Medicaid After the Pandemic: How State Renewal Rules Drove Coverage Losses in the “Great Unwinding”

A historic rise—and a sharp reversal

Medicaid, the government health insurance program for people with low incomes and disabilities, does not typically grow in a steady, uninterrupted line. In ordinary times, enrollment rises and falls as people’s incomes and household circumstances change, and as states periodically ask beneficiaries to confirm they still qualify.

During the COVID-19 pandemic, that pattern changed dramatically. Month after month, Medicaid enrollment increased—an unusual trajectory driven by a temporary policy that made it easier for people to stay insured during the public health emergency. By early 2023, enrollment reached an all-time high of more than 94 million people.

Then came the reversal. Between April 2023—when states began resuming eligibility checks that had been paused during the pandemic—and mid-2025, more than 25 million people were disenrolled. This period became known as the “Great Unwinding,” a large-scale return to eligibility reviews and renewals after years of continuous coverage.

Now that the unwinding has mostly played out, the data reveal a fragmented, state-by-state picture. Coverage losses were not evenly distributed. Instead, differences in state policies and administrative practices shaped who stayed covered and who lost coverage—often for reasons that had little to do with whether a person was actually eligible.

How Medicaid normally works: renewals, paperwork, and churn

Before the pandemic, Medicaid and the Children’s Health Insurance Program (CHIP)—which provides coverage for children in families with modest incomes—together covered about 71 million Americans.

Under normal rules, people enrolled in Medicaid and CHIP must regularly renew their eligibility. That typically means confirming income and household information. States then remove people who no longer qualify. But states also remove people who fail to complete required paperwork, even if they remain eligible.

This routine “churn”—people moving in and out of coverage—can disrupt access to care. It can also create administrative workload for states and confusion for families, especially when renewal notices are missed or contact information is outdated.

The pandemic temporarily interrupted that cycle. When the policy changed again, the churn returned—sometimes quickly and at large scale.

Continuous coverage during the pandemic: why enrollment surged

In March 2020, the Families First Coronavirus Response Act included a provision requiring states to keep most people continuously enrolled in Medicaid in exchange for additional federal funding. In practical terms, this policy largely halted routine Medicaid disenrollment during the public health emergency.

At the same time, job losses and income declines made more Americans eligible for Medicaid. Those two forces—expanded eligibility due to economic disruption and the suspension of routine disenrollments—combined to push enrollment upward.

Over the course of the pandemic, Medicaid enrollment increased by roughly 23 million people, reaching about 94.1 million by 2023.

During this period, the national uninsured rate fell to a record low of 8%. However, the increase in Medicaid enrollment did not translate one-for-one into fewer uninsured people. Some people who gained Medicaid had previously been insured through employer-sponsored plans, reflecting shifts in coverage sources as well as new coverage gains.

Importantly, the continuous coverage policy was always intended to be temporary. Congress ended it in late 2022, allowing states to restart eligibility reviews beginning April 1, 2023.

The “Great Unwinding”: tens of millions reviewed, millions disenrolled

Once eligibility checks resumed, tens of millions of people had to confirm they were still eligible or risk losing Medicaid coverage. The scale of the administrative task was enormous, and it unfolded differently across states.

By the time most states finished the process, about 56 million people had their coverage renewed, while more than 25 million were disenrolled.

One of the most striking findings from the unwinding is not just how many people lost coverage, but why they lost it. The majority—69% of those who were disenrolled—did not lose Medicaid because the state formally determined they were ineligible. Instead, they lost coverage for administrative reasons such as failing to return renewal forms or having outdated contact information.

These are known as “procedural disenrollments.” They highlight how the mechanics of renewal—mailings, deadlines, documentation requirements, and the ability to reach someone when information changes—can determine coverage outcomes.

Procedural disenrollments and the real-world impact of administrative hurdles

Administrative hurdles during the unwinding disrupted continuity of coverage and, in turn, access to care. When someone loses coverage due to a missed form or a letter sent to an old address, the consequences can extend well beyond insurance status. Coverage gaps can interrupt care, delay medications, and increase financial risk during periods of instability.

The disruptions were not felt equally. Racial and ethnic minorities and those with greater health needs were most affected by the administrative barriers that drove procedural disenrollments.

The unwinding period therefore became an example of how policy design and implementation can shape outcomes. Even when eligibility rules are the same on paper, the burden placed on beneficiaries to prove eligibility can vary by state, and those differences can affect who stays enrolled.

State policy choices that reduced unnecessary coverage loss

As Medicaid enrollment declined, many states adopted policies intended to reduce unnecessary coverage loss. These decisions did not change the underlying fact that states were required to restart eligibility checks. But they did influence how many eligible people remained covered.

