The Tamesis
Nebraska on Friday became the first U.S. state to enact a Medicaid work requirement, seven months ahead of the deadline set by Republicans’ “Big and Beautiful Bill” law.
Health care policy experts say they are paying close attention to Nebraska’s early rollout of new rules that apply to people enrolled in Medicaid, a program that allows more low- and moderate-income people to qualify for the government health insurance program. Through the expansion, approximately 70,000 of Nebraska’s approximately 346,000 Medicaid beneficiaries have been enrolled in Medicaid.
House Speaker Mike Johnson, R-Louisiana, 2025 descriptive The new requirements are a way to reduce “fraud, waste and abuse” in Medicaid.
However, some experts warn that the restrictions could hinder Medicaid access, and the Urban Institute estimates that the changes could cause as many as 10 million people to lose Medicaid coverage over the next two years.
“Nebraska’s early action will allow us to understand what may be working and what aspects of implementation may not be working,” Jennifer Tolbert, associate director of Medicaid and Uninsured Programs at KFF, said during an online event Thursday focused on work requirements.
About 25,000 Medicaid enrollees in Nebraska could lose health coverage under the new rules, or about 36% of those who are restricted, according to the Urban Institute.
The new rules apply to Medicaid expansion enrollees ages 19 to 64, who must prove they work or perform community service at least 80 hours a month, or are at least part-time students. There are some exemptions, including people with health conditions, pregnant women and caregivers of people with disabilities.
The group said many of the enrollees who lost coverage were eligible but were dropped due to paperwork issues or failure to prove exemptions, such as disabilities.
The recipe for chaos?
Three other states plan to implement Medicaid work requirements by the end of the year: Iowa, Montana and Nebraska. Montana has said it will begin enforcing the rules on July 1, while Iowa will begin on December 1, KFF reported.
However, health care experts say that even as Nebraska moves forward with new Medicaid rules, many questions remain about how to implement the policy. For example, the KFF analysis found that states are still awaiting guidance from federal authorities on how to define participants in the program as “medically frail,” one of the exemptions from work requirements.
KFF said many states are still working on implementation plans because the “Great and Beautiful Act” signed into law by President Trump in 2025 requires rules to be established by January 1, 2027.
Amy Behnke, CEO of the Nebraska Association of Health Centers, told The Associated Press that workers helping people sign up for Medicaid and their clients have questions the state has yet to answer. She said people traveling to hospitals for treatment, for example, would be exempt from work rules, but it was unclear how far they would need to travel to qualify.
“The speed at which we’re choosing to implement job requirements doesn’t leave a lot of room for truly meaningful communication,” Behnke said.
frailty rate
KFF found in its analysis that other U.S. states are currently implementing their plans and hiring additional state staff or contractors to handle the additional work. Six states plan to use artificial intelligence to help with documentation and data matching, according to Health Policy Research.
A major question facing states is how to prove someone is “medically infirm,” which the Big Beauty Act says includes people who are blind or disabled; people with physical, intellectual or developmental disabilities; individuals with substance abuse disorders or “disabling” mental disorders; or people with “serious or complex” health conditions.
Kate McEvoy, executive director of the National Association of Medicaid Directors, said during a KFF webinar that states are grappling with whether they can use medical claims to verify medical vulnerability or rely on enrollees’ self-declarations.
In a December statement, Centers for Medicare and Medicaid Services Director Dr. Mehmet Oz praised Nebraska for announcing it would be the first state in the nation to introduce new work requirements, saying the early rollout demonstrates the state’s “commitment to helping more Nebraskans move toward greater independence and opportunity.”
In the same statement, Nebraska Gov. Jim Pillen described the new rules as helping Medicaid recipients “achieve greater self-sufficiency through employment and other meaningful activities.”
As of February, Nebraska had one of the lowest unemployment rates in the country at 3.1%, while the national unemployment rate that month was 4.4% (unemployment rate fell to 4.3% March. )
Learn from Arkansas and Georgia
Some experts are skeptical that Medicaid work requirements will spur more program participants to find jobs, pointing to cases in Georgia and Arkansas, two states that enacted similar rules several years ago.
An analysis by researchers at the Harvard Chan School of Public Health shows Arkansas’ requirements failed to boost employment. But about 18,000 adults in the state lost health insurance after the policy took effect, with more than half reporting they had put off medical care and more than 6 in 10 saying they had put off taking medications because of the cost.
Arkansas abandoned the order after it was overturned by a court in 2019, a year after it was implemented.
Georgia’s program has proven costly, costing $110 million and rejecting about 60% of Medicaid applicants, often because of paperwork issues such as failure to provide birth certificates or driver’s licenses, according to the Georgia Budget and Policy Institute, a state-focused think tank. In its first two years, the program enrolled approximately 8,000 Georgians.
“Essentially, work requirements prevent people from obtaining or canceling health insurance, and in fact, millions of people will lose health insurance even if they qualify,” the Center on Budget and Policy Priorities, a nonpartisan think tank, said in a report this week. “This conclusion is supported by unfortunate real-world experience in Arkansas and Georgia.”
