Nebraska is poised to become the first US state to implement work, volunteering or education requirements for new Medicaid applicants, launching the controversial policy eight months ahead of federal mandates.
The move has sparked significant concern among advocates who fear a rapid rollout could lead to eligible individuals losing vital healthcare coverage, while state officials insist they are prepared.
Health policy experts and other states will be watching closely, with Jennifer Tolbert, deputy director of KFF's Program on Medicaid and the Uninsured, noting it "can be used as a lesson for other states, both where things go well and where things don’t go well."
The new mandate forms part of a broader tax and policy law signed by President Donald Trump last year. Nebraska's Republican Governor, Jim Pillen, announced in December that the state would fast-track its implementation, stating the aim was "making sure we get every able-bodied Nebraskan to be a part of our community."
This comes as Nebraska boasts one of the lowest unemployment rates in the US, at 3.1 percent in February.
The federal policy will not apply to all Medicaid beneficiaries, but specifically to those enrolled under the expansion adopted by most states to extend healthcare access to more low-income individuals.
Under the changes, many Medicaid participants aged 19 to 64 will be required to demonstrate at least 80 hours of work or community service per month, or be enrolled in school at least half-time. Eligibility will also be reviewed every six months, rather than annually, potentially accelerating coverage loss if circumstances change. Exceptions are planned for those deemed medically frail or participating in addiction treatment programs.
A report from the Urban Institute in March estimated that these changes could result in approximately 5 million to 10 million fewer people nationally being enrolled in Medicaid than would otherwise be the case.
Michael Karpman, a health policy researcher at Urban, highlighted the administrative burden: "The higher the administrative burden, the more likely people are found noncompliant and disenrolled."
Nebraska officials plan to utilize existing data to identify participants who are already working or exempt, stating they hold this information for most of the roughly 70,000 people enrolled via the expansion. This leaves an estimated 20,000 to 28,000 individuals, plus an average of 3,000 to 4,000 new monthly enrollees, who will need to provide additional information.
Initially, proof of meeting requirements for just one month within the previous 12 will suffice, though this timeframe will extend to six months in 2027. Flexibility is offered, for instance, by allowing proof of earning at least $580 – the equivalent of 80 hours at minimum wage – instead of direct work records. Failure to submit requested information within 30 days could lead to application denial or loss of existing coverage.
The impending changes are already generating significant anxiety and confusion. Bridgette Annable, a 21-year-old mother from southwest Nebraska, received a letter informing her she must meet the new work requirements or risk losing the benefits that cover her insulin and diabetic supplies. Despite medical advice against it for her mental health, she has secured a part-time job but worries about her ability to maintain it.
"I am working 30 to 25 hours a week — as much as my employer can provide," Annable said. "Although I call out of work often due to fibromyalgia pain and bipolar episodes that leave me too tired to leave the house. I have enough energy to take care of my daughter and do some cleaning, but that’s about it."
Amy Behnke, CEO of the Health Center Association of Nebraska, reported that both her staff and their clients have numerous unanswered questions from the state. These include specifics on whether all apprenticeship programs count towards work requirements, or the precise travel distance for hospital care exemptions.
Jennifer Tolbert of KFF noted that the state's recently issued 295-page list of conditions qualifying individuals as medically frail might not be comprehensive.
"The speed at which we are choosing to implement work requirements hasn’t left a lot of space for really meaningful communication," Behnke added.
As health policy experts and other states closely monitor Nebraska's rollout, the state may yet be forced to adjust its approach following anticipated federal guidance in June.
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