Meet the Man Launching Trump’s Medicaid Work Requirements Months Early

Dan Gorenstein: About 75,000 people in Nebraska got a letter in May.

It said if you want to keep your Medicaid insurance you may need to prove you are working, studying or volunteering 80 hours a month.

Since then – thanks to those letters – doctors and nurses have gotten slammed with questions.

Callers have clogged the state’s help line.

And starting in August, people in Nebraska will lose coverage. Maybe they failed to meet the new work requirements, maybe they are still eligible but never got that first letter.

Nationwide – about 5 million Americans are expected to lose Medicaid due to work requirements over the coming years. 

States have until January 1st to implement the new requirement. 

But eager to get going, the Cornhusker State is first in the nation. 

Today, we sit down with Nebraska’s Medicaid director to hear what he’s learned from going first and what he’s watching to make sure his state gets it right.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

*****

Dan Gorenstein: Drew Gonshorowski visited Nebraska for the first time just days before he took over as the state’s Medicaid director in December 2024.

Hey, Drew. How you doing? 

Drew Gonshorowski: I am good, Dan. How are you? 

Dan Gorenstein: I’m fine thanks for asking.

I know you’re not a Nebraska native, but  a couple of summers ago I went out to the Panhandle. Man, I fell in love.

Drew Gonshorowski:  it’s just gorgeous country.  Oh. Like, uh-

Dan Gorenstein: Gorgeous, yeah. Yeah. Yeah, it’s astounding. Yeah, no, no, I, uh, I, I’m, I’m looking forward to finding a way back.

Drew Gonshorowski:  You could definitely fly in either, like, Scottsbluff or Denver even, and then time it in the spring with the crane migration.  

Dan Gorenstein: Ohhh.

Drew Gonshorowski: It’s, like, thousands or millions of cranes. And it’s, it’s awesome. It’s so cool. That’s a good, good way to get you back to the state.

Dan Gorenstein: Before moving to Nebraska, Drew spent more than decade crunching numbers and analyzing federal health policy for big conservative think tanks in Washington.

Drew Gonshorowski: A lot of our work was about bringing that down to the state level and that was some of my favorite work, being able to sit with people, talk about how it impacted their people in their state. And I think that that sort of just created an environment, where folks were like “Hey, would you ever think about being a Medicaid director?” 

You have a lot of people in DC and in the federal government who haven’t ever sat in states and thought about how to actually operationalize the policies that come down. They, they stay in that kind of think tank world. Once the opportunity presented itself, it was pretty much a no-brainer. 

Dan Gorenstein:  When you were approached to run Nebraska’s Medicaid office, it was a chance to walk the walk. 

Drew Gonshorowski: Yeah I think that’s fair. There’s often multiple layers of disconnect between all of the work that states are doing and all the work that federal governments are doing. So so yeah, spot on. It’s a it’s a walk the walk moment.

I grew up in Michigan, I grew up on a farm. Many people and family that I know were on Medicaid. 

I had this experience of observing kind of in a bunch of different instances where I always call it, like, a lack of purpose when it comes to how policy responds to needs. AAnd one example that, that always really stuck for me growing up was there was this sort of state park that had a series of caves on it that had become a homeless encampment in my small town. So, you know, there’s a underlying need here, right? A population that could probably use some community support.

But instead of choosing that kind of, you know, person-centered solution, the, the city decided to effectively implode or, or blow up those caves, uh, and displace that community without any sort of plan or purpose around how to make their lives better. 

Dan Gorenstein: What’s the lesson you kinda took from that?

Drew Gonshorowski:   I think ultimately the lesson is you need to evaluate the needs of the population and think about actually solutions that serve the person., the work that is for vulnerable communities should be for those vu-vulnerable communities. It should actually address the core issues that, that you’re observing rather than, uh, just doing a convenient solution that, that might make people feel a little better or a little less inconvenienced.

Dan Gorenstein: I was reading a little bit about you and I know that you went to Nebraska sight unseen. Here you are driving across the country to a place you’ve never been for a job you’re really psyched for and I’m curious, what was the conversation running through your head? 

Drew Gonshorowski: Wow that’s, that’s a, such a great question. 

And, I’ll tell you, the first drive out, it was eight hours to Michigan, and then another 11 or 12 to, to Nebraska. It was December. It was cold . 

When I was headed out there, I took the opportunity to call a bunch of people, former Medicaid directors or former administrators, I was so excited that I wanted to be able to hit the ground running in terms of what to expect or what not to expect. And then I  took some quiet time to just reflect on, uh, what I had got myself into.

Dan Gorenstein: But beyond that, as a guy who’s, right, like this has given you this chance to walk the walk, what were you thinking about? What were your hopes? What were your fears?

