On May 1, 2026, Nebraska became the first state to start the new work requirements under H.R. 1, the law passed last year making historic cuts to Medicaid. We have reported extensively on why work reporting requirements are a bad idea.
Nebraska was not adequately prepared to launch work reporting requirements, nor has the Centers for Medicare & Medicaid Services (CMS) given the state enough information about how to implement the work reporting requirements. You can expect many problems to emerge in the coming weeks and months. This is true despite the fact that Nebraska is planning to “start gently,” apparently offering “generous” self-declaration of compliance policies in the early implementation of its work reporting requirements. The purpose of this blog is to make sure that no one loses the forest for the trees during the Nebraska launch. (Or maybe the cornfield for the cornstalks?) Self-declaration is a central issue for reducing the harm of work reporting requirements and there are three important things you need to understand about self-declaration in the Nebraska launch.
- Self-Declaration Isn’t Generous Policy. It’s the Law.
CMS has been shockingly nontransparent about its work reporting requirement policies. Although CMS apparently first told the National Association of Medicaid Directors about its self-declaration policy plans last November, the public has not yet seen the policy. (Maybe we will find out when CMS is required to issue regulations later this month.) Based on what CMS told the Medicaid directors, and what we can infer from what Nebraska has launched, CMS’s long-term policy appears to be: some permission for full self-declaration in the short-term, but eventually verification of self-declaration will be mandatory, as will be re-verification on a regular basis.
There’s just one elephantine problem: H.R. 1 actually requires that states be allowed to use self-declaration without verification for the purpose of work reporting requirement exceptions, if they so choose. H.R. 1 specifies that states “may elect to not require an individual to verify information resulting in” an individual being deemed eligible for an exception (such as for a mental health exception). Thus, under the law, CMS must allow states to use full self-declaration, without verification, if they so choose. This is important because verification in this context means burdensome documentation requirements for enrollees—it’s the added red tape of having to find documentation, upload documents, etc.
So, while the initial self-declaration policy in Nebraska may be characterized by some as “generous,” CMS’s emergent policy is in fact not only not generous, but actually unlawfully restrictive. While it’s true that under H.R. 1 Nebraska could choose to refuse full self-declaration at a future date, recent KFF/CCF survey data indicates that 29 out of 43 states subject to the work reporting requirement mandate are planning to use self-declaration, 9 are still considering using self-declaration, and only 5 have said they don’t want to use it. In the states that want to use self-declaration without verification, the CMS policy of requiring to states to use verification would explicitly violate the clear letter of the law.
- Nebraska Is Not the Preview — It’s the Exception
A second critical thing to understand is that while the “generous” self-declaration policy in Nebraska will help reduce harm in the early months, this is not where CMS policy is headed nor where Nebraska itself will end up. As mentioned above, CMS has indicated that self-declaration would eventually require verification. Nebraska’s policy appears to allow full self-attestation during the first year, but the state has said that “[o]ver time, the State will move from self-declaration to” other verification methods.
The net conclusion here is that Nebraska’s initial policy is not an accurate preview of what is coming, not even for Nebraska and much less nationally in 2027, and the initial termination rate in Nebraska will likely be lower than what we will see when work reporting requirements spread nationally throughout 2027. Things are going to get a lot worse before they never get better.
- Even the Soft Start Will Have a Hard Landing
Finally, the “generous” self-declaration policy will help reduce coverage loss at the margins (this is good!), but it won’t actually solve the problem or fix the inherent harmfulness of work reporting requirements. Tens of thousands of Nebraskans will still lose their health insurance, even though they shouldn’t. We are talking about workers, caregivers, and people with disabling health conditions and others, most of whom aren’t supposed to lose their health insurance, but will.
Yes, the state will be able to automatically identify some people based on work or similar data. But all of the remaining people will need to take action. Even Nebraska’s conservative estimate acknowledges this could be as many as 28,000 people needing to take action and navigate added red tape to prove their compliance—twice a year. Some of those will successfully self-declare. But large numbers of people will not successfully self-declare, for a whole host of reasons. Those individuals, tens of thousands of them, will lose their health insurance. It is important to understand that a huge proportion of them are people who are eligible but will lose coverage because of the paperwork. This will include people who lose coverage because state eligibility staff will not be able to keep up with all of the additional work due to self-declarations and related documentation—and the state has not increased staffing levels which are already insufficient to keep up with current work. Even the soft start will lead to a brutal outcome. And even the best case scenario is a tragedy.
Conclusion
Work reporting requirements in Medicaid are simply a bad idea. But Nebraska has found a way to make it worse, by starting the work reporting requirements early, before the state is even prepared to implement them. The smartest move would be for Nebraska to delay implementation until January 1, 2027, or better yet, to delay implementation and request a good-faith exception to start even later than January 2027. In any case, if the state does continue with its early implementation plan, it should freeze any terminations during 2026, to give its own staff and adults covered by Medicaid expansion a chance to adjust to the new rules. Nebraska should not rush to implement a policy that is destined to fail.