From March 2023 onward, states resumed checking Medicaid eligibility after a three-year pause during the COVID-19 public health emergency. This nationwide event, known as the unwinding, became the largest coverage transition in the program's history. More than 20 million people were disenrolled. The data it produced is the closest thing we have to a controlled experiment in coverage retention at scale.
The Procedural Problem Was Real and Measurable
Across states, roughly 70 percent of disenrollments were procedural rather than based on a determination that the person no longer qualified. People were dropped for not returning a form, for mail that never reached them, or for documents the state never received. A large share of those people were almost certainly still eligible.
Children were hit especially hard. Because eligibility thresholds for children are higher than for adults, many kids remained eligible even when a parent did not, yet entire households were sometimes dropped together when a renewal packet went unanswered.
What Worked
States that invested in a few specific practices saw meaningfully lower procedural disenrollment. Raising the ex parte automatic renewal rate kept eligible people on without any action required. Updating addresses through managed care plans, the postal service, and pharmacy data reduced returned mail. Plain-language, multilingual notices and text-message reminders before deadlines moved people to act in time.
Partnerships mattered too. Community health centers, schools, and managed care organizations that reached out directly to members, rather than relying on a single state mailing, recovered people who would otherwise have fallen through. The most effective campaigns used multiple channels and repeated contact, not a one-time notice.
The durable lesson is that coverage retention is an operational discipline, not a one-time event. The same machinery that mattered during the unwinding, accurate contact data, clear notices, multilingual outreach, and proactive reminders, is exactly what every annual renewal cycle requires. The unwinding simply made the stakes impossible to ignore.