Medicaid’s post-pandemic “Great Unwinding”: How state renewal rules drove coverage losses
A historic swing in Medicaid coverage
During the COVID-19 pandemic, Medicaid enrollment moved in a direction that is unusual for a means-tested public program: it rose steadily month after month. The increase was not a small fluctuation. By early 2023, enrollment reached an all-time high of more than 94 million people.
The surge was driven by two forces operating at the same time. First, a pandemic-era policy of continuous coverage made it easier for people to stay insured by essentially halting Medicaid disenrollment during the public health emergency. Second, job losses and income declines during the pandemic made more people eligible for Medicaid, adding to the rolls.
When that temporary policy ended and states resumed routine eligibility checks, the program experienced a dramatic reversal. Between April 2023—when states began restarting eligibility reviews—and mid-2025, more than 25 million people were disenrolled from Medicaid. This rollback became widely known as the “Great Unwinding.”
Now that the unwinding has mostly played out, the enrollment data show a fragmented, state-by-state picture. Coverage losses were not evenly distributed across the country. Instead, differences in state policy and administrative practices shaped who stayed covered and who fell off the program—even among people who remained eligible.
How Medicaid and CHIP usually work—and what changed during the pandemic
Before the pandemic, Medicaid and the Children’s Health Insurance Program (CHIP) together covered about 71 million Americans. These programs provide health coverage for people with low incomes, children in families with modest incomes, and people with disabilities.
Under normal rules, people must regularly renew their eligibility. That means confirming income and household information on a recurring schedule. States remove people who no longer qualify, but they also remove people who fail to complete required paperwork, miss deadlines, or cannot be reached.
The pandemic disrupted that typical renewal cycle. 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, the policy largely stopped routine disenrollments during the emergency period.
With disenrollments paused and more people becoming eligible due to economic instability, Medicaid enrollment increased by roughly 23 million people during the pandemic, reaching about 94.1 million by 2023.
Record-low uninsured rates—but not a one-for-one change
During the pandemic, the national uninsured rate fell to a record low of 8%. However, the jump in Medicaid enrollment did not translate one-for-one into a drop in the number of uninsured people.
One reason is that not everyone who gained Medicaid coverage had previously been uninsured. Some people moved from employer-sponsored plans into Medicaid, reflecting shifts in coverage sources as well as new coverage gains. The result was a complicated picture: Medicaid grew dramatically, uninsured rates fell, and coverage churn across different types of insurance continued in the background.
The Great Unwinding: restarting eligibility checks at scale
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.
Restarting renewals meant that tens of millions of people had to confirm they were still eligible or risk losing Medicaid coverage. States worked through this backlog over many months. By the time most states finished, more than 25 million people had been disenrolled, while about 56 million had their coverage renewed.
These topline numbers capture the magnitude of the unwinding, but they do not explain why coverage losses were so widespread—or why the experience varied so much from one state to another.
Procedural disenrollments: losing coverage because of paperwork
One of the most striking findings from the unwinding is that most people who lost Medicaid did not lose it because the state determined they were ineligible. Instead, 69% of disenrollments were for administrative reasons.
These administrative reasons include failing to return renewal forms, missing renewal deadlines, or having outdated contact information that prevented beneficiaries from receiving notices. Disenrollments for these reasons are commonly described as “procedural disenrollments.”
The high share of procedural disenrollments matters because it suggests that coverage loss was often driven by process rather than eligibility. In other words, many people may have remained eligible but still fell off the program because they could not navigate the renewal steps, did not receive the right communications, or were unable to complete paperwork on time.
Why administrative burden matters for access to care
Administrative hurdles during the unwinding disrupted continuity of coverage and, in turn, access to care. When people lose coverage unexpectedly, they can face delays in getting routine care, filling prescriptions, or maintaining relationships with providers.
The disruption did not affect all groups equally. Racial and ethnic minorities and people with greater health needs were the most affected by these coverage interruptions during the unwinding.
