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........

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