Drew Gonshorowski: It was sort of that question.

It’s like, I’m gonna have to hit the ground and just learn. I’m gonna have to learn how things work. I’m gonna have to learn how processes work. I’m gonna have to learn if there’s specific political frictions within my program. and then figure out the actual nuts and bolts of it.

Dan Gorenstein: So, so you get to Nebraska in December of 2024, and within a few months, President Trump signs into law major changes to Medicaid, including work requirements, which apply to the so-called ‘Medicaid expansion population’ – basically low-income adults. 

There are, as you know, exemptions for certain people, if you’re pregnant or disabled.

States have until January 1st, 2027 to implement this massive change. But you all decide to start this eight months before the deadline. 

Drew, what is it about Nebraska that sets you up to do this entirely new thing so quickly?  

Drew Gonshorowski: So Nebraska’s eligibility system is state-owned, and what that means is. I can get on the system. I can make a little request and hit enter without reaching out to the member, we can confirm that they’re compliant for, with work requirements.  

Dan Gorenstein: Can you give me an example of how that works? 

Drew Gonshorowski: I’ll give you a good example on this. If a member earns $580 in income a month, they count as having been compliant for work requirements. We know we have income data for all our members. Let’s pull that. Let’s set the threshold. Let’s see how many already qualify.

Dan Gorenstein:  So Nebraska had the technical ability to move quickly. But having the ability to do this is different than deciding that you should. Drew, you and I both know when it comes to work requirements and Medicaid, this is super controversial. 

Every conservative I’ve talked to about this over the last 25 years has said that they see work requirements as a hand up as opposed to a handout, you think about this in a similar way. Is that why you decided to move as quickly as you did? 

Drew Gonshorowski: Yeah, I think that played a part in the decision to, to move more quickly.  You know, why wait if you can, and then also it is an opportunity to sort of build to something that, that can reach out a hand to our membership.

We have been working to coordinate with our Department of Labor so that we can actually, you know, effectively do warm handoffs to job programs as well. We still have this new data stream in our program that does give us an opportunity to look to that membership and say, okay, you know, what do you want your purpose to be? How can we help you? And I think that that is sort of amidst all this controversy, one of those great opportunities in this implementation is for states to use that data for good too.

Dan Gorenstein: That’s the promise of this policy as you see it: using the new information to connect people with help. 

But, Drew, in just a few days, people can begin losing coverage if the state determines they’ve failed to meet the requirements.  

A report from the consultancy Manatt Health estimates that up to 30,000 Nebraskans could lose Medicaid due to work requirements – by 2028.

That obviously is a big deal. Drew, what will you be watching for to see if you got this right or if there’s some changes you need to make?

Drew Gonshorowski: Yeah. So so first and foremost, we’ve ensured that we have extra steps in place that we are, you know, making sure we review any denial multiple times before it goes out the door to ensure that, given where we are, we’re making the right decisions.

We’re a small state, small expansion population, we can really have a hands-on process early on to ensure that, you know, all of these decisions are correct. And if any issue arises, we can have that hands on approach to make sure that that we address anything. I think the small population that you would worry about in any state is, uh, did we just not reach someone?

Dan Gorenstein: When we come back, Nebraska’s rollout faces its first real test: Can the state implement work requirements without people losing their coverage who are actually still eligible for Medicaid? 

BREAK

Dan Gorenstein: Welcome back. 

We’re talking with Nebraska Medicaid Director Drew Gonshorowski about his state’s rollout of work requirements for Medicaid.

Drew, you started reviewing people’s eligibility back in May for folks whose coverage was up for renewal this summer. 

And now we’re just a few days away from Aug. 1 when your office will terminate coverage for the first batch of people who fall short of the work requirements or just for one reason or another never responded. 

You’re reviewing cases month by month, only looking at the people who are up for renewal in that month, not your entire population at once.

How many people do you expect are going to lose their coverage in this first group?

Drew Gonshorowski: Yeah , it’s gonna be a, given the small volume in Nebraska, it’s gonna be a handful of people. It’ll, it will be, uh, on estimate probably less than, I I would say less than, like, 250, 200. Very small subset of, of our expansion population.

Dan Gorenstein: But some of those people, as you said, will be dropped because they are hard to reach, in some way or another got lost in the shuffle. 

Drew Gonshorowski:  Yeah, we’ve had a lot of conversations around ensuring that anyone impacted the, by this has opportunity to have access to our job programs and our work supports, as we move into this new, new period. We’re putting extra lenses on review just to ensure that, that, ultimately we don’t want folks falling through the cracks on this.

Dan Gorenstein: I know it’s early days, Drew. But as you think about this rollout so far, what’s one number that you can point to over these first three months that you’re really proud of?  

