200 Nebraskans Lost Medicaid Last Saturday. Up to 8.6 Million Americans Could Be Next.

The Firing Line | Barking Justice Media
Daily Intelligence Briefing
August 13, 2026
By Mika Douglas and Robert Anderson

A 2025 federal law now requires proof of 80 work hours a month to keep Medicaid coverage. Nebraska moved first, months ahead of the national deadline, by choice. The state’s own architect says one number about the rollout keeps him up at night.

Nebraska has become the first state in the country to remove people from Medicaid for failing to document 80 hours a month of work, school, or community service, a requirement created by the 2025 federal reconciliation law and now rolling out five months ahead of the national deadline.

Roughly 200 people lost coverage on August 1. Nebraska’s Medicaid director, Drew Gonshorowski, told the nonprofit newsroom Tradeoffs his office reviews every denial multiple times before it goes out, and named the scenario he’s watching for: someone with a real disability or real earned income getting cut off because the paperwork didn’t clear. “That is the one scary number,” he said.

Up to 44 states now have to implement the same rule by January 1, 2027. Federal estimates of national coverage loss range from 3 million to 8.6 million people by 2028.

We’re tracking this as it expands state by state. Full breakdown, including the verification mechanism behind who falls through and what to watch next, in tomorrow’s DIB.

On Saturday, August 1, the state of Nebraska mailed no ambulance, fired no missile, and passed no new law. It simply stopped renewing paperwork for roughly 200 people, and their Medicaid coverage ended.

That is the opening move in the largest change to Medicaid since the program covered pregnant women and children under the Affordable Care Act. Under a provision buried inside the 2025 federal reconciliation law, most working-age adults on Medicaid expansion coverage, people between 19 and 64, now have to document at least 80 hours a month of work, school, job training, or community service to keep their health coverage. Miss the paperwork, lose the coverage. There is no floor on how sick you can be before the state decides your illness doesn’t count as an exemption. There is only a form, a deadline, and a call center.

Nebraska did not have to go first. The national deadline for states to implement the work requirement is January 1, 2027. Nebraska’s Medicaid director, Drew Gonshorowski, chose to launch five months early, in part because the state runs its own eligibility system and can verify roughly three-quarters of affected enrollees automatically, without ever contacting them. “Why wait?” he told the nonprofit health newsroom Tradeoffs in an interview published the day before the first cuts took effect.

Here is the mechanism, stated plainly: this is not a rule that removes people because they refuse to work. It is a rule that removes people because they, or the state, failed to produce paperwork proving they work, inside a system that both sides admit is still being built while it is already in use.

Start with what “80 hours” actually requires. It is not simply holding a job. It is generating a monthly record, of employment, of school enrollment, of job training, or of qualifying volunteer hours, that a caseworker can verify inside a state computer system on a fixed schedule. People with documented disabilities, parents of young children, caregivers, and a handful of other categories are exempt. Everyone else has to prove, every month, on paper or online, that they cleared the bar. Miss a form, misclassify an exemption, get lost in a data mismatch between your job and the state’s system, and the default outcome is the same as if you had never worked a day: termination.

Nebraska is the pilot state, and Gonshorowski, to his credit, has been unusually candid about where this can go wrong. Nebraska sent tens of thousands of letters, texts, and emails, and ran radio and television ads warning residents the rule was coming. It was not enough. Amy Behnke, who leads the Health Center Association of Nebraska, told Tradeoffs the state’s notices left many low-income residents confused about whether the rule even applied to them. When Tradeoffs’ reporters tested Nebraska’s Medicaid help line themselves, ahead of the first cutoff, they hit long hold times, a dropped call, and trouble getting through on the Spanish-language line. State officials say their average wait time is ten minutes. Picture that ten minutes as the last conversation standing between a diabetic Nebraskan and their insulin coverage, on hold, in a language the automated system barely supports, with a clock the caller cannot see.

Gonshorowski was direct about the stakes when asked what he’ll be watching as the cutoffs continue. “You can imagine a world where a state gets that very wrong because you missed that they had a disability, or you missed that they had earned income every month,” he said. “That’s the thing that keeps me up at night. That is the one scary number.”

That is the man who designed the rollout, describing the failure mode of his own system, out loud, on the record, five days before it started removing people from coverage.

Nebraska is small. Roughly 70,000 of its residents are subject to the new requirement, and state officials expect about 30,000 to eventually lose coverage. Multiply that ratio across the 44 states now required to implement work requirements, covering close to 20 million Medicaid enrollees nationwide, and the range of projected national coverage loss becomes the real story here. The Robert Wood Johnson Foundation puts the number as low as 3 million. The federal government’s own analysis, built into the July 2026 CMS rule, puts it as high as 8.6 million by 2028. The Congressional Budget Office’s original estimate, 11.8 million losing Medicaid coverage over ten years from the broader law, with 4.8 million of that tied specifically to the work requirement, was calculated before a June 2026 rule narrowed the definition of who qualifies as “medically frail” enough to be exempt. Every one of those projections may now be too conservative.