Reliable, comprehensive data is important in determining the overall well-being of Nebraskans, and access to critical health care is an essential component of the Good Life. It is also a wise investment. Being able to access preventive care and prescription medications helps avoid costly and dangerous emergency services down the road. Medicaid also plays an important role in the stability of local healthcare infrastructure by reimbursing the costs of care for rural hospitals, urban clinics, and everywhere in between. In 2018, Nebraskans voted to join a growing list of states opting into the Affordable Care Act’s Medicaid expansion, which opened the door to accessible health care for tens of thousands of Nebraskans after implementation in 2020.
Using census data from the National Historical Geographic Information Systems (NHGIS) and enrollment data from the Centers for Medicare and Medicaid Services (CMS), this analysis examines the impact of Medicaid expansion in Nebraska and subsequent policies that affected Medicaid coverage for children, adults, and seniors at the county level for two time periods: 2015-2019 and 2020-2024. Additionally, data from Lancaster County provides a unique opportunity to contextualize these findings in greater detail and examine the financial impact of Medicaid expansion on the acute care hospitals serving Lancaster’s mixed urban and rural population and its neighboring counties. At a time when federal policymakers have enacted significant reductions in Medicaid funding, reliable and comprehensive data is key to determining how federal actions will affect Nebraskans. These findings provide an empirical basis for understanding what is at stake for the Nebraskans who rely on Medicaid expansion and for the hospitals and clinics that provide critical health care services to all of Nebraska’s communities.
Key Findings
Use the Demographics and/or County dropdown(s) for more specific information.
Lancaster County is the second most populous county in Nebraska with an estimated population of 334,049 (2025), a 17% increase from 2010 and an estimated 3.5% increase from 2020. It is a major population center with a mix of urban and rural characteristics. For instance, Lancaster County is home to the capital city of Lincoln, multiple post-secondary institutions, and has over 1700 farms and ranches.
The county’s healthcare infrastructure serves as a regional hub not only for its residents but also for northern Kansas, southeast Nebraska, and other areas across the state. This case study provides an overview and analysis of Medicaid’s financial impacts on two hospitals in Lancaster County. The two hospitals examined will be referred to as Hospital A and Hospital B from this point forward. We offer an empirical basis for understanding how changes in Medicaid policy affect hospital finances and the communities they serve.
Using data from the Centers for Medicare and Medicaid Services (CMS) hospital provider cost reports from 2019-2023 (the most recent year for which data was available), we analyze the changes in uncompensated care and net Medicaid revenue to assess the effects of Medicaid expansion on the two hospitals’ finances. Previous literature overwhelmingly has found that Medicaid expansion has resulted in improved payer mix (i.e., declines in the number of uninsured patients and/or increases in Medicaid-covered patients, as well as decreases in uncompensated care costs). Improvements in payer mix have also improved the financial performance of hospitals and other providers, especially in rural and small hospitals. Despite Lancaster County being a larger county, our analysis highlights clear, observable changes in Medicaid enrollment and hospital financial performance that may shed light on the impacts on smaller hospitals across the state.
In 2019, an estimated 7.6% of adults in Lancaster County were enrolled in Medicaid at some point during the year. After expansion was implemented, coverage increased to 17.4%, a 9.8 percentage point increase, representing a 129% increase relative to the 2019 baseline. These changes were accompanied by declines in the uninsured rate across all age groups, but the most prominent decline was in the expansion age group: adults 19-64 years old who are at or below 138% of the federal poverty level. For that group, the uninsured rate fell from 19% in 2019 to 13.9% in 2023, a 5.1 percentage point decline, which represents a 27% decrease relative to the 2019 baseline. Though Nebraska expanded Medicaid in 2018 and implemented it in 2020, this change cannot entirely be attributed to expansion, as the COVID-19 pandemic brought both continuous enrollment of Medicaid enrollees and its unwinding through 2023.
