SouthernWorldwide.com – Nebraska has made history by becoming the first state in the United States to implement work requirements for Medicaid recipients.
This new policy went into effect seven months ahead of the deadline established by a federal law passed in 2025, often referred to as the “big, beautiful bill.” Health care policy experts are now closely observing Nebraska’s early implementation of these rules.
The requirements specifically target individuals enrolled in Medicaid through an expansion that broadened eligibility to include more low- and middle-income earners. In Nebraska, approximately 70,000 individuals gained Medicaid coverage through this expansion, out of a total of about 346,000 Medicaid recipients in the state.
According to House Speaker Mike Johnson, the new requirements were intended to combat “fraud, waste and abuse” within the Medicaid program. This perspective was articulated in 2025.
However, concerns have been raised by various experts who warn that these restrictions could negatively impact access to healthcare. The Urban Institute has projected that these changes might lead to as many as 10 million people losing their Medicaid coverage over the next two years.
“Nebraska going early is going to allow us to kind of see what might be working, what aspects of implementation may not be working,” stated Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured. She made these remarks during an online event on Thursday that focused on the work requirements.
The Urban Institute’s analysis suggests that approximately 25,000 Medicaid enrollees in Nebraska could lose their health insurance due to these new rules. This figure represents about 36% of those who are subject to the restrictions.
The new regulations apply to individuals aged 19 to 64 who are enrolled in Medicaid expansion. They are required to demonstrate that they are working or engaged in community service for at least 80 hours per month. Alternatively, they can be at least part-time students. Several exemptions are in place, including for individuals with medical conditions, pregnant women, and caregivers of disabled individuals.
A significant number of individuals who may lose coverage are those who meet the eligibility criteria but are disenrolled due to issues with paperwork or an inability to prove their exemption status, such as being disabled, according to the report.
Recipe for chaos?
Three other states are also planning to implement Medicaid work requirements by the end of the current year: Iowa, Montana, and Nebraska. Montana has indicated that it will begin enforcing its rules on July 1, while Iowa is scheduled to implement its requirements on December 1, as reported by KFF.
Despite Nebraska’s early move, many questions surrounding the practical implementation of these Medicaid rules remain unanswered, according to health care experts. For instance, states are still awaiting definitive guidance from federal authorities on how to precisely define an enrollee as “medically frail,” which is one of the specified exemptions from the work requirements. This was highlighted in a KFF analysis.
Given that the “big beautiful bill,” signed into law by President Trump in 2025, mandates the implementation of these rules by January 1, 2027, many states are still in the process of developing their implementation plans, KFF noted.
Amy Behnke, CEO of the Health Center Association of Nebraska, informed The Associated Press that staff members who assist individuals with Medicaid enrollment, as well as their clients, have pending questions that the state has not yet addressed. For example, the exemption for individuals who travel for medical care is unclear regarding the required travel distance to qualify.
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“The speed at which we are choosing to implement work requirements hasn’t left a lot of space for really meaningful communication,” Behnke commented.
Frail rate
Other U.S. states are currently working through their implementation plans and are in the process of hiring additional state workers or contractors to manage the increased workload, KFF’s analysis revealed. Six states are reportedly planning to utilize artificial intelligence for processing documents and data matching, according to the health policy research firm.
A significant challenge facing states is establishing a reliable method to verify “medical frailty.” The “big beautiful bill” defines this category to include individuals who are blind or disabled; those with physical, intellectual, or developmental disabilities; individuals with substance use disorder or a “disabling” mental disorder; or those with “serious or complex” medical conditions.
States are actively debating whether they can use medical claims data to confirm medical frailty or if they will need to rely on enrollees’ self-declarations, as explained by Kate McEvoy, executive director of the National Association of Medicaid Directors, during KFF’s webinar.
In a statement released in December, Dr. Mehmet Oz, administrator of the Centers for Medicare and Medicaid Services, commended Nebraska for its initiative in becoming the first state to introduce these new work requirements. He described the early rollout as a demonstration of the state’s “commitment to helping more Nebraskans move toward greater independence and opportunity.”
In the same statement, Nebraska Governor Jim Pillen characterized the new regulations as a means to help 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 U.S., standing at 3.1%. This contrasts with the national jobless rate of 4.4% recorded in the same month. The unemployment rate subsequently decreased to 4.3% in March.
Learning from Arkansas and Georgia
Some experts express skepticism about the effectiveness of Medicaid work requirements in encouraging more program participants to find employment. They point to the experiences of Georgia and Arkansas, two states that implemented similar policies several years ago.
An analysis conducted by researchers at Harvard University’s T.H. Chan School of Public Health indicated that Arkansas’s work requirements did not lead to an increase in employment. However, approximately 18,000 adults in the state lost their health care coverage after the policy was enacted. More than half of these individuals reported delaying medical care, and over 6 in 10 stated they postponed taking medications due to cost.
Arkansas ultimately discontinued the mandate after a court ruling in 2019 struck down the requirements, one year after their implementation.
Georgia’s program proved to be expensive, with a total cost of $110 million. It rejected about 60% of Medicaid applicants, often due to issues with documentation such as failing to provide a birth certificate or driver’s license, according to the Georgia Budget and Policy Institute, a state-focused think tank. During its initial two years, the program enrolled approximately 8,000 Georgians.
“At their core, work requirements keep people from or take away health coverage, and indeed people will lose coverage by the millions, even if they are eligible,” stated the Center on Budget and Policy Priorities, a nonpartisan think tank, in a recent report. “This conclusion is supported by ill-fated, real-world experiences in Arkansas and Georgia.”
