Nebraska's efforts to implement new, federally mandated work requirements for Medicaid underscore fears that millions of people will experience avoidable barriers to healthcare coverage, Human Rights Watch, Oxfam America, and Nebraska Appleseed said today.
On May 1, 2026, Nebraska became the first state to implement work requirements for Medicaid, the public health insurance program for people with low- or no-income, as part of public spending cuts mandated by the Trump administration's One Big Beautiful Bill Act (OBBBA), which also extended and deepened tax cuts that overwhelmingly benefit high-income households and corporations. These new rules will require most adults without dependents to document at least 80 hours per month of work, education, or other approved activities to maintain Medicaid coverage. States must implement the requirements by January 1, 2027, though they may do so sooner, as Nebraska has.
"Nebraska is the canary in the coal mine for issues that most states will face when they begin implementing these work requirements," said Matt McConnell, US researcher on economic, social, and cultural rights at Human Rights Watch. "As they do, they should make sure red tape doesn't strip people of health care."
Human Rights Watch and Oxfam America in August and September interviewed a dozen Nebraskans with personal or professional experience with Medicaid and a public employee involved in the process.
People interviewed said that the state's rollout of new work requirements increased administrative burdens and risked disruptions in access to health care following the rushed implementation of these federal requirements. Data suggests that large numbers of people are already losing coverage in Nebraska because of the work requirements.
Eli McCreary, age 64 at the time, said he lost his Medicaid coverage while undergoing treatment for kidney cancer and multiple chronic health conditions. He said a representative of the health plan that managed his Medicaid coverage informed him he lost access because he was not working, even though he is unable to work due to his condition. "If I could work, I would work," he said. "But I can't…. I can't walk around. I mean, I can't breathe. I can't walk very far." The sudden lapse in coverage disrupted his planned care. "I was supposed to go see the cancer specialist here…. And that date was canceled, so I couldn't. I had to wait until I got insurance again to even come back out here.... Everything was delayed."
A Medicaid eligibility worker from the Nebraska Department of Health and Human Services said that poor training, vague and inconsistent guidance, and technical issues, including unprepared software systems, had caused stress and uncertainty for applicants and for state employees.
"We just sometimes don't know what we're doing," the worker said, describing the rollout as rushed and confusing. "I wish the people who make policies knew what they were doing."
The OBBBA, which became law in July 2025, imposed new eligibility criteria on the nearly 20 million adults without dependents in the 40 states and the District of Columbia who rely on expanded Medicaid coverage under the Affordable Care Act. Nebraska expanded coverage through a ballot initiative in 2018.
Adults in this expansion population will be required to prove that they either satisfy these new work requirements or qualify for a statutory exemption, including for caregivers of young children, pregnant people, certain people with disabilities, and those deemed medically frail. States may also choose to offer short-term hardship exceptions for certain individuals, such as those in counties with a federally declared emergency or disaster.
The Urban Institute estimated that between 3 and 7 million people in the United States could lose Medicaid coverage by 2028 because of these new requirements. The Congressional Budget Office, a nonpartisan government research agency, estimated that work requirements would increase the number of uninsured people in the United States by 4.8 million by 2034.
Nebraska Appleseed, a Lincoln-based nonprofit advocacy organization, has repeatedly requested data from the state regarding its implementation of these requirements. On September 29, 2026, Nebraska publicly released initial figures showing that over 1,000 people lost or were denied Medicaid coverage under the new requirements between May and August of this year. The number of people affected is likely to grow significantly over the coming months as state officials review enrollees' eligibility on a rolling basis.
"Getting data from the state about how many people are losing coverage and why shouldn't be like pulling teeth," said Sarah Maresh, healthcare access program director at Nebraska Appleseed. "Nebraskans deserve access to this information. You can't fix problems you refuse to measure."
In May, Human Rights Watch and Oxfam America warned that millions of people were at risk of losing coverage due to the work requirements. In a joint letter to the US Department of Health and Human Services and the Centers for Medicare & Medicaid Services (CMS), the organizations urged federal authorities to issue guidance for states that would help prevent these new federal requirements from causing harmful and unnecessary Medicaid denials and terminations. But CMS issued binding guidance on June 1 that will require burdensome case-by-case assessments.
"Federal authorities could have chosen to blunt the impact of the OBBBA's inequality-fueling Medicaid cuts," said Jackson Gandour, senior economic justice policy adviser at Oxfam America. "Instead, they added even more convoluted requirements that will deprive people of the health care they are entitled to."
Under international human rights law, everyone has the right to the highest attainable standard of physical and mental health. Medicaid eligibility requirements already exclude people who earn too much to meet extremely low-income eligibility limits but not enough to afford private health insurance. Complex work reporting requirements may exclude millions more, undermining their rights to health, social security, and an adequate standard of living. Because the rules largely affect people with low incomes, these losses may also deepen inequality, the organizations said.