Drew Gonshorowski: One number I’m really proud of is our ex parte number, which is a wonky term that describes the ability to confirm a Medicaid member’s compliance or exclusion from work requirements without asking them for anything.  

Dan Gorenstein: And that number is?

Drew Gonshorowski: Right around 74%.  It varies by month, uh, but, but we’re pretty proud of that system. 

Dan Gorenstein: So just to make sure I’m following along, you’re saying that 74% of the people who are enrolled in Medicaid, you don’t need to engage with them because you know you have all the information you need.

Drew Gonshorowski: Correct yeah.

Dan Gorenstein: Now the other side of the coin, what’s one number from these early days that worries you?

Drew Gonshorowski:  It’s actually currently zero. This number is the number of appeals and state fair hearings. I view this as the ultimate bellwether on whether or not you got your process right on implementation.

All Medicaid members have the right to appeal a decision made by the state. You can imagine a world where, a state gets that very wrong, because you missed, uh, that they, you know, had a disability, or you missed that they had earned income every month. That is the one, the one scary number. 

Dan Gorenstein: And when you say that number is zero, you have not yet gotten any of those appeals because no one has been disenrolled yet. And where my mind goes on that is there are some people who, for whatever reason, ultimately feel disenfranchised enough, they get kicked off Medicaid, they’re not gonna appeal.

That is gonna be invisible to you, and could end up missing some of the people who would have a real strong case to make in the appeals process, but don’t even bother. What are you trying to do to try to catch those folks? 

Drew Gonshorowski:  The hope is to catch as much as you can in that, in, in outreach and public communication, and then also ensuring that our staff, uh, is reaching out to members when, when they need to provide information to ensure, you know, you don’t get to that point. That’s the ultimate goal, right? Is to make sure that, you know, you can make a correct determination before it gets to an appeal.  

Dan Gorenstein:  You alluded to this a second ago, communication and how important and essential, how vital communication is right now between the state and beneficiaries. 

Nebraska sent out more than 75,000 letters, 38,000 text messages, 10,000 emails, plus TV and radio ads. Still, there are a lot of reports that people are confused. Our producer, Julie Wernau, tested the Medicaid helpline that you all set up.

She called several times before reaching a person, waited about 30 minutes, was disconnected once, and encountered problems trying to get help through the Spanish language line. Advocates have flagged similar issues. 

A recent survey found that 55% of Medicaid recipients were completely unaware of new work requirements.

Are there steps that you guys have already taken, are in the process of taking, to address, to improve some of these issues that have been flagged?

Drew Gonshorowski: Yeah, like, this is a constant exercise in improvement and enhancement. We’re taking all of the comments that we hear from our, from our partners and stakeholders in the state, uh, and, and reflecting on them and, and implementing enhancements as we go.  

We were sort of brainstorming about this yesterday, And we’re a small enough state that, uh, it- it’s probably not an idea that we will adopt, but, but the Medicaid director could go to everybody’s house probably, Like, I could be on the, the, the road tour.  

Dan Gorenstein: Another major test is making sure people who are too sick to work are identified and allowed to keep their coverage.

The Trump Administration issued a rule earlier this summer saying people will have to submit proof – likely a note from a doctor – that they are too sick to work. 

A higher standard than many expected. 

More than two dozen states have filed a lawsuit to block this.

You had to come up with a plan, Drew, before this rule came out. And you decided to use the diagnosis codes to automate which Medicaid recipients would qualify as medically frail. 

For example, if someone has a cancer diagnosis on record they are exempt… automatically.

What do you think of the administration’s plan? Do you think federal health officials should reconsider based on your experience so far? You guys are the canary in the coal mine.

Drew Gonshorowski: We do have a diagnosis code list, uh, but it did, it does have a view into the severity of the member. So a lot of it does sort of hinge on whether or not it, it generates an inpatient hospital stay. Different codes that would indicate whether someone had a wheelchair or other sorts of indicators of the severity of their condition. 

Dan Gorenstein: So not just “do you have cancer” but “have you been to the hospital in the last 30 days because of your cancer? Going one more step beyond the diagnosis itself to see how severe someone’s condition is.

Drew Gonshorowski: I think that that’s the best way to do this sort of work. Not naming any specific states, but you can sort of look at other med frail code lists, and you’ll have things that are just a, a code list that has wrist splints, or just broadly all of the diabetes codes signaling that they would exempt someone from work requirements just by having those codes. But it seems like the intent should have that lens on severity.

We’re sort of expecting further guidance from CMS in the coming weeks, uh, to see if there’s any additional interpretations in that place.

Dan Gorenstein: Right, the administration said for the first year, 2027, people will be able to just tell their state they’re too frail to work and that’ll be enough. Until 2028 when this higher threshold starts.

