Eli McCreary of Omaha, Neb., said he had recently been diagnosed with kidney cancer when he got a call from a local hospital run by CHI Health. He said he was informed that he wasn't insured anymore under Medicaid — and that the hospital would cancel his appointments unless he paid out-of-pocket.
McCreary, who was 64 at the time, said he phoned a call center for help. He said he was told his benefits under Medicaid, the government health program for people with low incomes or disabilities, now required that he have a job.
"You're required to do work to stay on," McCreary said a representative told him. "And you haven't fulfilled your work requirement."
For decades, McCreary said, he has battled drug addiction. A substance use treatment program discharged him in March, and in June he was diagnosed with cancer in his right kidney, according to documents reviewed by KFF Health News. He also has diabetes and chronic obstructive pulmonary disease.
"I don't understand what job I can get," McCreary said. "I can't walk. I can hardly breathe. I can't move around. What job am I going to get?"
McCreary said he canceled a CT scan and other tests at the hospital, which is part of CommonSpirit Health, the nation's largest Catholic health system. He also delayed a cancer-related appointment with a physician who travels back and forth to Omaha. "I missed my window of opportunity with him for another month," he said.
Taylor Miller, a spokesperson for CHI Health, declined to answer questions about McCreary's experience. In an emailed statement, she said that "CHI Health is committed to helping patients understand their health care coverage and access to care, including available financial assistance resources."
Determined to be the first state to enforce Medicaid work requirements under President Trump's signature One Big Beautiful Bill Act, Nebraska launched the new rules May 1 — eight months before most states are set to do the same. With their newly elected majorities in Congress, Democrats have said they plan to repeal the changes to Medicaid in their first 100 hours in office in January. But it is unclear if they will be successful, because Trump could veto it.
Nebraska Gov. Jim Pillen said in December that state officials "certainly appreciate President Trump and his whole administration for delivering this key reform." Pillen spoke alongside a videoed-in Mehmet Oz, the Trump administration official overseeing Medicare and Medicaid.
"We're excited to be able to be the first to make it happen," the Republican governor said.
Laura Strimple, a spokesperson for the governor, didn't respond to requests for comment. Jeff Powell, a spokesperson for Nebraska's Department of Health and Human Services, said its rollout "has been very successful." He pointed to state data showing 86% of affected applicants met the requirement or qualified for an exclusion and 93% of existing enrollees kept their coverage.
Health clinics and organizations advocating for poor and working-class Nebraskans say the rollout has been rife with problems — many due to poor training and inadequate staffing.
The high price of cutting benefits
About 70,000 adult Medicaid recipients in Nebraska are subject to the work requirements. They must prove they're working or participating in a similar activity for 80 hours a month, unless they qualify for an exemption. State officials and consultants advising them have said the May 1 date was challenging to meet.
To deploy the law's Medicaid coverage restrictions, Nebraska budgeted millions of dollars for government contractors, according to state documents KFF Health News obtained via a public records request. Documents from Nebraska's health department outline $8.2 million in contractor costs to enact Medicaid changes, including work requirements and more frequent checks for whether people still qualify.
Nebraska operates the information technology system that determines who in the state qualifies for Medicaid, unlike most states, which outsource the work to companies under contracts often worth hundreds of millions of dollars. But Nebraska's health department nonetheless relies on the private sector to help administer its Medicaid program.
The $8.2 million in costs span two years. They stem from two companies that Nebraska uses to increase agency staffing: Public Consulting Group, based in Boston, and Atlanta-based Covendis, which supplies information technology staffers.
One of the companies has praised Nebraska's implementation of work requirements. A post on Public Consulting Group's website quotes senior consultant Latanya Michaux.
"I really cannot brag enough about how well Nebraska handled this requirement," Michaux said, crediting the firm's "incredible relationship" with the state.
Covendis executives did not respond to requests for comment. Powell said the health department "uses contracted staff when hiring a state employee is either uneconomical or impractical because of time constraints, or when the role requires highly specialized skill sets."
Advocates who work with Medicaid enrollees in Nebraska say that participants are confused and don't know whether the rules apply to them. These advocates say enrollees also have gotten inaccurate information. In December, Pillen said the state "won't be adding workforce" to implement the work requirements, a decision those advocates have criticized. Pillen in July also instituted a government-wide hiring freeze.
