The work-requirement map, 6 months out: 4 states going early, Nebraska's freeze is the preview, and Georgia's 5% enrollment rate is the warning

With CMS-2454-IFC taking effect July 31 and full implementation due January 1, 2027, the state map has taken shape. Correction verified August 2 against the printed DATES section at 91 FR 33348: comments were also due July 31, 2026; an earlier update incorrectly said the Federal Register published only an effective date and no comment deadline.

Four states are going early: Nebraska (enforcing since May 1), Montana (July 1), Arkansas (soft launch July 1), and Iowa (December 1, with no high-unemployment hardship exception) — plus Idaho (Dec 31 statutory deadline with the nation's longest 3-month lookback) and Kentucky (HB 2's pre-enrollment proof requirement, enacted over the governor's veto).

Nebraska's 'soft start' is producing the first hard national data: ZERO new Medicaid enrollees in May versus a typical ~15/month at the state's health centers (a pure chilling effect — termination checks don't even begin until July 31), with 20,000-28,000 of ~70,000 expansion enrollees flagged for documentation. Georgia's Pathways — the only mature work-requirement program — has enrolled ~16,183 people in three years, about 5% of its potential population.

A separate 2028 boundary: Oregon guidance restates Section 71120's exclusion for specified community-clinic services; it does not create a current or universal visit exemption or support patient, demand, reimbursement, revenue, staffing, or financial outcome forecasts. The operational takeaway repeats Nebraska's lesson everywhere: the chilling effect arrives before the disenrollments do, and clinics' navigation capacity is the rail it all runs on.