Schmeeka Simpson of Omaha juggles three jobs — patient navigator with the ACLU, an administrative assistant at Nebraskans for Peace, and shifts at Dunkin’ — yet she fears losing Medicaid now that Nebraska has begun enforcing a federal work requirement for some enrollees on May 1. Simpson, 46, has depended on Medicaid since her 2014 divorce and said technical problems that once cost her food assistance have left her anxious about similar bureaucratic miscues costing her health coverage.
Nebraska officials say they are trying to minimize administrative barriers so people do not lose coverage over paperwork. The state has posted a long list of medical conditions that would exempt enrollees from the requirement, and Drew Gonshorowski, Nebraska’s Medicaid director, called helping members understand the changes and maintain coverage a top priority.
CMS Administrator Mehmet Oz praised Nebraska for moving first when he spoke with KFF Health News on April 28, acknowledging the state was still “working out the kinks” and expressing hope it would improve by year’s end. Still, health policy experts, advocacy groups and hospitals worry thousands will become uninsured, losing access to care and protection from medical debt.
Jeremy Nordquist, president and CEO of the Nebraska Hospital Association, said hospitals fear a rise in uninsured patients and are concerned many enrollees won’t realize they must take action to remain covered. Nebraska plans to implement the new rules eight months ahead of the federal deadline created by last July’s law signed by President Donald Trump, which requires states that expanded Medicaid to add work requirements starting in 2027. The law applies to the 42 states and D.C. that fully or partially expanded Medicaid under the Affordable Care Act. Full expansion covers adults with incomes up to 138% of the federal poverty level — $22,025 for a single person this year.
KFF reports more than 20 million people gained coverage through expansion. The Congressional Budget Office estimates the new work requirement will leave about 4.8 million people uninsured over the next decade.
Under the new rules, enrollees must work or volunteer at least 80 hours a month, attend school at least part-time, or take part in job training. They may instead prove they qualify for exemptions, such as caring for a child 13 or younger, caring for a disabled parent, or having a health condition that prevents employment. Nebraska estimates about 70,000 enrollees will be subject to the requirement; the state says roughly 72% likely won’t have to do anything because their work or exemption status is already verifiable through state or federal databases.
To confirm compliance, Nebraska and other states intend to tap various administrative sources, including Medicaid claims and data held by credit agencies. Enrollees without verifiable records will be notified and can complete an online form to report work or exemptions. Unlike some states, Nebraska does not plan to hire additional staff to carry out the program, prompting skepticism about whether automation alone will suffice.
Nebraska officials say they will accept self-attestation for volunteering, schooling or qualifying exemptions and will not require supporting documentation such as medical records. That could make it easier for people to claim the law’s “medical frailty” exception. The state’s published list of exempting medical billing codes includes many cancers and mental health and heart conditions, but advocates say the list still falls short because it does not account for different levels of illness severity.
Kelsey Arends, senior staff attorney at Nebraska Appleseed, said the list is not broad enough. Crystal Schroer, 30, who has been on Medicaid since 2022 and has been unemployed since 2024, said she is “insanely worried.” She struggles to find work near Kearney, Neb., that would allow her to bring her psychiatric service dog, which helps her manage anxiety. She said the uncertainty has worsened her depression.
CMS’ eventual national guidance on work requirements, expected this summer, will influence whether other states allow self-attestation. Oz told KFF Health News he prefers documentation over self-attestation and called documentation “critical.”
Advocacy groups including the American Diabetes Association, the HIV+Hepatitis Policy Institute and the National Bleeding Disorders Foundation urged Nebraska to exempt enrollees with particular conditions, warning that losing coverage would mean losing access to medications that prevent hospitalizations.
Work requirements have been a policy priority for Trump since his first term. The Trump administration first allowed states to adopt such rules in 2018; only Arkansas implemented one before a federal judge ruled it unlawful. In the nine months it was active there, more than 18,000 people lost coverage — nearly one in four subject to the rule — mostly for failing to file paperwork correctly and on time rather than for not meeting the work criteria.
Georgia’s partial expansion, operating under a work requirement since 2023, enrolled far fewer people than officials expected: about 8,000 in its first two years versus a projected 25,000 in year one. Paperwork problems have led to many denials.
Research suggests many adults at risk of losing coverage under work rules have health problems. A recent Annals of Internal Medicine study found roughly one-third 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 co-author and health policy researcher at Beth Israel Deaconess Medical Center.
In Nebraska, roughly two-thirds of Medicaid expansion enrollees already work or attend school, and the state’s unemployment rate is about 3%. Clinics like One World Community Health Centers in Omaha worry about the financial hit if patients lose coverage. CEO Andrea Skolkin said about 4,000 of the clinic’s 52,000 patients are covered under expansion; losing 10% of those patients could mean $500,000 less in revenue. The clinic plans to hire staff to help patients complete forms.
Advocates remain skeptical that automation will prevent coverage losses and say early implementation increases risk. Nebraska Appleseed’s Arends called the state’s plan “very concerning.” There are financial and operational concerns beyond loss of coverage: the federal law also reduces retroactive eligibility for expansion enrollees from three months to one month, making it harder for people to have past medical bills covered if they lose and later regain Medicaid.
Two other states plan early launches: Montana in July and Iowa in December. Many states will watch Nebraska closely to learn what works and what does not before the nationwide deadline. Some state officials and consultants say preparedness is better now than in 2018 because eligibility reconfirmations after the COVID-19 public health emergency gave states more experience using public and private databases and communicating with enrollees. Still, experts warn the rollout “won’t be perfect” and will require adjustments as states implement the new requirements.
KFF Health News is a national newsroom producing in-depth journalism about health issues and is part of KFF, an independent source for health policy research and journalism.