Nebraska listed at least half a dozen contractors costing more than $250,000 each, including one person whose compensation exceeds $1.8 million, the documents show. Nebraska submitted the records to federal Medicaid regulators as part of a routine process to secure federal money. Powell said the funding requests "may not reflect actual expenditures."
Sarah Maresh, a program director with the social justice advocacy nonprofit Nebraska Appleseed, said the amounts were "shocking."
"When you put in complicated policies like this, there are large corporations making money behind the scenes," Maresh said. "This just further confirms that it's happening in Nebraska quietly."
Confusion and longer wait times
The Medicaid work requirements in the One Big Beautiful Bill Act and other changes shepherded by Republicans will curtail insurance gains that came from the Affordable Care Act, also known as Obamacare. The GOP tax and spending law, which the Congressional Budget Office estimated would reduce federal Medicaid spending by more than $900 billion over a decade, adds reporting requirements and restrictions that make it harder for people to stay enrolled.
As of early July, most denials related to the work requirements among Nebraska adults applying for Medicaid were due to unsubmitted paperwork, according to internal documents from Nebraska's health department that KFF Health News obtained through a public records request. The state wrote this was "expected."
State data shows that average wait times at a Nebraska health department call center nearly doubled between May and July, going from about 13 minutes to 26 minutes, before declining in August. In interviews, advocates for Medicaid enrollees said they've encountered people who have waited on the phone for hours.
Nebraska received more than 101,000 calls in August, a 66% jump from May.
"If people are working, they just don't have time to be sitting on the phone to go through all of this stuff," said Kenny McMorris, CEO of the Charles Drew Health Center, a federally qualified health center in North Omaha. He said roughly half of Charles Drew's 13,385 patients are on Medicaid, and of those, 42% are subject to the work requirements.
"You can leverage the technology, but you still got to have people there to help," McMorris said.
Then there are experiences the official data may not catch, like what happened to McCreary — saddled with figuring out what happened with his Medicaid benefits amid a health crisis, and whether it was even true that he had to work to keep them.
McCreary had heard about the Medicaid work requirements but didn't know they might apply to him. Powell confirmed McCreary was eligible for Medicaid because of the ACA — putting him in the population subject to work requirements.
His ordeal underscores the fallout from being caught in confusing government systems and silos that aren't obvious to the public.
"This cancer ain't going to stop just because I ain't got insurance," he said. "It's going to keep working on me."
When he received the call from the hospital about his coverage, "I was really in despair," McCreary said. Eventually, he said, he called for help.
Nebraska's health department runs AccessNebraska, a call center for help with safety net benefits such as Medicaid and the Supplemental Nutrition Assistance Program, commonly known as food stamps. But the number McCreary recalls dialing ended up not being AccessNebraska — it was for a different call center, one for SNAP accounts that Nebraska outsources to a private company. Powell said the state has no record of McCreary calling the health department.
McCreary said the worker didn't have a good explanation for why the Medicaid work requirements would apply to him. Before his health deteriorated, McCreary worked as a driver for an asphalt services company. He said he worked "until I couldn't do the job anymore."
"I really had hoped to work longer," he said. "I kind of enjoyed that job."
Attorneys and policy professionals who work with people on Medicaid and other public benefit programs said that McCreary's substance use treatment, lasting four months starting in November 2025, and other health conditions should have exempted him.
The federal law outlines categories of exemptions, such as being too sick to work. People who are considered too ill include those who have a serious medical condition or a substance use disorder.
Nebraska's health department said it sent tens of thousands of letters, text messages and emails to inform enrollees about the new requirements. According to state documents, Nebraska said it would "implement enhancements" to its computer system and online portal, including allowing people to submit documents online and having "clear, plain-language" enrollee notices. McCreary, however, doesn't have an account on Nebraska Medicaid's online portal, preferring to handle things over the phone or in person.
He also said it's possible he missed letters from Nebraska Medicaid about his coverage.
"I don't know if it's my fault or not," McCreary said.
