Nebraska is set to become the first state in the nation to enforce work, volunteer, or education requirements for new Medicaid applicants, launching the policy on Friday—eight months before the federal mandate takes effect. The move, part of a broader tax and policy law signed by President Donald Trump, is being closely watched by health policy experts and other states as a potential template for similar efforts.
State officials say they are prepared, having trained staff and begun sending letters, emails, and texts to those who may be affected. But advocates warn that the rapid rollout leaves critical details unresolved, risking coverage for eligible low-income residents. “It can be used as a lesson for other states, both where things go well and where things don’t go well,” said Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured.
What the Requirements Entail
Under the new rules, Medicaid participants aged 19 to 64 must show they work or perform community service for at least 80 hours per month, or are enrolled in school at least half-time. Eligibility reviews will shift from annual to every six months, meaning recipients could lose coverage faster if their circumstances change. Exceptions exist for those deemed medically frail or in addiction treatment, among others.
Nebraska Governor Jim Pillen announced the early implementation in December, saying the goal is “making sure we get every able-bodied Nebraskan to be a part of our community.” The state’s unemployment rate stood at 3.1% in February, one of the lowest in the country. The policy applies only to those enrolled under the Medicaid expansion, which covers low-income adults.
An Urban Institute report from March estimated that similar changes nationally could reduce Medicaid enrollment by 5 million to 10 million people. “The higher the administrative burden, the more likely people are found noncompliant and disenrolled,” said Michael Karpman, an Urban Institute health policy researcher.
Data Matching and Administrative Hurdles
Nebraska plans to use existing data to verify employment or exemptions for most of the roughly 70,000 expansion enrollees. That leaves 20,000 to 28,000 who must provide additional proof, plus 3,000 to 4,000 new applicants each month. Initially, they need to show compliance for just one month in the past 12, but that window will tighten to six months in 2027. Those who fail to respond within 30 days could see their applications denied or coverage revoked.
The state has also released a 295-page list of conditions that may qualify as medically frail, but Tolbert noted uncertainty about its comprehensiveness. “We don’t know if it’s a comprehensive list,” she said.
Real-World Impact: Confusion and Fear
Bridgette Annable, a 21-year-old mother from southwest Nebraska, received a letter warning she must meet the work requirements or lose benefits covering her insulin and diabetic supplies. Despite being advised against working for her mental health, she took a part-time job. “I am working 30 to 25 hours a week—as much as my employer can provide,” she said. “Although I call out of work often due to fibromyalgia pain and bipolar episodes that leave me too tired to leave the house.”
Amy Behnke, CEO of the Health Center Association of Nebraska, said staff and clients have many unanswered questions. For instance, apprenticeship programs count toward the requirement, but it’s unclear if only state-certified ones qualify. Similarly, an exemption for those traveling to a hospital for care lacks clarity on distance thresholds. “The speed at which we are choosing to implement work requirements hasn’t left a lot of space for really meaningful communication,” Behnke said.
The federal government is expected to issue guidance in June, which could force Nebraska to adjust its approach. Meanwhile, the state’s early move is seen as a test case for other states weighing similar policies, particularly as the Trump administration’s broader agenda continues to reshape domestic policy. As tensions simmer in other arenas—such as the ongoing foreign policy reckoning and GOP infighting over DHS funding—Nebraska’s Medicaid experiment offers a stark look at the real-world consequences of administrative changes.
