Schmeeka Simpson of Omaha, who balances three jobs — as a patient navigator for the ACLU, an administrative assistant at Nebraskans for Peace and shifts at Dunkin’ — said she is terrified of losing Medicaid now that Nebraska began enforcing a federal work requirement for some enrollees on May 1. Simpson, 46, has relied on Medicaid since her 2014 divorce and said past technical glitches that cost her food assistance make her anxious about similar bureaucratic mistakes costing her health coverage.
State officials say they are trying to limit paperwork barriers so people do not lose coverage. Nebraska has published a long list of medical conditions that would qualify someone for an exemption, and Drew Gonshorowski, the state’s Medicaid director, said helping members understand the changes and keep coverage is a top priority.
CMS Administrator Mehmet Oz told KFF Health News on April 28 that he applauded Nebraska for moving first, while acknowledging the program was still “working out the kinks” and expressing hope it would improve over the year. Still, health policy experts, advocacy groups and hospital leaders warn that thousands of people could become uninsured, losing access to care and protection from medical bills.
Jeremy Nordquist, president and CEO of the Nebraska Hospital Association, said hospitals fear a rise in uninsured patients and worry many enrollees will not realize they must take action to remain covered. Nebraska is rolling out the requirement about eight months earlier than a federal deadline set by last July’s law requiring states that expanded Medicaid to add work rules starting in 2027. That law affects 42 states and Washington, 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, which is $22,025 for a single person this year.
KFF reports that expansion gained coverage for more than 20 million people. The Congressional Budget Office has estimated the new work requirement could leave about 4.8 million people uninsured over the next decade.
Under Nebraska’s rules, enrollees must work or volunteer at least 80 hours a month, attend school at least part time, or join a job training program. People can instead show they qualify for exemptions, such as caring for a child 13 or younger, looking after a disabled parent, or having a health condition that prevents employment. Nebraska estimates roughly 70,000 enrollees will be subject to the requirement and says around 72% likely will not need to act because their work or exemption status can already be verified through state or federal databases.
To confirm compliance, Nebraska and other states plan to rely on administrative sources, including Medicaid claims and data from credit agencies. Enrollees without verifiable records will be notified and given an online form to report work or claim exemptions. Unlike some states, Nebraska does not plan to hire additional staff to run the program, a decision that has raised skepticism about whether automation alone will be enough.
Nebraska officials say they will accept self-attestation for volunteering, schooling or qualifying exemptions and will not demand 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 conditions related to mental health and heart disease, but advocates say the list still fails to account for differing severity and functional limitations.
Kelsey Arends, a senior staff attorney at Nebraska Appleseed, said the list is too narrow. Crystal Schroer, 30, who has been on Medicaid since 2022 and unemployed since 2024, said she is very worried. Schroer struggles to find work near Kearney, Nebraska, that would allow her to bring her psychiatric service dog, which helps manage her anxiety, and said the uncertainty has worsened her depression.
CMS is expected to issue national guidance on work requirements this summer, and that guidance may shape whether states continue to allow self-attestation. Oz told KFF Health News he prefers documentation over self-attestation and called paperwork “critical.”
Advocacy organizations, including the American Diabetes Association, the HIV+Hepatitis Policy Institute and the National Bleeding Disorders Foundation, urged Nebraska to exempt people with certain conditions, warning that losing coverage would cut off access to medications that prevent hospitalizations.
Work requirements have been a policy priority for former President Trump for several years. The Trump administration permitted states to adopt such rules in 2018, but only Arkansas implemented one before a federal judge found 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 — largely because they failed to file paperwork correctly and on time rather than because they did not meet the work criteria.
Georgia’s partial expansion, which has operated under a work requirement since 2023, enrolled far fewer people than officials predicted: about 8,000 in its first two years compared with a projected 25,000 in year one. Administrators and advocates said paperwork issues drove many denials.
Research indicates many adults at risk of losing Medicaid under work rules have health problems. A recent Annals of Internal Medicine study found about 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 study co-author and health policy researcher.
In Nebraska, roughly two-thirds of expansion enrollees already work or attend school, and the state’s unemployment rate is about 3 percent. Clinics such as One World Community Health Centers in Omaha worry about the financial impact if patients lose coverage. CEO Andrea Skolkin said about 4,000 of the clinic’s 52,000 patients are covered under expansion and that losing 10 percent of those patients could mean about $500,000 less in revenue. The clinic plans to hire staff to help patients complete forms.
Advocates remain doubtful that automation will prevent coverage losses and say the early rollout increases risk. Arends called Nebraska’s plan “very concerning.” Beyond potential coverage loss, the federal law also shortens 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 have announced early launches: Montana in July and Iowa in December. Many states will watch Nebraska closely for lessons about what works and what does not before the national deadline. Some officials and consultants say states are better prepared than in 2018 because eligibility reconfirmations after the COVID-19 public health emergency gave agencies 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 reporting on health issues and is part of KFF, an independent source for health policy research and journalism.