Medicaid After the Pandemic: How State Renewal Policies Shaped Coverage Losses in the “Great Unwinding”
A historic swing in Medicaid enrollment
During the COVID-19 pandemic, Medicaid enrollment moved in a direction that is unusual for a program tied closely to income and life changes. Instead of the normal pattern of people cycling on and off coverage, the number of people insured through Medicaid rose month after month. By early 2023, enrollment reached an all-time high of more than 94 million people.
The main driver was a pandemic-era “continuous coverage” policy that essentially halted most Medicaid disenrollment during the public health emergency. That policy was designed to make it easier for people to remain insured at a time when the health system and the economy were under severe strain. At the same time, job losses and income declines meant that more people met Medicaid eligibility rules, further contributing to enrollment growth.
This period of rapid growth was always intended to be temporary. Congress ended the continuous coverage provision in late 2022, and states were allowed to restart eligibility reviews beginning April 1, 2023. What followed was a large-scale shift in coverage that came to be known as the “Great Unwinding.”
What the “Great Unwinding” did to coverage
Between April 2023 and mid-2025, more than 25 million people were disenrolled from Medicaid as states resumed eligibility checks that had been paused during the pandemic. Over the same period, about 56 million people had their coverage renewed. By December 2025—the most recent month for which data is available—total Medicaid enrollment stood at roughly 76 million.
That post-unwinding level is still above prepandemic enrollment. Before the pandemic, Medicaid and the Children’s Health Insurance Program (CHIP) together covered about 71 million Americans. But it is far below the pandemic peak of 94.1 million, reflecting the scale of the unwinding and the return of routine eligibility processes that had been largely suspended.
The unwinding also underscored a basic feature of Medicaid administration: while broad rules can be set at the federal level, the day-to-day experience of staying enrolled is shaped heavily by state processes. As the unwinding played out, the data revealed a fragmented, state-by-state picture, with coverage losses not evenly distributed across the country.
Why enrollment rose so sharply during the pandemic
To understand why the unwinding produced such large coverage losses, it helps to revisit what changed during the pandemic. Under normal circumstances, people enrolled in Medicaid and CHIP must periodically renew their eligibility by confirming income and household information. States remove people who no longer qualify, but they also remove people who fail to complete paperwork on time or cannot be reached.
During the pandemic, those routine disenrollments largely stopped. The March 2020 Families First Coronavirus Response Act included a provision requiring states to keep most people continuously enrolled in Medicaid in exchange for additional federal funding. This meant that many people who might otherwise have been disenrolled—whether because they missed a renewal notice or because their eligibility was in question—remained covered for the duration of the policy.
These policy changes coincided with economic disruption. Job losses and reduced income made more Americans eligible for Medicaid. Together, the pause in disenrollment and the increase in eligibility drove a surge of roughly 23 million additional Medicaid enrollees during the pandemic, pushing enrollment to about 94.1 million by 2023.
Coverage gains did not map perfectly to a lower uninsured rate
The pandemic period was also associated with a national uninsured rate that fell to a record low of 8%. However, the increase in Medicaid enrollment did not translate one-for-one into fewer uninsured people. Some of those who gained Medicaid coverage had previously been insured through employer-sponsored plans, reflecting shifts in where people got coverage rather than only net-new coverage gains.
This distinction matters because it highlights that Medicaid enrollment totals can rise for multiple reasons: people becoming newly insured, people switching from one type of insurance to another, and people staying enrolled longer because of administrative protections such as continuous coverage.
Procedural disenrollments: the paperwork problem
One of the most striking findings from the unwinding is not just the number of people who lost Medicaid, but why they lost it. A majority—69% of those disenrolled—were removed for administrative reasons rather than because the state formally determined they were ineligible. These administrative removals are often referred to as “procedural disenrollments.”
Procedural disenrollments can happen for several reasons described in the data and reporting around the unwinding, including failure to return renewal forms or states having outdated contact information. In other words, many people lost coverage not because they no longer met eligibility rules, but because the renewal process broke down somewhere between the state and the beneficiary.
This kind of coverage loss is significant in insurance terms because it disrupts continuity. Even short gaps in coverage can interrupt access to care and medications, and can weaken the financial protection that insurance is meant to provide. During the unwinding, administrative hurdles disrupted continuity of coverage and, in turn, access to care.
Uneven impacts and the role of health needs
The unwinding’s administrative burden did not affect all groups equally. The disruptions were most pronounced among racial and ethnic minorities and among people with greater health needs. This pattern is consistent with the idea that when coverage depends on completing time-sensitive paperwork, those facing barriers—whether logistical, informational, or related to health—can be more likely to experience preventable loss of coverage.
Because Medicaid is a key source of insurance for people with low incomes and disabilities, the stakes of these administrative outcomes are high. Coverage is not only an enrollment statistic; it is closely tied to consistent access to care, medications, and protection from medical bills during periods of instability.
