The First State To Try It

On Nebraska becoming the first state to impose Medicaid work requirements, and what being first actually costs the people living inside it

Patricia and I saw The Odyssey last week, at the new theater at the mall with the lean-back chairs. I ordered tickets online and misread the seating chart, ended up in the front row and we spent the next three hours with our necks in figure-four position like men who had been asking the weather for three hours.

Nevertheless I sat through the show and watched a man spend ten years in transit returning to a wife whose face no one could predict.

This is the summary of the whole performance, actually, because in the end that’s what it’s about: debt. The debt of a man to return to a wife, the debt of a wife to know when her husband is coming. The debt of the men of Ithaca who turned up at Penelope’s door demanding to know the day of the king’s return; the debt of the woman who sent them all away but who now knows the day of the return anyway and won’t say.

The whole of ancient Greece is in debt to Odysseus and not one of the creditors is prepared to admit for even a moment that he himself might be the one in need of reimbursement for the costs of war.

I was thinking about this as we drove back from the movie through the dark past the Sugar Factory, past the empty downtown, and thinking about it again this morning as I read a letter that was not mine.

My neighbor brought me the letter last week, state seal on the top, generic typeface, informing her that henceforth she must complete 80 hours of community service per month or provide documentation explaining why she should not be charged with failure to do so.

She has lived here eleven years and in that time has never once asked the state to explain its requirements to her.

She asked me this time, because I am the one who writes things down, and also because the letter explained virtually nothing that could be considered relevant to her circumstances.

This letter didn’t originate in Lincoln.

It was written in Washington last year, on the Fourth of July, while two senators from the state were congratulating themselves on having the good sense not to slow up the passage of the reconciliation bill during the holiday.

Here is what actually happened, in the exact chronological order it happened:

Last summer, Congress passed H.R. 1, the reconciliation bill the president likes to call One Big Beautiful Bill. The Senate voted it through, 51-50, needing the tie-breaking vote from the Vice President in order to pass it on schedule for the president’s vanity day.

The governor’s staff had the same reaction to the news that Nebraska’s senators had voted to advance the bill that I had: surprise and a general sense of unwelcome inevitability.

There was no reason for me to believe it wouldn’t happen. There was no reason for the staff to believe it would.

Nebraska’s two senators, Deb Fischer and Pete Ricketts, each issued statements that same day celebrating the news, before a single Nebraskan had received the first letter from the new program.

Ricketts called it a once-in-a-lifetime opportunity.

That’s the talking point for a bill that removes health care from hundreds of thousands of Nebraskans on the grounds that their papers were in order but their work schedules happened to fall on the wrong side of a bureaucratic coin toss, and it’s the talking point he used on the same day a state newspaper story was already estimating how many hospitals the loss of Medicaid expansion would close in the state.

Six.

Six hospitals, a figure he was already aware of before he took the podium, and he called it an opportunity nevertheless.

Fischer spoke about the tax credits she had added to the bill for middle-class families as if she were test-driving a new car with no engine, hoping no one would ask to see what was under the hood.

Neither she nor Ricketts spoke during the entire week about the fate of the average Nebraskan who would be dropped from Medicaid rolls for failing the work requirement, or the fate of the hospitals that would close once their funding was cut.

Neither has spoken about it since.

Two politicians, entrusted with representing the state in Washington, looked upon a bill that would end six of the state’s hospitals and decided the most responsible use of their time on that particular Thursday was to congratulate themselves on moving forward with the program anyway.

This is the point where you might say something about how unfair it is, how you wish all these decisions were made in another state, a more distant state, a state you don’t have to live in while you try to understand what’s happening.

You can say this to yourself if you like, as Governor Jim Pillen also had the option to respond to the news in Washington by doing nothing.

He did not do nothing.

He stood alongside CMS Administrator Mehmet Oz this spring and announced that Nebraska would be the first state in the country, the first of any state with the same law, to impose the work requirement.

Eight months before the law took effect, he signed up for the obligation anyway, having received no particular prompting to do so.

He praised the administration for the bill and spoke of long-term independence and community self-sufficiency.

Independence is the word he used for a system his own advisers had no staff for, and I am waiting for someone to present a microphone to him, if he will take it, and ask him to define independence for the hypothetical woman who loses coverage over the technicality of being enrolled in the wrong database.

No one at the podium had to sit at a kitchen table explaining the terms of the new system to a neighbor who had just received her letter, and Pillen especially did not have to do so.

He had a press conference.

Somebody in Lincoln had a form.

He got to talk about what the law was supposed to do.

She had to find out what it was going to do to her.

Here’s what that form actually says, in the fine print that no one felt any particular need to explain to her.

The language applies to Nebraska’s Medicaid expansion population, approximately 70,000 working-age adults who have income up to 138 percent of the federal poverty level, or roughly $22,000 a year for one person.

Seniors, disabled people, pregnant women, and children are exempt.

Anybody already earning $580 per month for a household of one satisfies the work requirement automatically, since that’s about 80 hours at minimum wage.

