Millions of people have lost Medicaid coverage since April 2023, when states began removing enrollees who no longer qualify or who failed to complete required paperwork. During the COVID-19 pandemic, the federal government barred states from dropping anyone from Medicaid rolls. That protection ended on March 31, 2023, triggering a massive review of every person enrolled in the program.
The Pandemic Protection That Expired
In March 2020, Congress passed a law requiring states to keep everyone enrolled in Medicaid for the duration of the public health emergency, regardless of whether their income or circumstances changed. This “continuous enrollment” rule meant that even if someone got a raise, moved to a different state, or turned 19 and aged out of children’s coverage, they stayed on Medicaid. Enrollment swelled as a result.
When that protection expired on March 31, 2023, states had up to 14 months to review every single enrollee and determine whether they still qualified. This process, known as the “unwinding,” was the largest eligibility review in Medicaid’s history. States had to work through tens of millions of cases, and many people who had been covered for years suddenly found themselves cut off.
The Two Reasons People Lose Coverage
People lose Medicaid for one of two reasons: they no longer meet the income or eligibility requirements, or they fail to complete the renewal paperwork. The second category, called procedural disenrollment, has been one of the most controversial aspects of the unwinding. Many people who likely still qualify have been dropped simply because a renewal form went to an old address, got lost in the mail, or was never returned.
Disenrollment rates vary enormously by state. Montana saw the highest rate at 57% of reviewed cases resulting in disenrollment, while North Carolina had the lowest at 12%. States that expanded Medicaid eligibility or adopted it for the first time during this period tended to have lower disenrollment rates. North Carolina and South Dakota, for example, both adopted Medicaid expansion during the unwinding, which helped offset losses.
Procedural Losses and Paperwork Barriers
A significant share of people losing coverage never had their actual eligibility evaluated. Their renewal forms went unanswered. This happens for predictable reasons: people experiencing homelessness don’t receive mail, families move without updating their address, and non-English speakers struggle with complicated forms. Some people don’t even realize they need to take action because they’ve been automatically enrolled for three years straight.
States have tools to reduce these losses. The most effective is something called ex parte renewal, where the state checks income and other data through existing government databases and automatically renews people without requiring paperwork. A Health Affairs study of four states (California, New York, South Carolina, and Wisconsin) found that interventions to improve this automated process increased renewal rates by nearly 8 percentage points and decreased procedural denials by more than 8 percentage points. States like Washington and Oregon moved quickly to automate their systems and saw better results. Other states have tried text message and phone reminders, allowed managed care plans to help enrollees fill out forms, and delayed terminations by a month to give people extra time to respond.
Income Limits and Who Qualifies
Medicaid eligibility is tied to income, and the thresholds are lower than many people expect. In the 40 states (plus Washington, D.C.) that have expanded Medicaid under the Affordable Care Act, adults generally qualify if their household income falls below 138% of the federal poverty level. For a single person in 2025, that’s about $21,600 a year. For a family of four, it’s roughly $44,400.
Children qualify at higher income levels in most states, often up to 200% or 300% of the poverty level. Young adults who aged out of foster care qualify regardless of income. People 65 and older, or those with disabilities, have their eligibility determined through a different set of rules tied to Social Security income standards.
Even a modest pay increase can push someone over the threshold. A single adult in an expansion state who goes from earning $20,000 to $23,000 may no longer qualify. During the pandemic freeze, that income change wouldn’t have mattered. Now it does.
The Coverage Gap in Non-Expansion States
Ten states still have not expanded Medicaid, and this creates a particularly harsh situation. In those states, adult eligibility thresholds are often far below the poverty level, sometimes limited to parents earning less than a few thousand dollars a year. Adults without children frequently don’t qualify at any income.
An estimated 1.4 million people fall into what’s called the “coverage gap” in these states. They earn too much to qualify for their state’s Medicaid program but too little to qualify for subsidized insurance through the ACA marketplace, which starts at 100% of the poverty level ($15,650 for a single person in 2025). These individuals have essentially no affordable coverage option. If all ten states adopted the expansion, roughly 2.7 million uninsured adults would gain coverage.
What to Do After Losing Medicaid
If you’ve lost Medicaid coverage, you qualify for a Special Enrollment Period to sign up for a marketplace health plan through HealthCare.gov or your state’s exchange. You have 60 days before losing coverage or 90 days after losing it to enroll. You don’t have to wait for the annual open enrollment window.
When you apply, you’ll find out whether you qualify for premium subsidies based on your income, which can significantly reduce monthly costs. If your income is close to the Medicaid threshold, your out-of-pocket costs on a marketplace plan may be very low.
If you believe you were dropped from Medicaid incorrectly, especially for procedural reasons, you can contact your state Medicaid office to request a new review. Many states allow you to reapply immediately if your circumstances haven’t changed. Updating your mailing address, phone number, and email with the state agency can prevent the same problem from happening at your next renewal.
Where Enrollment Stands Now
Despite millions of people being disenrolled, overall Medicaid enrollment remains higher than pre-pandemic levels in the majority of states. Eighteen states and Washington, D.C., have seen enrollment dip below where it was before COVID, including large states like Florida, Texas, and Pennsylvania. But states that expanded eligibility during the pandemic, such as Nebraska, Oklahoma, Missouri, South Dakota, and North Carolina, have seen net enrollment gains that partially offset the unwinding losses.
The unwinding has exposed longstanding weaknesses in how states manage Medicaid renewals. States that invested in automated systems and proactive outreach kept more eligible people covered. States that relied heavily on mailed paper forms and manual processing lost far more people to paperwork failures, many of whom still qualified for the program.