Congress passed H.R. 1, President Trump's "One Big Beautiful Bill Act," in 2025 with mandatory Medicaid work requirements built in for the first time. The Centers for Medicare and Medicaid Services issued its implementing rule on June 1, 2026, requiring most Medicaid expansion enrollees ages 19–64 to demonstrate 80 hours per month of work, community service, education, or job training. That rule took legal effect today, July 31, with the public comment period also closing today. On July 30, U.S. District Judge Richard G. Stearns denied 25 states and DC's request to pause implementation while their lawsuit proceeds. Nebraska is the first state to implement, cutting coverage starting Saturday, August 1 — eight months before the January 1, 2027 federal deadline. Medicaid Director Drew Gonshorowski says 200 Nebraskans lose coverage immediately; the Center on Budget and Policy Priorities estimates 28,000 to 41,000 are at risk overall.

1. This Is a Minimal Ask (CMS, Nebraska Gov. Jim Pillen, Medicaid Director Drew Gonshorowski)

The government says the requirements barely amount to 20 hours a week and the exemptions protect those who genuinely can't comply.

It's about 20 hours a week, and paid work is optional. Eighty hours a month works out to roughly 20 hours per week, and enrollees can satisfy it through school, volunteering, or job training. CMS says multiple exemptions protect people who can't comply: parents of young children, caregivers, people with disabilities, and the medically frail.

Nebraska is moving early because it thinks it's ready. Director Drew Gonshorowski and Gov. Jim Pillen defended the state's decision to implement eight months ahead of the federal deadline, saying Nebraska is "uniquely positioned" for a successful rollout and that outside coverage-loss estimates don't account for the state's operational safeguards.

The projected savings are significant. CBO estimates the requirements will save the federal government $325 billion over 10 years — the main reason Republicans built the provision into H.R. 1.

2. But Sick People Are Already Falling Through the Cracks (Blood Cancer United, National Organization for Rare Disorders, Nebraska Appleseed)

Patient advocates say the medically frail exemption is so poorly designed that even people in active cancer treatment might not qualify.

The exemption doesn't protect sick people the way it sounds. CMS doesn't exempt enrollees just because they have a serious illness. To qualify, they must show the illness causes "functional impairments" that prevent them from working 20-plus hours a week. Gwen Nichols, MD, Chief Medical Officer of Blood Cancer United, wrote that the rule breaks what Congress promised cancer patients: someone in active chemotherapy "could be forced to work the same number of hours as a healthy person — regardless of whether that's physically possible."

Getting the exemption requires paperwork most sick people can't navigate. Nebraska's Medicaid call centers are already backed up to 90-minute wait times, and caseworkers are giving callers incorrect information. The National Organization for Rare Disorders warned that "patients with serious and complex conditions could lose their health care coverage because the system is too hard to navigate."

Very sick Medicaid enrollees could still lose coverage. A recent study found roughly half of low-income adults on Medicaid with serious health conditions would be vulnerable to disenrollment despite their illnesses. Sara Maresh, Healthcare Access Program Director at Nebraska Appleseed, said: "This is a really complicated system that's been set up to have people lose coverage."

Twenty-five states and DC have a live federal lawsuit arguing CMS added requirements to the medically frail exemption that Congress never authorized.

There's a test in this rule that Congress didn't put there. H.R. 1 created a "medically frail" exemption. But the June 1 interim final rule added a new condition: enrollees must show their illness prevents them from complying with the work requirement — not just that they have a qualifying condition. Andy Schneider, a research professor at Georgetown University's McCourt School of Public Policy, argues this goes beyond congressional authorization and violates the Administrative Procedure Act.

States had planned to exempt people automatically; CMS said no. States expected to waive the work requirement for anyone with a qualifying condition, without conducting individual case-by-case assessments. CMS required individualized review instead — and states say they lack workable methods to assess each enrollee's functional capacity. The coalition of 25 states and DC (Massachusetts v. Oz, filed June 29) argues CMS changed the rules without adequate notice, triggering an APA violation.

Denying the injunction didn't settle whether the states are right. Judge Stearns ruled on July 30 only on whether the harm was immediate enough to pause implementation. He explicitly said the case raises "difficult issues" about the scope of congressional delegation to HHS. He's promised an expedited briefing schedule so the court can settle the merits before states must comply in January 2027.

Where This Lands

CBO projects 5.3 million more Americans will end up uninsured under the requirements. The administration's own estimate puts the reduction at 2.3 million. Nebraska's rollout starting Saturday is the first real test of whether this system works as designed. The government says healthy adults who could work should work, and it protects those who can't. Patient advocates say the exemption is already broken before it hits scale: wrong guidance, overwhelmed phone lines, paperwork that patients with serious illnesses can't complete. Twenty-five states and DC have a live lawsuit arguing CMS exceeded what Congress authorized. We'll know more when Judge Stearns holds the expedited merits hearing he's promised before states must comply in January.

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