During the COVID-19 pandemic, the number of people covered by Medicaid – an unusual pattern for the government’s insurance program for people with low incomes and disabilities.
Why? A policy of continuous coverage during the pandemic essentially to make it easier for people to stay insured during the public health emergency. By early 2023, enrollment had reached an .
Then the trend abruptly reversed.
Between April 2023 – when states began resuming eligibility checks that had been paused during the pandemic – and mid-2025, . The process became known as the “.”
As a who studies and health outcomes, I’ve been following these enrollment shifts closely. Now that the unwinding has mostly played out, Medicaid enrollment data reveal a . Coverage losses were not evenly distributed, reflecting differences in how states carried out eligibility checks and how much administrative burden they placed on eligible people trying to stay enrolled.
That patchwork of state policies still matters now. Under the , widely referred to as the One Big Beautiful Bill Act, as of Jan. 1, 2027, states will have to and more frequently check eligibility for many adults who gained coverage during the expansion. So the same administrative differences exposed by the rollback of Medicaid coverage after the pandemic are likely to play a role again in who keeps their coverage and who loses it.
Pandemic enrollment jump
Before the pandemic, Medicaid and the , which provides coverage for children in families with modest incomes, together .
Normally, people must regularly renew their eligibility for these programs by confirming their income and household information. States remove people who no longer qualify or who fail to complete paperwork.
During the pandemic, however, those routine disenrollments largely stopped as part of the , which included a provision requiring states to keep most people continuously enrolled in Medicaid in exchange for additional federal funding. At the same time, job losses and income declines made more Americans eligible for Medicaid.
Together, those factors caused Medicaid enrollment to surge. Enrollment increased by roughly 23 million people during the COVID-19 pandemic, .
While the national uninsured rate fell to a , 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 coverage as well as new coverage gains.
The ‘Great Unwinding’
The pandemic era’s continuous coverage policy was always meant to be temporary. Congress ended it in late 2022, allowing states to restart eligibility reviews beginning April 1, 2023.
That process required tens of millions of people to confirm they were still eligible or else lose their Medicaid coverage.
By the time most states finished the process, , while about 56 million had their coverage renewed.
One striking feature of the unwinding is that – did so not because they were formally determined to be ineligible but because of administrative reasons, such as failure to return renewal forms or outdated contact information. These are known as “.”
Administrative hurdles during the unwinding and, in turn, . and those with were most affected.
State policy shapes coverage losses
As the number of people covered by Medicaid plunged, many states adopted policies to reduce unnecessary coverage loss. These administrative choices ultimately .
The most common and most effective administrative tool was . Instead of requiring beneficiaries to submit paperwork, states used existing government data such as tax records or participation in other assistance programs to automatically verify eligibility.
Six months into the unwinding process, more than half of Medicaid renewals . States that relied more heavily on ex parte renewals .
States also experimented with , including extending deadlines for renewal paperwork, adding more staff to answer phones and help people complete renewals, and running outreach campaigns reminding people to update contact information.
Where Medicaid enrollment stands now
The most recent data shows 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 – above prepandemic levels of about 71 million but below the pandemic peak of 94.1 million.
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.
Looking ahead, the same state-by-state differences in policies that helped or hindered people’s ability to maintain Medicaid enrollment as pandemic coverage wound down are likely to matter again. Under the 2025 budget law, states must begin checking eligibility for many adults . States must also for many adults starting in 2027.
The law also delayed some federal changes that were supposed to make Medicaid enrollment and renewal easier. So even when the rules come from Washington, who keeps their coverage may still depend heavily on how much paperwork, automation and hands-on help each state builds into the process.
Together, these trends suggest that future enrollment levels will be shaped by both expanding and constraining forces. These forces will have real consequences for the millions of people who rely on Medicaid – not just for coverage, but for consistent access to care, medications and financial protection during periods of instability.
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