An Examination of Medicaid Renewal Outcomes and Enrollment Changes at the End of the Unwinding

Jennifer Tolbert and Bradley Corallo
Sep 18, 2024 - KFF

In April 2023, states began the process of unwinding the Medicaid continuous enrollment provision, a pandemic-era policy that protected Medicaid coverage for millions of enrollees. During the unwinding, states redetermined eligibility for everyone on the program and disenrolled those who were no longer eligible or who did not complete the renewal process. Before the start of the coronavirus pandemic in February 2020, there were 71 million people enrolled in Medicaid and CHIP. After the three-year pause in disenrollments, that number grew to a record high of 94 million people by April 2023, the month after the end of continuous enrollment. From the outset of the unwinding, there were major questions related to how many people would be disenrolled versus retain coverage and how that would affect overall Medicaid enrollment. Now that nearly all states have completed the unwinding of the Medicaid continuous enrollment provision, it is possible to take stock of overall renewal outcomes as well as where Medicaid enrollment stands and how current enrollment compares to pre-pandemic levels, nationally and across states. The Medicaid and CHIP enrollment data show more recent changes in enrollment that are not reflected in national survey data that report the overall uninsured rate in 2023 did not change from 2022, although there was an increase in the uninsured rate for children in 2023.

Using data from the KFF Medicaid Enrollment and Unwinding Tracker, this analysis reports data on unwinding renewal outcomes through June 2024 and examines Medicaid enrollment changes from February 2020 through May 2024, the most recent federal enrollment data available, nationally and across states. While the available data provide a nearly complete picture of renewals and disenrollments during the unwinding period, some data are preliminary with cases still pending in some states. These data mark the end of KFF’s independent effort to use state and federal data to monitor the Medicaid unwinding. Going forward, KFF will continue to track monthly Medicaid enrollment data reported by the Centers for Medicare and Medicaid Services (CMS).

Key Takeaways

During the unwinding of the Medicaid continuous enrollment provision, over 25 million people were disenrolled and over 56 million had their coverage renewed. Overall, 31% of people whose coverage was redetermined during the unwinding were disenrolled, but that share ranged widely across states. For example, five states—Montana, Utah, Idaho, Oklahoma, and Texas—have disenrollment rates over 50%, while five states—North Carolina, Maine, Oregon, California, and Connecticut—have disenrollment rates under 20%.
Despite millions of disenrollments during the unwinding, nationally, nearly 10 million more people are currently enrolled in Medicaid/CHIP than at the start of the pandemic. While enrollment among adults is over 20% higher than in February 2020, child enrollment has nearly returned to pre-pandemic levels and is only 5% higher.
Several factors likely explain the net growth in Medicaid enrollment. The pandemic may have encouraged some people who were previously eligible for Medicaid but not enrolled to newly enroll, and during the unwinding, many states took steps to improve their renewal processes to reduce the number of people who were disenrolled despite remaining eligible. In addition, several states expanded eligibility for certain groups, including five states that adopted Medicaid expansion since the onset of the pandemic.
Similar to the national trend, Medicaid/CHIP enrollment in most states is higher than it was in February 2020; however, total Medicaid/CHIP enrollment has fallen below pre-pandemic enrollment in three states, Montana, Colorado, and Arkansas, and child enrollment is lower in 12 states.

A look back on both the period of continuous enrollment and the unwinding period provides numerous potential lessons for Medicaid policy:

The growth in Medicaid enrollment during the pandemic demonstrated that continuous enrollment can stabilize coverage by reducing churn in the program that occurs when eligible people are disenrolled and then reenroll within a short period of time. Beginning January 2024, states are required to provide 12 months of continuous eligibility for children (previously 12-month continuous eligibility for children was optional for states). Many states are expanding on that policy to provide multi-year continuous eligibility for young children, and in some cases, two-year eligibility for older children and adults even though these policies will likely increase state and federal Medicaid spending.

At the same time, providing continuous coverage increases spending and results in people being enrolled who are not necessarily eligible based on their current circumstances. Federal Medicaid spending increased with rising enrollment during the pandemic, but enhanced federal matching payments to states stabilized state Medicaid costs despite large gains in enrollment.

In addition, streamlining renewal policies and procedures, particularly increasing ex parte or automated renewal rates, can improve coverage retention, but eligibility system capacity and functionality also plays a role.

And, finally, having timely and reliable data on renewal outcomes and enrollment enables closer monitoring of state Medicaid programs to identify problems but also to inform the strategies and flexibilities that can help states improve their processes. In May, CMS extended monthly reporting of renewal outcomes data required during the unwinding period to allow for continued monitoring of state programs.