Nebraska first to enforce Medicaid work rules, tens of thousands at risk

Nebraska began enforcing Medicaid work rules on May 1, becoming the first state to put the new federal requirement into practice and putting between 28,000 and 41,000 people at risk of losing coverage. The policy lands in a state where many Medicaid expansion adults already work, raising the prospect that paperwork, reporting gaps, or exemption mistakes will drive losses more than any failure to meet the hours test.

Nebraska’s Department of Health and Human Services says most expansion enrollees ages 19 to 64 must work, volunteer, attend school, or participate in an approved program for 80 hours a month. The state also says earning at least $580 a month counts as satisfying the requirement. Exemptions cover pregnant people, medically frail enrollees, people with disabilities, and temporary hardships such as hospitalization.

The scale of the risk is significant. The Center for Budget and Policy Priorities estimates that 28,000 to 41,000 Nebraskans could lose coverage once the rule is fully in effect. KFF says roughly 65% of Nebraska Medicaid adults without dependent children who could be subject to the requirement already work 80 or more hours a month or are in school, a warning sign that administrative barriers could hit eligible people who are already meeting the spirit of the law. Nebraska says the rule applies only to Medicaid expansion enrollees, not the traditional Medicaid population.

The move makes Nebraska a test case for a broader Republican push to use community-engagement rules to narrow Medicaid expansion in states that were once pushed to broaden coverage. Across the country, 41 states and Washington, D.C., have adopted and implemented Medicaid expansion, while 10 states have not. Seven states expanded only after voters overrode resistant officials through ballot initiatives: Idaho, Maine, Missouri, Nebraska, Oklahoma, South Dakota and Utah. That history matters because the current strategy relies less on repeal than on tightening the bureaucracy around coverage.

The federal backdrop is just as important. The Centers for Medicare & Medicaid Services says the new community-engagement requirements were created by the 2025 reconciliation law and must be implemented by January 1, 2027, although states may start earlier if they choose. Nebraska moved first, and its early launch gives Washington and other states a preview of what these rules will look like when the deadline arrives. What unfolds there will show whether the policy is a work test in name, or a coverage cut by another route.