doesn’t trust the state to implement the new work rules without problems.
“Adding more barriers won’t make the program work any better,” she said.
Nebraska Medicaid officials say they are trying to make compliance as easy as possible so people don’t lose coverage for administrative reasons, such as failing to file the proper paperwork. Enrollees with one of thousands of qualifying health conditions would be exempt.
“Our top priority is making sure members clearly understand changes to the program and how to maintain their coverage,” said Drew Gonshorowski, the state’s Medicaid director.
But 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, their access to health services and protection from medical debt.
Hospitals also worry an increase in uninsured patients will hurt their bottom lines, said Jeremy Nordquist, 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.
What the Law Requires
The law President Donald Trump signed last July requires the 42 states — plus the District of Columbia — that fully or partially expanded Medicaid under the 2010 Affordable Care Act to implement a work requirement starting in 2027. The full expansion enables adults with incomes of up to 138% of the federal poverty level ($22,025 for a single person this year) to be eligible for Medicaid.
More than 20 million people gained coverage through Medicaid expansion, according to KFF, a health information nonprofit. The Congressional Budget Office estimates 4.8 million will become uninsured over the next decade as a result of the work requirement.
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 an exemption — such as caring for a child 13 or younger, a disabled parent, or having a health condition that prevents employment.
Nebraska’s Plan
Nebraska is implementing the provision eight months ahead of the national deadline. About 70,000 Medicaid enrollees will need to meet the requirement, 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.
Nebraska is not adding any employees to implement its work requirement. “The fact that they say they do not need additional resources raises questions” about whether “they will be able to pull this off without future headaches,” Nordquist said.
Enrollees for whom Nebraska doesn’t have data will be notified and can complete an online form to confirm they meet the new rules. Nebraska officials say they will allow enrollees to self-attest that they volunteer, go to school, or qualify for exemptions. “Supporting documentation, such as medical records, will not be required,” Spilinek said.
The long list of health conditions that qualify for an exemption includes many types of cancers, heart conditions, and mental health conditions. But Kelsey Arends, senior staff attorney for Nebraska Appleseed, said the list still isn’t comprehensive enough — different levels of illness severity are not always included.
Whether self-attestation will be broadly allowed in other states will depend on CMS’ work requirement rules, expected this summer. Centers for Medicare & Medicaid Services Administrator Mehmet Oz told KFF Health News that “we don’t like self-attesting” and that “documentation is critical.”
National Precedent
Adding a work requirement to Medicaid has been a priority for Republicans since Trump’s first term. In 2018, 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 didn’t meet the requirements but because of paperwork failures.
Georgia has had a work requirement under its partial Medicaid expansion since 2023. Only about 8,000 people signed up in its first two years — far fewer than the 25,000 officials predicted for the first year alone — and many have been denied because of paperwork issues.
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 have a physical or mental illness or disability. “This is not a case that we have mostly healthy adults choosing not to work,” said study co-author Darshali Vyas, a 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.”
In Nebraska, about two-thirds of Medicaid expansion enrollees already work or attend school, according to KFF. The state’s unemployment rate is 3%, one of the lowest in the nation.
Only two other states plan to implement the work requirement early: Montana in July and Iowa in December. Many states will be closely watching Nebraska’s implementation for lessons ahead of their own January launches.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. Reporting by Phil Galewitz, KFF Health News. USA TODAY Network via Reuters Connect.
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