The Cornhusker State's experience could be a harbinger of things to come. Next year, work requirements will apply to millions of adult Medicaid enrollees in more than 40 states.
The nonpartisan Congressional Budget Office has estimated the policy will lead to 5.3 million more people being uninsured in the U.S. by 2034.
"We definitely had fun"
The One Big Beautiful Bill Act's Medicaid changes are the most complicated in years — changes that government benefit experts say will strain and exacerbate long-standing problems with state technology systems for health benefits.
"It's already a shaky system, and now you've added more burdens on top of that," said Gelila Selassie, director of health advocacy for the nonprofit Justice in Aging.
Nebraska and federal officials, as well as consultants advising the state, detailed the difficulties and successes with the state's May 1 launch during an August panel discussion at a national conference in Oregon.
"They said, 'We're going to go live May 1.' To which CMS said, 'Oh, my God!'" Brent Weaver, an official who specializes in Medicaid IT at the U.S. Centers for Medicare & Medicaid Services, said about Nebraska.
Nebraska officials knew "they weren't as agile as they probably would have liked to have been," Weaver said, "but they didn't let that stop them."
"If they fail, we looked at it as a failure," he added in comments that broadly praised the state's approach.
CMS did not answer questions from KFF Health News about Nebraska's rollout and Weaver's remarks.
In Nebraska, a group of 60 people held hours-long meetings three days a week that were "very exhausting," Michaux, of Public Consulting Group, said during a different session at the conference.
"Our calendars were cleared, and that was the focus," Michaux said.
Because CMS had not yet issued regulations outlining key details such as how people could get exemptions — it would do so June 1 — Nebraska officials said they had to rely on the law's broad language to make initial decisions.
"We had to get comfortable being uncomfortable," Jacob Kawamoto, a deputy director at Nebraska's Medicaid division, said at the conference.
Public Consulting Group said it worked with the state to develop new guidance and "process guides" — materials for Nebraska eligibility workers with instructions on how to process Medicaid applications or renewals. Training materials for Nebraska caseworkers reviewed by KFF Health News refer to those guides.
"The training was very robust, and the process guides were very robust," Michaux said.
Maresh disagreed with that characterization. "There are gaps" in the state's training materials, she said, and caseworkers "are confused" about work requirements.
Public Consulting Group also helped the state institute changes to Nebraska's Medicaid IT system, according to the company. "We are preparing for future updates and enhancements," Michaux said.
In response to questions, Public Consulting Group spokesperson Alyssa Brown said the company "has supported Nebraska Medicaid via a broad range of consulting services since 2019, including work on federal and state compliance initiatives." She said Michaux "discussed" the process guides at the conference but Nebraska developed them. Similarly, Brown said the company did not develop training.
Federal taxpayers will largely bear the costs of implementing the One Big Beautiful Bill Act's Medicaid policies in Nebraska and elsewhere. Congress allocated $200 million in one-time funding to states. Under federal regulations, the U.S. government picks up most of the tab for state IT system changes, paying as much as 90% of the cost.
"Even though it was not so easy," Michaux said at the conference, "we definitely had fun standing up the Medicaid work requirement program."
Public Consulting Group's employees, Brown told KFF Health News, are "passionate about public service and helping our clients improve the lives of the people they serve."
Dropping Medicaid enrollment
As of August, roughly 1,100 Nebraskans had been denied benefits because of Medicaid work requirements. Most denials were because people did not respond to requests for information.
Nebraska's total Medicaid enrollment has declined by roughly 4,600 people since May, a drop of 1.4%, according to an August report.
As for McCreary, the Nebraska health department's Powell maintained he experienced "no lapses in coverage" and said he was disenrolled from Medicaid after turning 65. Despite what McCreary said he was told, Powell said Medicaid work requirements weren't the reason: He aged out of Medicaid and into Medicare before they could be applied to him.
Selassie, from the nonprofit Justice in Aging, said McCreary's care shouldn't have been disrupted.
McCreary is now enrolled in Medicare, and Medicaid covers some of his health costs. He was able to reschedule his canceled appointments.
"The cancer has grown so much," he said.
He had surgery in early November to remove his right kidney.
KFF Health News correspondent Samantha Liss contributed to this report.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
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