The unwinding ultimately showed that administrative choices—how renewals are processed, how much help is available, and how deadlines are structured—can be as important as eligibility rules themselves.

Automatic renewals (“ex parte”) emerged as a key tool

The most common and most effective administrative tool used by states was the ex parte renewal, often described as an automatic renewal. Rather than requiring beneficiaries to submit paperwork, states used existing government data—such as tax records or participation in other assistance programs—to verify eligibility.

This approach reduces the number of steps a beneficiary must take to stay covered. It also reduces the chance that a person will lose coverage simply because a form was missed or a letter was not received.

Six months into the unwinding process, more than half of Medicaid renewals were being completed automatically. The data show that states relying more heavily on ex parte renewals had lower disenrollment rates.

In other words, automation—when done through available data sources—was linked with fewer coverage losses during the unwinding.

Other administrative approaches states used during the unwinding

States also experimented with additional approaches aimed at keeping eligible people enrolled while still completing required eligibility checks. These steps included:

• Extending deadlines for renewal paperwork, giving beneficiaries more time to respond.
• Adding more staff to answer phones and help people complete renewals.
• Running outreach campaigns reminding people to update contact information.

Each of these tactics addresses a common failure point in renewal systems. Deadlines can be missed when families are juggling work, caregiving, or housing instability. Phone lines can be overwhelmed during high-volume periods. And outdated addresses or phone numbers can prevent renewal notices from reaching the right person.

While the unwinding was national in scope, these operational choices were made state by state, contributing to the uneven pattern of coverage losses across the country.

Where enrollment stands now: stabilized, but not back to pre-pandemic norms

The most recent data indicate that Medicaid enrollment has largely stabilized after several years of dramatic change. As of December 2025—the most recent month for which data is available—total enrollment stands at roughly 76 million.

That figure is above pre-pandemic levels of about 71 million, but well below the pandemic peak of 94.1 million.

This new level reflects the combined effects of the pandemic-era surge, the end of continuous coverage, and the administrative outcomes of the Great Unwinding. It also underscores that policy shifts can reshape enrollment quickly, even when the program’s core purpose remains the same.

What the unwinding revealed about Medicaid when rules change

The unwinding offers a clear picture of how Medicaid functions when its rules change. During the pandemic, continuous coverage policies largely eliminated the usual cycle of people moving in and out of the program. When those policies ended, that churn returned—often driven not by changes in eligibility, but by how renewal processes were implemented.

The data from this period point to a central lesson: administrative design matters. When renewals depend heavily on beneficiary action—returning forms, meeting deadlines, navigating phone systems—coverage continuity becomes more fragile. When states can verify eligibility using existing data and renew coverage automatically, fewer eligible people appear to fall through the cracks.

This lesson is not only retrospective. It sets the context for how future changes may play out.

New federal requirements are coming—and state implementation will matter again

Under the 2025 budget law, widely referred to as the One Big Beautiful Bill Act, states will face new requirements that are expected to make administrative processes even more central to coverage outcomes.

As of Jan. 1, 2027, states will have to enforce new Medicaid work rules for many adults who gained coverage during the expansion. In addition, states must begin checking eligibility for many adults every six months instead of once a year.

These changes raise the stakes of administrative systems. More frequent eligibility checks mean more opportunities for paperwork problems, missed notices, and procedural disenrollments—depending on how states structure their processes.

The law also delayed some federal changes that were supposed to make Medicaid enrollment and renewal easier. That means that even when the rules are set at the federal level, the day-to-day experience for beneficiaries may still depend heavily on how much paperwork, automation, and hands-on help each state builds into its system.

Why this matters for coverage, care, and financial protection

Medicaid is more than an enrollment number. For the millions of people who rely on it, coverage supports access to care, medications, and financial protection. When enrollment systems create avoidable gaps—especially through procedural disenrollments—people can lose continuity in treatment and face increased uncertainty.

The Great Unwinding demonstrated that administrative burden is not an abstract concept. It can determine whether eligible people stay enrolled. It can also shape which groups experience the greatest disruption, with racial and ethnic minorities and people with greater health needs particularly affected by administrative hurdles.

Looking ahead, future enrollment levels will be shaped by both expanding and constraining forces. The unwinding showed how quickly coverage can change when policies shift—and how strongly state administrative choices can influence outcomes.

As new work rules and more frequent eligibility checks approach, the state-by-state differences exposed during the unwinding are likely to matter again. The practical question for beneficiaries will remain familiar: not only whether they qualify, but whether the renewal and verification process is designed in a way that allows eligible people to stay covered.