Officials in Nebraska and other states preparing to implement the work requirement provisions should identify ways to reduce administrative burdens and simplify eligibility assessments. Officials should also take steps to strengthen existing exemptions; improve communication about, and understanding of, who is subject to work requirements and who is exempt; and enhance transparency by regularly publishing data on application denials, coverage terminations, appeals, reinstatements, and the reasons underlying these decisions.
"Work requirements are a solution in search of a problem," McConnell said. "The truth is that they make life harder for people who are already working or can't work."
Widespread Confusion; Risk of Disrupted Care
People currently on Medicaid expressed confusion about whether work requirements or relevant exemptions applied to them, and what steps they needed to take to maintain coverage.
"I got a letter early in January stating that the work requirements were coming, and then basically, that's it," said Schmeeka Simpson, a 44-year-old community organizer in Omaha and mother of three. She said she received a letter informing her that she was approved for Medicaid in August, but with no explanation for how Nebraska determined she complied with the work requirements. "I'm like 'great, that's wonderful,' but I don't know how they came to those conclusions." Due to the lack of clarity, Simpson said, it is difficult to know how to maintain Medicaid eligibility. "Who, what, when, where, why, and how hasn't been answered…. These are life and death situations for people. This is not just politics."
Melissa Craig, a single mother in Omaha who relies on Medicaid, said she only learned that she qualified for an exemption to work requirements shortly before they went into effect: "It is very stressful for me on a day-to-day basis about what my future and my son's future looks like. Staying on top of it is a full-time job."
Megan Word, government relations director covering Nebraska and Kansas for American Cancer Society Cancer Action Network (ACS CAN), said "The workers can't even quickly identify whether somebody is on the expansion population or not." She said even Medicaid eligibility workers may be unaware of whether someone will be subject to work requirements.
"The biggest concern is the administrative burden that is going to be placed on ... the patient," said Amy Behnke, who leads the Health Center Association of Nebraska, which represents the seven healthcare providers operating federally qualified health centers in Nebraska. She said:
"Prior to Medicaid expansion, our health centers had a 50 percent uninsured rate, and now we're down to about a third. So, expansion has been incredibly significant to our health centers and to their patients … [But] often what we see with patients is that … they're working sometimes multiple jobs, they're taking care of their families, they're figuring out how to put food on their table. And so, any time you ask somebody to take one more step when it comes to verifying their health insurance, the higher the likelihood is that something is going to fall through the cracks."
She described a recent case at one of the centers she represents. A pregnant woman arrived for a prenatal appointment and learned she no longer had Medicaid coverage, despite being exempt from work requirements. Eventually staff determined that state officials had overlooked a box indicating she was pregnant and the woman was able to regain Medicaid coverage, but it took multiple calls and she had to reschedule appointments. "This never should have been an issue," Behnke said.
Confusion surrounding work requirements may also discourage otherwise eligible people from applying for Medicaid coverage. "I had three different patients outright tell me, 'What's the point of enrolling? I'm not employed,'" said a licensed social worker based in Omaha who like some others spoke on condition of anonymity. She stressed that working with a social worker was essential to getting these people to apply. "It really, in our experience, becomes a game of how connected you are to a caseworker who can write these accommodations or write these letters and verify your status. And it really just becomes, just kind of a dice roll of privilege, unfortunately."
This confusion may already be causing disruptions in care.
McCreary, the Omaha man who lost coverage while undergoing cancer treatment, learned that he had lost Medicaid coverage from his healthcare providers. "Unless you're going to self-pay, we can't take you, because your insurance canceled out," he said, describing his conversation with hospital staff. "I had to cancel all of my appointments."
He said that when he contacted the managed care organization that administered his Medicaid coverage, he was informed that he had lost coverage because he was not working. "They said, you're not working. I can't really do anything for you."
Administrative Capacity and Perverse Incentives
Implementing these work requirements involves creating new administrative processes within state agencies overseeing Medicaid, as well as training for the public employees who administer them, the organizations said. The federal law also requires all states, starting in January 2027, to increase the frequency of eligibility redeterminations from once per year, as required by the federal Affordable Care Act, to every six months. While this will effectively double the number of eligibility determinations the department must process each year, staffing is not keeping up with the increased workload.
In the December 2025 news conference to announce that Nebraska would be the first state to implement work requirements under the OBBBA, Governor Jim Pillen said that no extra staff would be hired to help track work requirements. In July, Nebraska instituted a hiring freeze for state agencies including the health department citing a state budget shortfall that has been worsened by a 2023 law that nearly halved Nebraska's tax rate for the highest earners.
One Medicaid eligibility worker said that capacity issues, along with internal bureaucratic incentives, exacerbate the risk that eligible people will be denied coverage. They said chronic understaffing and pressure to clear cases is compounded by confusion and a lack of adequate training around the eligibility changes: "We just sometimes don't know what we are doing … and then you have [Medicaid applicants] coming in, understandably they're upset."