There’s a lot of noise around these work requirements. A lot of people are really excited for them. A lot of people are really upset and scared that people are going to lose coverage unfairly. 

You believe in this policy, and like you’ve said – it’s important to you that the program actually works for people who are enrolled in it. 

On the cusp of the first people in the country losing their Medicaid under these new rules, what’s your bottom line on this policy?

Drew Gonshorowski: We have to implement this law. Uh, but at the same time, we can ensure that we have created opportunities to, you know, line people up in jobs or give them warm handoffs to employment opportunities or, you know, have good conversations around where they are in their life and their purpose moving forward.

I think that is, that’s where that positive s- you know, so- solution space lives in this. Because ultimately it is, it is the law, we’re implementing the law, but there is that latitude to, to bring in those additional conversations and support.

Dan Gorenstein: Drew, thanks so much for taking the time to talk to us on Tradeoffs.

Drew Gonshorowski: Yeah. Well, thank you for taking the time too, Dan.

Dan Gorenstein: Before we sign off today, I want to get a sense of what this rollout could look like across the country. Nebraska first out of the gate. But ultimately, 20 million people across 44 states will be subject to some version of these rules. So I asked Tradeoffs producer Julie Wernau to swing by for a quick debrief on these Medicaid changes.

Julie, one thing that really stood out to me in this conversation with Drew was how confident he is in Nebraska’s ability to use its own data to figure out who’s meeting these work requirements without making people submit a bunch of paperwork. 

Is Nebraska a model that other states can follow here?

Julie Wernau (JW): Yeah, I mean, maybe in principle, but not in practice. The big idea of being able to automatically exempt people behind the scenes is a good one, because less people are likely to lose coverage.

But the research shows us that even in places like Arkansas where they used automation to approve lots of people, most everyone else who had to file their own paperwork lost coverage. 

Here’s what’s tricky Dan, every state has the same goal as Nebraska. 

Harvard Economist Ben Sommers says tho that doesn’t necessarily mean they have the same capacity. 

Ben Sommers: They are trying to automate exemptions and qualifications as much as they can. But every state’s kind of gotta come to its own balance of what’s feasible.

JW: A lot of other states have these old legacy systems where it’s hard to track gig workers or see medical conditions that can be hard to detect in the claims data.

Dan Gorenstein: Got it. Drew also emphasized all this outreach Nebraska has done those letters, texts, emails, radio, TV ads, all that stuff. But we also heard about long waits on the help line. I know that you talked to folks on the ground who work with people on Medicaid. Julie. In a word, what’s the overall feeling that you’re getting from Medicaid beneficiaries themselves?

JW: Just confusion. I talked to the head of the Health Center Association of Nebraska, Amy Behnke, and she said people are coming to them saying they don’t understand all all these forms and notices that they’re getting

Amy Behnke: They’re filling all of that out online and then getting that same individual declaration form in the mail and being asked to fill it out a second time and so that creates confusion, because then somebody doesn’t know, “Do I have to fill this out again? I thought I already filled this out.”

JW: One advocate told me there’s a woman who is blind that started canceling all her doctors’ appointments because she just assumed she is losing her coverage. Dan, this is a person who is exempt because of her disability.

I’m hearing problems like this come up all around the country. To help address the confusion, academics are studying better ways to get the message out 

I talked to one researcher who has found that text messages can help. They work as well as postcards and cost a lot less money. Even prerecorded calls can give a little bump//

But ultimately, nothing beats humans. The problem is it’s also the most expensive option.

Dan Gorenstein: So it sounds like if Nebraska was able to get Drew into that car and send him around making those house calls, that could be effective.

JW: Yeah, that’s right. Just someone being able to sit in front of another person and say, “What am I supposed to be doing here? I’m not really sure I understand the paperwork.”

Dan Gorenstein: Right some real hand-holding here. 

Julie, so what’s the bottom line here? States have until January 1st to turn on work requirements around the country. What are you going to be watching you cover this historic Medicaid change?

JW: I’m going to be looking out for that confusion that we heard about. Right. Are there overloaded phone lines? Are people showing up at the doctor’s office and suddenly finding out, oh, I don’t have Medicaid. What happened?

And is there a lot of this behind the scenes work that does pan out? You know, the more automation that happens, the better. That means that people don’t even need to, you know, go into a portal to keep their Medicaid.

Ultimately, what I’m going to be watching for is who loses Medicaid, who remains eligible and fell through the cracks.

Dan Gorenstein: Right. This really is about falling through the cracks. How big will those cracks be—or not? 

JW: That’s right.

Dan Gorenstein: Julie, thanks so much for your reporting on this.

JW: Happy to help, Dan.

Dan Gorenstein: I’m Dan Gorenstein, this is Tradeoffs.