Everyone else, including those with significantly lower earnings, must complete 80 hours of community service, education, training, or volunteer service each month, or qualify for an exemption for reasons of medical frailty, substance use treatment, childcare or eldercare assistance, or a temporary hardship the state has determined to be valid for the month in question.

Anyone failing to complete these requirements will lose Medicaid coverage and must reapply for eligibility.

The Nebraska Hospital Association raised concerns with Congress about the expected impact on hospitals while the bill was being drafted.

They were correct in their estimates and they were correct in assuming no one in Congress would listen.

Hospital administrators usually aren’t tasked with responding to legislation; that’s a job for people with other qualifications, and the people who responded to the bill as it was being passed had other jobs as well.

They answered to the governor, whose staff has until now seen the passage of the bill as a victory.

The Nebraska Hospital Association has advised its members that they anticipate a significant number of patients presenting to care with questions regarding their Medicaid eligibility due to the uncertainty of the compliance monitoring procedures.

They spoke to Jeremy Nordquist, president of the Nebraska Hospital Association, who explained the situation as best he could in the limited time he had.

“There are going to be a lot of folks who are going to come in who don’t know what they need to do to comply,” he said.

Nebraska’s Medicaid Advisory Committee has advised the state that it will not hire additional staff to supervise any aspect of the new program.

The same staff, who have maintained operations at the same level for the last several years, will be overseeing an additional eighty-hour-per-month compliance program.

The recommendations have been published and they appear to have been accepted, with no adjustments made to staffing, as of the meeting minutes published in January.

Someone within the staff, someone who has seen the projections, must have believed hiring no one at all was an appropriate response to the question of how they would deal with errors in judgment made by constituents.

I am interested, in the future, in speaking with that person.

You may be interested as well, if you were in the room.

Then there is Jane, a Lincoln resident whose case was documented by the legal aid group Nebraska Appleseed in March, notified by a DHHS representative that she would be losing coverage due to a failure to meet the work requirements of the new law, a requirement that turned out not to apply to her at all.

She believed this to be accurate information, as any citizen would, and consequently rescheduled a medical procedure for a later date when she felt more confident coverage would be in place for the costs.

It took Jane, her attorney, and multiple DHHS representatives nearly an hour of phone tag to discover the notification had been based on incorrect information and was entirely erroneous.

An hour is not a long time.

I know that.

Jane knows that.

The representatives know that.

We were all waiting for someone to say, when in the end no one did, that Jane’s fear had been misplaced.

That kind of hour is practically a decade in Odysseus’ world, where the only work to be found takes place in war and the only reason not to return home is to be stopped by the sea.

Nevertheless Penelope waits on her own front porch with her dogs for the man she loves to show up alive despite the odds, and in the end, she gets what she wanted.

She gets back her husband.

She gets her house.

She gets the bow only she can string, proof that the house is really hers and she can keep it, and Odysseus shows up to prove it.

No one wrote it for her, that happy ending, but it was on its way, and it arrived, and now she has it.

Jane did not get a bow.

Jane did not receive a message, on her phone or on the porch, informing her that the home she lives in and the services she pays for through taxes remain entirely hers.

She got an hour’s worth of grief and then the next form to file, and she went back to her job.

When her hour was over she filed the form away in the kitchen drawer with all the others, the ones asking for her permission to take her insurance, the ones asking her to keep the bill, the ones asking for her cooperation when the mistake, this month, was discovered.

She folded the form twice and tucked it in behind her notes, all folded neatly, for easy reference.

She shut the drawer.

She went to work.

I think about that sometimes, how much of a person’s life can end up folded into a drawer. Bills. Receipts. Letters from people you’ve never met telling you what you have to prove next.

You keep them because you might need them.

You keep them because somebody might ask.

And after a while you stop noticing how strange it is that a life can be reduced to pieces of paper somebody else gets to decide are important.

I told Patricia about the letter later that night, out on the porch, after we’d been home a while. She didn’t say much, really. Just asked if the neighbor was doing okay. I said I didn’t know yet.

I still don’t, actually.

If you’ve gotten this far, I’m grateful for your time.

Most of what I write is free, and I will continue to make it free, but pieces like this one take longer to produce, the research involved being considerable.

If you find this kind of thing worthwhile, a subscription is available if you’d like one, a small token of appreciation from me that costs roughly the price of a cup of coffee from a vending machine every month.

If not, no worries at all.

I’ll be here either way.

Jane gets to go to work and keep her house and her cat and the neighbors will water her plants while she’s gone.

Odysseus gets to have his wife wait for him and his dogs keep him company and the sea gets to decide who goes home and who has to stay.

What neither of them gets is mercy.

The sea doesn’t know mercy and mercy is not a quality expected in a public servant, not when he has a family to feed and a reputation to maintain and a whole state ready to cheer him on for the privilege of making decisions for someone else’s life.

No one wrote mercy into Nebraska’s Medicaid law, and no one is likely to, not this year or next.

No one thinks it necessary, because no one believes in it, not really.

It is an hour spent waiting for an explanation, not an hour spent waiting for a soldier to return from war.

It is the kind of hour anyone would have dreaded, that Jane in particular, that any one of us.