Medicaid Work Requirements Are Already Running in Nebraska. Montana Starts Thursday. Here Is What DPC Practices Need to Know.

Analysis by DPC Insider
#Medicaid#work requirements#primary care access#uninsured#One Big Beautiful Bill#DPC growth
Sources: Nebraska becomes first state to implement Medicaid work requirements after passage of the One Big Beautiful Bill Act · Nebraska rolls out Medicaid work requirements, putting tens of thousands at risk of coverage losses · CMS Launches Nationwide Framework to Implement Medicaid Work Requirements · Medicaid Community Engagement Requirement for Certain Individuals Interim Final Rule — CMS Fact Sheet · Tracking Implementation of the 2025 Reconciliation Law: Medicaid Work Requirements — KFF · MACPAC Releases June 2026 Report to Congress · A Summary of Federal Medicaid Work Requirements — Center for Health Care Strategies · An Early Look at Policy Decisions as States Get Ready to Implement Work Requirements — KFF

Nebraska became the first state in the country to run Medicaid work requirements when its program launched May 1, seven weeks ago. Montana follows Thursday. Arkansas begins verifying compliance on the same day, though it won’t start disenrolling anyone until January 2027. Iowa’s program starts December 1. Every state must have a system running by January 1, 2027 under the One Big Beautiful Bill.

CMS’s own June 1 interim final rule projects that 2.3 million people will lose Medicaid coverage in FY2027. That number rises to more than 3 million in the fiscal years that follow.

For DPC practices in early-implementing states, that’s not an abstraction. It’s a question showing up in intake calls right now.

Who the Work Requirement Actually Covers

The requirement under the One Big Beautiful Bill applies to adults aged 19 to 64 in the Medicaid expansion group — people who are not pregnant, not enrolled in Medicare, and not medically frail. They must document 80 hours a month of qualifying community engagement: working, in job training, enrolled in school, or performing community service. Fail to document it, and coverage ends.

These are not people who don’t work. The Medicaid expansion population earns too much to qualify for traditional Medicaid but too little to access employer-sponsored coverage. They work in construction, food service, retail, home care, and agriculture — industries where employers rarely offer group coverage, hours fluctuate, and payroll systems don’t automatically report to state Medicaid agencies. The Urban Institute projected that about 25,000 Nebraskans — roughly 36 percent of those subject to the requirement — could lose coverage. Losing Medicaid under these rules often reflects a documentation failure, not an employment failure.

What Happens to Their Primary Care

When someone loses Medicaid and can’t find or afford a replacement plan, primary care access deteriorates fast. Emergency departments absorb acute illness. Preventive visits, chronic disease management, and prescription renewals get deferred until something breaks. Community health centers serve some of this population, but they were already operating near capacity, and their funding certainty runs only through December 2026 under the 2026 Consolidated Appropriations Act.

MACPAC — the federal commission that advises Congress on Medicaid policy — released its June 2026 report to Congress with specific recommendations on monitoring what happens to coverage continuity and primary care access after work requirements take effect. The commission’s attention to access separately from enrollment numbers signals that policymakers understand “left Medicaid” and “found other care” are two different outcomes — and that the gap between them is often significant.

Where DPC Fits

Direct primary care runs on a monthly membership with no insurance company involved. For a single adult, the national average sits between $75 and $100 a month. A member texts or calls their physician, gets same-day or next-day access, and pays one predictable fee every month. No prior authorization. No claim form. No deductible to hit before care begins.

For a working adult who just lost Medicaid and earns $28,000 or $35,000 a year, that fee structure has real practical appeal. They can’t afford marketplace plan premiums — in most early-implementing states, those run several hundred dollars a month before cost-sharing. DPC doesn’t replace catastrophic coverage; it doesn’t pay for hospitalizations, imaging, or specialist procedures. But it keeps primary care accessible and continuous. The physician relationship stays intact even when insurance doesn’t.

The same One Big Beautiful Bill that established Medicaid work requirements also, in a separate section, recognized DPC fees as HSA-qualified medical expenses for patients enrolled in qualifying high-deductible health plans — the first time federal law formally validated DPC within the tax code. That HSA provision won’t help people who just lost Medicaid and don’t have an HDHP. But it reflects a congressional posture toward DPC that didn’t exist before July 2025.

The Limits of This Argument

The honest version of this story has to include the income math. Someone earning $15 an hour working 30 hours a week grosses roughly $23,000 a year. After taxes, $75 to $100 a month for primary care is a meaningful share of the budget, especially if they’re also carrying rent, food, and transportation costs on a single income. DPC membership at prevailing rates is most accessible for the working adult earning $30,000 to $50,000 annually who has no employer coverage and is looking for consistent, predictable primary care.

A handful of DPC practices have begun offering sliding-scale or reduced membership tiers for uninsured patients. That’s an operational choice that varies practice by practice, and it involves real trade-offs: a practice running on 400-patient memberships at $85 a month can’t reduce fees by 40 percent across a meaningful portion of the panel without affecting financial viability.

Montana, which implements Thursday, is a rural state with significant primary care shortages outside its largest cities. In markets like Billings or Great Falls, the choice for a newly uninsured working adult may not be DPC versus an insurance plan. In some communities, it’s DPC versus no consistent primary care relationship at all. Rural practices have historically operated with thinner margins, but they’ve also proven more likely to experiment with pricing flexibility because the alternative — patients simply not being seen — is more visible when the practice is the only one in the county.

What This Means

DPC practices in early-implementing states — Nebraska, Montana, Iowa, and Arkansas — should expect inquiries from a new category of prospective member: working adults who had Medicaid, lost it through the documentation process, and are looking for a primary care home. That intake conversation is different than an employer benefit rollout. The prospective member you might talk with may not know that DPC doesn’t require insurance, may never have had a primary care relationship before, and may not have a full 30 days of income flexibility to commit to a membership. The enrollment conversation requires meeting them where they are.

For the DPC field more broadly, the Medicaid disenrollment wave surfaces a long-standing tension. The industry’s recent momentum — employer benefits, HSA compatibility, professional-class patients choosing membership over co-pays — has been driven by the insured middle class opting into a different model. The working poor are a different market with different price constraints and different primary care histories. Practices that develop approaches to serve this group at accessible price points extend DPC’s reach into the communities most in need of consistent primary care. Those that don’t will leave the field’s credibility gap intact.

The One Big Beautiful Bill wrote DPC into the tax code in one section and rewrote Medicaid eligibility in another. Whether those two changes ultimately work together for patients at the bottom of the income ladder — or whether they point in opposite directions — is a question the field will be answering for the next several years.