Ballot-driven Medicaid gains face tougher rules and looming coverage losses

Seven states expanded Medicaid via ballot measures, but six are implementing stricter work rules, increased documentation, fewer exemptions, and earlier enforcement, risking large coverage losses. Urban Institute estimates 3–7 million could lose coverage due to work requirements alone, with Nebraska moving ahead on enforcement and some states exploring AI-assisted oversight. The policy split reflects ongoing battles over how to sustain expansion while addressing concerns about eligibility and fraud.