They said staff had recently been required to revisit some cases because supervisors had relayed incorrect information. "The supervisors were told something wrong and told us something wrong and now we're having to go back and fix all these cases."
The worker said they face pressure to increase the number of cases closed. "You have to get your numbers up," the worker said, relaying the message they and other staff regularly get from managers. "That's really messed up because denials are the easiest." This prioritizes speed over accuracy, the worker said, incentivizing staff to rapidly deny applications if there is any cause and disincentivizing staff from spending the time necessary to correct apparent errors, omissions, or inquiring more about potential pathways to coverage through existing exemptions. "All of that work that you do to try to verify, it doesn't count. So, it looks like you did nothing," the worker said. "All I think about is numbers and getting it done. I get so anxious and nervous."
Rushed and Unclear Implementation
In Nebraska's rush to be the first state to implement the work requirements, it developed eligibility criteria before official federal guidance was issued. The result has been a mismatch between the state and federal eligibility rules.
"Nebraska went live with their work requirement implementation on May 1 and the Feds published their [mandatory guidance] on June 1," said Megan Word of the ACS CAN. "[Nebraska] did not pause. They did not say, 'Wait a minute … we need to review the differences,' because there were many."
She said before the federal government issued mandatory guidance in June, through the Interim Final Rule, Nebraska had created a list of medical codes for diagnoses that might automatically satisfy the "medically frail" exemption to work requirements written into the OBBBA. "If you can find one of those medical conditions on the list, then theoretically, you should be eligible for an exemption," Word said.
However, this was inconsistent with the federal rule. Under that rule, a diagnosis such as cancer does not automatically establish an exemption, leaving many people who are unable to work because of their health unsure of whether they remain eligible for Medicaid. Instead, the federal rule defines "medically frail" as a "physical, mental, or other behavioral health condition [that] significantly impairs the individual's ability to comply" with work requirements.
"The Interim Final Rule makes it harder for patients to obtain this exemption," Word said, because it puts the burden of proving one's inability to work on enrollees, while also requiring a case-by-case review from implementing agencies. "That will involve some sort of independent verification, a process that no one really understands at this point."
For the time being, Nebraska is allowing people to submit a declaration-"self-attest"-that they are "medically frail" without having to provide additional supporting documentation. Human Rights Watch and Oxfam America recommended that federal authorities should help enable self-attestation in its May letter.
Although the rules published in June allowed states to accept self-attestation for an exemption from work requirements, it only allows states to do so until January 2028, after which states will only be allowed to accept self-attestation when documentation is not "reasonably available."
In practice, both a lack of awareness regarding the availability of these exemptions and a broad misunderstanding about who may be eligible for them undermines the temporary availability of self-attestation, the groups found. People who may be unable to work because of their health must also juggle bureaucratic hurdles to prove their eligibility, frequently while undergoing sometimes intensive medical treatment.
According to KFF, a nonpartisan health policy research organization, more than 6 out of every 10 people under age 65 on Medicaid are already working full or part time. About 3 out of 10 are not working because of caregiving responsibilities, disability, or illness, or because they are attending school. Fewer than 1 in 10 are unemployed for another reason, including retirement or the inability to find work.
"Why are you putting in work requirements when the majority of people who rely on Medicaid are already working anyway?" Word said.
Lessons from Georgia
Human Rights Watch and Oxfam America's joint research in the state of Georgia-which in 2023 expanded Medicaid coverage to adults without dependents but conditioned eligibility on meeting work requirements similar to those in OBBBA-indicate that work requirements compound existing barriers to accessing health care.
According to data provided by the state to the Georgia Budget & Policy Institute, a nonprofit advocacy organization, over 100,000 people are estimated to be eligible for Georgia's Medicaid expansion, but as of August 2026, only 20,321 were enrolled. According to the latest data published by the state of Georgia, about half of the 17,638 denials for their Medicaid expansion program between October 2024 and September 2025 were due to a failure to either meet or verify compliance with work requirements.
Lack of Transparency
Because Nebraska has been slow to release data on the impact of work requirements on Medicaid enrollment, advocates have struggled to assess the impacts of these policies.
"We're flying blind," Behnke said. Without detailed data, health centers cannot identify where patients are losing coverage or adjust outreach strategies effectively.
OBBBA's Disproportionate Impact on Low-Income Households
The addition of work requirements to Medicaid was among a series of provisions in OBBBA that reduced federal spending on public services and programs, including through restrictive eligibility and reporting requirements. These reductions were designed in part to offset tax cuts that disproportionately benefit high-income households and corporations.
The nonpartisan Congressional Joint Committee on Taxation found that the top 0.1 percent of earners will receive an average tax cut of $311,000 in 2027 because of the OBBBA, while taxes will increase for the lowest-income households. The Congressional Budget Office found that the OBBBA's Medicaid work requirements will reduce federal spending by $326 billion over the next decade. Meanwhile, the total cost of the OBBBA's tax breaks for corporations and the wealthiest 1 percent of households is estimated at around $2 trillion.
