Trump’s Big Medicaid Cuts Are About to Get Very Real

President Donald Trump, Health and Human Services Secretary Robert F. Kennedy Jr., and Centers for Medicare & Medicaid Services Mehmet Oz smile in the Oval Office of the White House on October 10, 2025 in Washington, D.C. (Photo by Andrew Harnik/Getty Images)

OMAHA, NEBRASKA HAS BEEN BUSTLING with activity these past few days thanks to the annual Berkshire Hathaway weekend, when tens of thousands of investors from around the world gather to hobnob with Warren Buffett while they figure out how to maximize their portfolios.

But inside one office, a woman named Amy Behnke has been preoccupied with something very different and much more urgent. She has been furiously working the phones with state officials, trying to figure out how to keep some of Nebraska’s poorest residents from losing their health insurance.

Behnke is CEO of the Nebraska Health Center Association, which represents clinics that provide care to the state’s underserved population. Since 2020, she tells me, the percentage of total patients showing up to member clinics with no insurance at all—the ones who represent the biggest drain on clinic finances—has dropped from half to one-third.

That’s a sign of progress, and it’s no mystery what’s behind it. In October 2020, Nebraska officially became part of the Affordable Care Act’s Medicaid expansion. By taking advantage of federal funding that the state’s GOP officials had long refused—but that voters eventually approved via ballot measure—Nebraska was able to open up its program to any citizen or qualifying legal resident with income below 138 percent of the federal poverty line.

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More than 70,000 Nebraskans are now on Medicaid because of the expansion. But as of May 1, they are also subject to new “work requirements” that became law last summer as part of the broader Medicaid cuts in President Donald Trump’s “One Big Beautiful Bill.” That legislation calls on states to impose their work requirements by January 1, 2027. Nebraska decided to go first, thanks to Republican Gov. Jim Pillen, who has said the rules will make sure Medicaid is a “hand up, not a hand out.”

Just how big that change will be in practice is impossible to say right now. As in the rest of the country, the majority of non-elderly adult Nebraskans on Medicaid expansion already work or are in school, according to estimates by KFF. In theory, they should have no problem getting and staying on the program. And of those who don’t work, many have a disability or caregiving responsibilities or something else that is supposed to exempt them from the requirement.

But what is supposed to happen and what will happen are two very different things.