The financial implications for Lancaster County hospitals following Medicaid expansion and other policies show a striking connection to prior literature that found a net positive financial impact on hospitals following expansion. At Hospital A, net Medicaid revenue grew from $36.7 million in 2019 to $71.2 million in 2023, a 94% change. Uncompensated care costs declined as well, falling from $41.7 million in 2019 to $26.1 million in 2023, a 37.4% decline. The trend follows at Hospital B, where net Medicaid revenue grew from $12 million in 2019 to $21.7 million in 2023, an 80.3% increase, and the cost of uncompensated care fell from $9.4 million in 2019 to $6.7 million in 2023, a 28.9% decrease. Additionally, the most dramatic decreases in uncompensated care costs occurred from 2019 to 2022, after which both hospitals saw these costs increase in 2023. From 2022 to 2023, uncompensated care costs rose by roughly $3 million for Hospital A, while Hospital B’s costs grew from $3.9 million in 2021 to $6.7 million in 2023. These increases coincide with the unwinding of continuous Medicaid enrollment, during which thousands of Nebraskans lost their Medicaid coverage, suggesting that coverage losses reverse progress made in lowering uncompensated care costs with comparable speed.
The financial trajectory of Lancaster County’s two acute care hospitals between 2019 and 2023 demonstrates that changes in Medicaid coverage can have immediate and material financial consequences for hospitals. As such, these findings provide an empirical basis for anticipating the financial consequences of Medicaid cuts resulting from the passage of H.R. 1, also known as the One Big Beautiful Bill Act, in 2025. Nationally, the Congressional Budget Office estimates that H.R. 1 would reduce federal Medicaid spending by roughly $911 billion between 2025-2034 and increase the number of uninsured people by 10 million.
For Nebraska specifically, studies estimate changes in eligibility and reapplication frequency could reduce Medicaid enrollment between 16,000 and 30,000 by 2028. Though we cannot estimate the potential financial impact on hospitals and other providers in this analysis with specificity, we do know that following sweeping coverage losses, health care providers have seen financial losses. While providers in a county like Lancaster may be large enough to weather these losses and adapt, smaller and more rural hospitals could encounter greater financial stress.
This project uses data from IPUMS NHGIS and CMS DQ Atlas beneficiary information to analyze county-level estimates of Medicaid coverage for children (0-18), adults (19-64), and seniors (65+) across all 93 counties in Nebraska for two time periods, 2015-2019 and 2020-2024. IPUMS NHGIS provides access to summary tables and time series of population, housing, agriculture, and economic data for all levels of US census geography. DQ Atlas uses the Transformed Medicaid Statistical Information System Analytic Files (TAF) to analyze selected demographic characteristics to understand the populations Medicaid serves.
This project was motivated by work from Georgetown Center for Children and Families on uninsured rates, Medicaid expansion, and Medicaid’s role in small towns and rural America. Our work provides a unique descriptive analysis of county-level Medicaid coverage in pre- and post-expansion Nebraska. The goal of this analysis is to highlight the impact of expanded healthcare access across Nebraska, and particularly in rural and small-town counties.
In the first step, we created Medicaid coverage estimates for two time periods and three age groups using NHGIS 5-year county-level estimates. We constructed coverage estimates and margins of error for children, adults, and seniors from 2015-2019 and 2020-2024. These non-overlapping periods coincide with the pre- and post-expansion periods in Nebraska.
In the second step, we adjust (“rake”) those estimates to known statewide totals for each age group and each time period. The anchor years for raking estimates are 2019 and 2024. These state totals come from the T-MSIS analytic files (TAF), accessed through CMS DQ Atlas beneficiary information. We rake to administrative totals for two reasons. First, it helps account for the undercount of health insurance coverage in Medicaid survey data. Second, it better represents Medicaid’s role as a safety net program that people may enroll, disenroll, and re-enroll in over a relatively short timeframe. Administrative data measures whether an individual has been enrolled in Medicaid at all in the last 12 months, while the ACS collects a point-in-time estimate that captures respondents’ coverage information only at the time of the survey. This distinction better represents Medicaid as a safety net by including all enrollment in the last 12 months, since people frequently churn on and off during that period. Despite this adjustment, it is important to note that these are model-based estimates and are most reliable for larger counties and broader age groups. For this reason, we have suppressed the estimates for counties where the underlying ACS enrollment counts are below 50 or the coefficient of variation exceeds 30%, indicating unreliable estimates.