As enrollment plunged, many states adopted policies intended to reduce unnecessary coverage loss. Those choices—how much a state relied on automation, how much hands-on help it provided, and how flexible it was with deadlines—ultimately influenced how many eligible people remained enrolled.
State policy choices that helped people stay enrolled
The unwinding highlighted that Medicaid is administered by states, and the details of how states implement federal rules can significantly shape outcomes. While states were all restarting eligibility checks, they did not all do it the same way.
Several administrative approaches emerged as especially important in reducing coverage losses among eligible people:
Ex parte (automatic) renewals: The most common and most effective tool was ex parte renewal, also called automatic renewal. Instead of requiring beneficiaries to submit paperwork, states used existing government data—such as tax records or information from other assistance programs—to verify eligibility.
Greater reliance on automation over time: 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.
Extending deadlines: Some states extended the time people had to return renewal paperwork, reducing the chance that eligible individuals would lose coverage simply because they missed a narrow window.
Adding staff and improving support: States also added more staff to answer phones and help people complete renewals, which can be crucial when large numbers of beneficiaries are trying to navigate the process at once.
Outreach to update contact information: Outreach campaigns reminded people to update addresses and other contact details, an important step given that outdated information can prevent people from receiving renewal notices.
These tools are administrative by nature, but the results are substantive. When states reduced the burden on beneficiaries—by renewing coverage automatically when possible and providing more time and support when paperwork was necessary—fewer eligible people lost coverage.
Where enrollment stands after the unwinding
After several years of dramatic change, the most recent data show that Medicaid enrollment has largely stabilized. As of December 2025, total enrollment stands at roughly 76 million.
That figure is still above prepandemic levels of about 71 million, but well below the pandemic peak of 94.1 million. The stabilization suggests the most intense phase of the unwinding is over, even as the program continues to reflect the effects of policy shifts and administrative decisions made during the rollback.
What the unwinding revealed about “churn” in Medicaid
The unwinding offers a clear view 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.
Importantly, the return of churn was often driven not by changes in eligibility but by the way renewal processes were implemented. Procedural disenrollments—coverage losses tied to paperwork and administrative steps—became a defining feature of the unwinding period.
This experience underscores a core reality of public coverage programs: eligibility rules may be set in law, but whether eligible people stay enrolled can depend heavily on day-to-day administration.
Why state differences may matter again under upcoming rules
The state-by-state differences exposed during the unwinding are not just a retrospective lesson. They are likely to matter again under new federal requirements scheduled for the coming years.
Under the 2025 budget law, widely referred to as the One Big Beautiful Bill Act, states will have to make two major changes affecting many adults who gained coverage during the Medicaid expansion:
More frequent eligibility checks: States must begin checking eligibility for many adults every six months instead of once a year.
New work requirements: States must enforce new Medicaid work rules for many adults starting Jan. 1, 2027.
The same administrative differences that mattered during the unwinding—how much paperwork is required, how effectively states use automation, and how much help is available to beneficiaries—are likely to shape who keeps coverage and who loses it when these new rules take effect.
The law also delayed some federal changes that were supposed to make Medicaid enrollment and renewal easier. That means that even when rules are set at the federal level, outcomes can still hinge on state implementation details and the administrative burden placed on beneficiaries.
The bottom line for coverage stability
The post-pandemic unwinding shows that Medicaid enrollment is shaped by both policy design and administrative execution. Continuous coverage during the pandemic reduced churn and helped push enrollment to record highs. When the policy ended, states faced the massive task of rechecking eligibility—and millions lost coverage, often for procedural reasons rather than confirmed ineligibility.
With enrollment now stabilized at a level above prepandemic totals, attention is shifting to what comes next. The combination of more frequent eligibility checks and new work requirements, alongside delayed efforts to simplify renewal, suggests that future enrollment levels will be shaped by competing forces that can either expand or constrain coverage.
For the millions of people who rely on Medicaid, these administrative and policy choices are not abstract. They influence whether coverage is continuous and dependable—affecting access to care, medications, and financial protection during periods of instability.