During the COVID-19 pandemic, the number of people covered by Medicaid rose month after month – 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 halted Medicaid disenrollment to make it easier for people to stay insured during the public health emergency. By early 2023, enrollment had reached an all-time high of more than 94 million people.

Then the trend abruptly reversed.

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 from Medicaid. The process became known as the “Great Unwinding.”

As a health economist who studies the effects of public policy on insurance coverage and health outcomes, I’ve been following these enrollment shifts closely. Now that the unwinding has mostly played out, Medicaid enrollment data reveal a fragmented, state-by-state picture. 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 2025 budget law, widely referred to as the One Big Beautiful Bill Act, as of Jan. 1, 2027, states will have to enforce new Medicaid work rules 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 Children’s Health Insurance Program, which provides coverage for children in families with modest incomes, together covered about 71 million Americans.

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 March 2020 Families First Coronavirus Response Act, 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, reaching about 94.1 million by 2023.

While the national uninsured rate fell to a record low of 8% during the pandemic, 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, more than 25 million people had been disenrolled, while about 56 million had their coverage renewed.

One striking feature of the unwinding is that the majority – 69% of people who lost coverage – 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 “procedural disenrollments.”

Administrative hurdles during the unwinding disrupted continuity of coverage and, in turn, access to care. Racial and ethnic minorities and those with greater health needs 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 influenced how many eligible people remained covered.

The most common and most effective administrative tool was ex parte – or 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 automatically verify eligibility.

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.

States also experimented with other approaches, 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 roughly 76 million – 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 every six months instead of once a year. States must also enforce new work requirements 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.

Aparna Soni receives funding from the American Lung Association, the Centers for Disease Control & Prevention, the National Institutes of Health, the Indiana Department of Health, Eli Lilly & Corporation, the Indiana Business Health Collaborative, and the Upjohn Institute.