Lastly, similar to previous reports, we classify Nebraska counties as either “Metro” or “Small Town/Rural” using the Missouri Census Data Center’s Master Area Block Level Equivalency (MABLE) Geocorr 2022 data engine. Small Town/Rural counties combine the micropolitan and noncore designations into a single category that represents the non-urban counties with central urban areas of fewer than 50,000 people. In Nebraska, only 12 counties are defined as “Metro”. We used this information to create a Medicaid gap analysis between metro and small town/rural counties across both periods. Because the rake factor is applied as a single statewide multiplier within each age group, raking adjusts the overall level of coverage but does not create or widen the gap between metro and small town/rural counties. That gap is driven
entirely by the underlying ACS estimates.
What is Medicaid?
A joint federal and state program helping to cover medical costs for people with low incomes and limited resources.
What is Medicaid expansion?
A provision of the Affordable Care Act (ACA) which allows states to expand Medicaid coverage to low-income adults aged 19-64 with incomes up to 138% of the federal poverty level (FPL). Medicaid expansion was enacted in Nebraska through a ballot initiative in 2018.
Who is eligible for Medicaid?
Medicaid is a means-tested program, and though the federal government mandates limitations on participation, states have broad discretion in administration of their own programs. In Nebraska, the following categories are broadly eligible for Medicaid coverage:
What income levels must Medicaid recipients fall under to receive coverage?
The income limitations for Medicaid recipients are tied to the federal poverty level (FPL). In 2026, 100% FPL is $15,960 for the first person with $5,680 added for each additional household member (ASPE, n.d.).
What changes did H.R. 1 or the One Big Beautiful Bill Act make to Medicaid?
The OBBBA made numerous changes to Medicaid. Most notably, it requires that those in the Medicaid expansion population provide evidence of working or participating in another qualifying activity for at least 80 hours per month in order to qualify for Medicaid coverage. These work requirements apply to parents of dependent children above age 13, non-elderly adults aged 19-64, and those who do not meet one of several exemptions (such as pregnancy, disability, medical frailty, or being a parent/caretaker of a disabled individual or dependent). States must implement the work requirements no later than December 31, 2026.
Additionally, the OBBBA requires states to review eligibility every 6 months for Medicaid expansion adults. Prior to the law’s passage, states were only required to review eligibility for expansion adults every 12 months.
What is uncompensated care?
Uncompensated care is defined as health care or services provided by hospitals or health care providers that do not get reimbursed. Uncompensated care often arises when people do not have insurance and cannot afford to pay the cost of care.
Alker, Joan, et al. “Medicaid’s Role in Small Towns and Rural Areas.” Georgetown University Center for Children and Families, January 2025. https://ccf.georgetown.edu/2025/01/15/medicaids-role-in-small-towns-and-rural-areas/.
Ammula, Meghana, and Madeline Guth. “What Does the Recent Literature Say About Medicaid Expansion?: Economic Impacts on Providers.” KFF, January 18, 2023. https://www.kff.org/affordable-care-act/what-does-the-recent-literature-say-about-medicaid-expansion-economic-impacts-on-providers/.
Buettgens, Matthew, Michael Karpman, Jennifer M. Haley, Jameson Carter, and Genevieve M. Kenney. “Projected Reductions in Medicaid Expansion Enrollment Under OBBBA’s Work Requirements and Six-Month Redeterminations: National and State Estimates for 2028.” Urban Institute, March 25, 2026. https://www.urban.org/research/publication/projected-reductions-medicaid-expansion-enrollment-under-obbbas-work.