State-by-state differences shaped who stayed enrolled
As the number of people covered by Medicaid fell, many states adopted policies intended to reduce unnecessary coverage loss. The unwinding therefore became a real-time demonstration of how state administrative choices influence enrollment outcomes. States differed in how they carried out eligibility checks and how much administrative burden they placed on people who were eligible and trying to stay enrolled.
These differences help explain why coverage losses were not evenly distributed. Two states could be operating under the same broad federal framework and still produce very different enrollment outcomes depending on how renewal systems were designed, staffed, and executed.
Automatic renewals (ex parte) emerged as a key tool
The most common and most effective administrative tool described during the unwinding was the use of ex parte renewals, also known as automatic renewals. Instead of requiring beneficiaries to submit paperwork, states used existing government data—such as tax records or participation in other assistance programs—to verify eligibility automatically.
This approach reduces the number of steps a beneficiary must take to remain enrolled, and it reduces the risk that a renewal notice goes to an old address or that a form is missed. Six months into the unwinding process, more than half of Medicaid renewals were being completed automatically. States that relied more heavily on ex parte renewals had lower disenrollment rates.
In practical terms, the ex parte experience illustrates how administrative design can act like a gatekeeper. When renewal is automated using reliable data sources, eligible people are less likely to fall through the cracks. When renewal depends primarily on mailed forms, phone calls, and strict deadlines, the risk of procedural disenrollment rises.
Other administrative strategies states used
States also experimented with additional approaches aimed at keeping eligible people covered while still resuming eligibility checks. The measures described during the unwinding included:
Extending deadlines for renewal paperwork so people had more time to respond.
Adding more staff to answer phones and help people complete renewals.
Running outreach campaigns reminding people to update contact information.
These steps share a common purpose: reducing avoidable coverage loss caused by administrative friction. Each one addresses a known failure point in the renewal process—limited time, limited access to assistance, and difficulty reaching beneficiaries when addresses or phone numbers change.
Where Medicaid stands now
After several years of dramatic change, the most recent data indicates that Medicaid enrollment has largely stabilized. As of December 2025, total enrollment is roughly 76 million. That figure reflects a system that has moved beyond the peak of pandemic-era continuous coverage but remains above prepandemic levels.
The stabilization does not erase the effects of the unwinding. Instead, it marks the end of an intense administrative period in which tens of millions of people had to re-verify eligibility. The unwinding offers a clear picture of how Medicaid functions when its rules change: when continuous coverage eliminated the usual cycle of people moving in and out of the program, churn decreased; when the policy ended, churn returned, often driven by renewal implementation rather than eligibility changes.
Why the unwinding matters for the next round of policy changes
The state-by-state patchwork exposed by the unwinding is not just a retrospective lesson. It may shape future coverage outcomes as new requirements take effect. Under the 2025 budget law, widely referred to as the One Big Beautiful Bill Act, states will face new obligations that could increase the frequency and complexity of eligibility administration.
As of Jan. 1, 2027, states will have to enforce new Medicaid work rules for many adults who gained coverage during the expansion. The same law also requires states to check eligibility for many adults every six months instead of once a year. These changes increase the number of times people must successfully navigate renewal and verification processes to keep coverage.
The law also delayed some federal changes that were supposed to make Medicaid enrollment and renewal easier. That combination—more frequent checks and delayed simplifications—suggests that the administrative choices states make will remain central to who stays covered.
Administrative design as a determinant of coverage
The unwinding highlighted a reality that can be easy to overlook in debates about eligibility rules: administrative processes can determine outcomes even when eligibility is unchanged. When 69% of disenrollments are procedural, the system is sending a clear signal that paperwork, contact information, and the capacity of state agencies are not peripheral concerns. They are core determinants of whether eligible people remain insured.
Automatic renewals, extended deadlines, increased call-center staffing, and outreach to update contact details are not merely operational tweaks. During the unwinding, they were associated with measurable differences in disenrollment rates and therefore in continuity of coverage.
What to watch as policies evolve
Looking ahead, future enrollment levels are likely to be shaped by both expanding and constraining forces. On one side are the tools that can reduce unnecessary loss of coverage, such as automation and hands-on assistance. On the other are policy changes that increase verification frequency and introduce additional requirements.
For the millions of people who rely on Medicaid, these forces have concrete implications. Coverage affects not just whether someone has an insurance card, but whether they can consistently access care, maintain prescriptions, and avoid financial shocks from medical expenses. The unwinding showed that when the rules change, the details of implementation—especially at the state level—can be the difference between staying covered and losing coverage.
In that sense, the Great Unwinding was more than a one-time administrative event. It was a large-scale test of how Medicaid systems perform under stress, and it produced a state-by-state map of which approaches helped eligible people remain insured. As new requirements approach, that map may prove relevant again.