Centers for Medicare & Medicaid Services (CMS). “DQ Atlas Beneficiary Information – Age.” Accessed June 2026. https://www.medicaid.gov/dq-atlas/landing/topics/single/table?topic=g3m13&tafVersionId=50.
Centers for Medicare & Medicaid Services (CMS). “Hospital Provider Cost Report.” data.cms.gov. Accessed May 2026. https://data.cms.gov/provider-compliance/cost-reports/hospital-provider-cost-report/data.
Centers for Medicare & Medicaid Services (CMS). “Uncompensated Care.” HealthCare.gov Glossary, n.d. Accessed May 2026. https://www.healthcare.gov/glossary/uncompensated-care/.
Euhus, Rhiannon, Elizabeth Williams, Alice Burns, and Robin Rudowitz. “Allocating CBO’s Estimates of Federal Medicaid Spending Reductions Across the States: Enacted Reconciliation Package.” KFF, July 23, 2025. https://www.kff.org/medicaid/allocating-cbos-estimates-of-federal-medicaid-spending-reductions-across-the-states-enacted-reconciliation-package/.
Georgetown University Center for Children and Families. “Health Insurance Coverage in Small Towns and Rural America.” Washington, DC: Georgetown University, September 2018. https://ccf.georgetown.edu/wp-content/uploads/2018/09/FINALHealthInsuranceCoverage_Rural_2018.pdf.
Hulver, Scott, Zachary Levinson, Alice Burns, Elizabeth Hinton, Tricia Neuman, and Robin Rudowitz. “5 Key Facts About Medicaid and Hospitals.” KFF, March 5, 2025. https://www.kff.org/medicaid/5-key-facts-about-medicaid-and-hospitals/.
IPUMS NHGIS. University of Minnesota. www.nhgis.org.
KFF. “Health Provisions in the 2025 Federal Budget Reconciliation Law.” Last updated December 5, 2025. Accessed May 2026. https://www.kff.org/medicaid/health-provisions-in-the-2025-federal-budget-reconciliation-law/.
KFF. “Status of State Medicaid Expansion Decisions.” Last updated May 21, 2026. Accessed May 2026. https://www.kff.org/medicaid/status-of-state-medicaid-expansion-decisions/.
Ku, Leighton, Julia Paradise, and Victoria Thompson. “Data Note: Medicaid’s Role in Providing Access to Preventive Care for Adults.” KFF, May 17, 2017. https://www.kff.org/medicaid/data-note-medicaids-role-in-providing-access-to-preventive-care-for-adults/.
Nebraska Department of Health and Human Services, Division of Medicaid and Long-Term Care. Nebraska Medicaid Annual Report. Lincoln: Nebraska DHHS, December 2025. https://dhhs.ne.gov/Reports/Medicaid%20Annual%20Report%20-%202025.pdf.
Office of the Assistant Secretary for Planning and Evaluation (ASPE). “Prior HHS Poverty Guidelines and Federal Register References.” U.S. Department of Health and Human Services, n.d. Accessed May 2026. https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines/prior-hhs-poverty-guidelines-federal-register-references.
U.S. Census Bureau. “QuickFacts: Lancaster County, Nebraska.” Accessed June 2026. https://www.census.gov/quickfacts/fact/table/US,lancastercountynebraska,NE/EDU685224.
U.S. Census Bureau. “Small Area Health Insurance Estimates (SAHIE) Program.” Accessed March 2026. https://www.census.gov/data-tools/demo/sahie/#/.
U.S. Department of Agriculture, National Agricultural Statistics Service (NASS). 2022 Census of Agriculture: Lancaster County, Nebraska County Profile. Washington, DC: USDA, 2024. https://www.nass.usda.gov/Publications/AgCensus/2022/Online_Resources/County_Profiles/Nebraska/cp31109.pdf.
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Advancing Understanding of Medicaid Across Nebraska Counties Reliable, comprehensive data is important in determining the overall well-being of Nebraskans, and access to critical health care is an essential component of the Good Life. It is also a wise investment. Being able to access preventive care and prescription medications helps avoid
