KFF Survey of Medicaid Unwinding

About the Survey

On March 18, 2020, in response to the outbreak of COVID-19 in the United States, the Families First Coronavirus Response Act (FFCRA) was signed into law. The FFCRA included a provision requiring state Medicaid programs to keep people enrolled, in exchange for additional federal funding. This continuous enrollment provision lasted for three years, ending on March 31, 2023, and states were able to resume disenrolling people from Medicaid who no longer met eligibility requirements or who did not complete the renewal process beginning on April 1, 2023. This process of conducting redeterminations for all Medicaid enrollees has been commonly referred to as “Medicaid unwinding.”

Since the start of Medicaid unwinding, KFF state tracking shows that more than 20 million people have been disenrolled from Medicaid, with states reporting renewal outcomes for two-thirds of enrollees so far. To shed light on the experiences of people who tried to renew their coverage or find a different source of health coverage during this period, KFF interviewed 1,227 U.S. adults who had Medicaid coverage in prior to April 1, 2023 – as states began the process of determining who was still eligible for Medicaid in their state. This report highlights people’s experiences with the Medicaid unwinding process and measures the financial and health impacts of being disenrolled from Medicaid and/or having to find other forms of coverage. While the scale of the unwinding is unprecedented, the survey findings can help policymakers understand how to improve the Medicaid renewal process more generally going forward.

Key Takeaways

• About one in five enrollees say they were disenrolled from Medicaid coverage at some point in 2023 and about a quarter (23%) of those who were disenrolled remain uninsured. Some of those who were disenrolled eventually re-enrolled in the program (47%) or found other forms of health coverage (28%), but the loss of coverage led many to worry about both their physical health and their mental health. Three-fourths of those who were disenrolled from Medicaid say they were worried about their physical health while six in ten say they were worried about their mental health. Additionally, a majority (56%) say they skipped or delayed getting health care services or prescriptions while attempting to renew their coverage (13% of total enrollees).
• Newly uninsured adults cite costs as the reason for not getting another form of health coverage. Most pre-unwinding enrollees say they either retained their coverage or were able to re-enroll in Medicaid (83%), but one in twelve (8%) of all enrollees are now uninsured, resulting in millions of newly uninsured individuals. More than a third (36%) of the currently uninsured group say they are still trying to get Medicaid coverage, and more than half (54%) cite costs as the reason why they haven’t gotten coverage from somewhere else.
• Health insurance costs are also a major concern for those who now have a different form of coverage. Among those who now have other forms of coverage (8% of enrollees), half (50%) say they worry about affording their monthly premium, and three-quarters (76%) say they are worried about affording the costs of health care services. Most who have another source of coverage say it is about the same as or better than Medicaid in terms of access to care.
• Many pre-unwinding enrollees who tried to renew their Medicaid coverage encountered some type of problem. Two-thirds (64%) of those enrolled in Medicaid before the unwinding process began say they took action last year to renew their coverage. Among those who tried to re-enroll, most found it very or somewhat easy, but 58% (37% of total enrollees) experienced at least one problem during the process, most commonly long call center wait times (44%). Other problems encountered include not knowing what documents were needed; trying to submit documents and being told they were incomplete, not received, or not processed; or having unreliable internet access to complete forms online. Notably, about half (54%) of those who experienced any problem when trying to renew their coverage say they found it difficult to renew their Medicaid coverage.
• Those living in states that have not expanded Medicaid are more likely to say they needed proof of residency to renew their coverage. Enrollees living in non-expansion states were at least twenty percentage points more likely than those in Medicaid expansion states to say they were asked to submit proof of residency. While states are required to first check available data sources to confirm ongoing eligibility, they may require enrollees to submit certain documents at renewal if the state cannot obtain the information electronically.

Half of Pre-Unwinding Enrollees Say They Heard Little or Nothing About the Medicaid Unwinding Process

A recent KFF Health Tracking Poll found that about seven in ten of the overall public (69%) say they have heard only “a little” or “nothing at all” about states removing people from Medicaid as pandemic policies came to an end. The KFF Survey of Medicaid Unwinding finds that among adults who were enrolled in Medicaid prior to the start of the unwinding process, about half (53%) say they heard “a little” or “nothing at all” about states removing people from Medicaid as pandemic policies came to an end. This includes three in ten (31%) who say they heard “nothing at all” about states removing people from Medicaid last year. One in six (17%) enrollees say they heard “a lot” about Medicaid unwinding and three in ten (30%) say they heard “some.”

Those with lower levels of educational attainment, especially those with a high school diploma or less, were much more likely to say they heard “nothing at all” about states removing people from Medicaid. Additionally, enrollees living in non-expansion states were more likely to say they have heard “a lot” or “some” about Medicaid unwinding (59%), compared to 45% of those living in expansion states.

For a Sizeable Share of Pre-Unwinding Enrollees, the Medicaid Re-Enrollment Process Proved Difficult

After a three-year pause in disenrolling individuals from the Medicaid program, on April 1, 2023, states resumed disenrolling those who were no longer eligible or who did not complete the renewal process. As part of that process, states send notices to enrollees indicating whether the enrollee needs to take action to renew their Medicaid coverage. Among adults who were enrolled in Medicaid prior to the start of the unwinding process, seven in ten (71%) say they remember receiving information about renewing, confirming, or re-enrolling in Medicaid while about three in ten (29%) say they do not remember receiving renewal information.

Similar to overall awareness of the Medicaid unwinding process, those with a high school degree or less (67%) are less likely than enrollees with at least some college education (76%) and college graduates (80%) to say they remember receiving notice about renewing their Medicaid coverage. One-third (33%) of enrollees with a high school degree or less say they do not remember receiving any information about renewing, confirming, or re-enrolling in Medicaid.

Similar to overall awareness, enrollees living in non-expansion states were generally less likely than those living in expansion states to remember receiving notice about renewing their Medicaid coverage (61% vs. 74%).

The most common way people remember receiving information was through the U.S. mail. About six in ten (63%) Medicaid enrollees say they received notice via mail regarding Medicaid renewal while about one in five (22%) say they received renewal information via email. One in ten pre-unwinding enrollees say they received notice via an online Medicaid portal (10%) or via text message (10%). Last year’s KFF Survey of Consumer Experiences with Health Insurance reported that the mail was the preferred method of contact for Medicaid enrollees about renewing their coverage.

The Medicaid renewal process varies slightly among states but the first step is for states to attempt to verify an individual’s eligibility by checking available data sources. If the state can confirm eligibility using these data sources, the individual’s coverage will be renewed, and the individual does not need to take any action. However, if eligibility cannot be confirmed using data sources, the state must send a renewal form to the individual.

Because not everyone needs to take action to renew their Medicaid coverage, not every Medicaid enrollee will have experience with trying to renew their coverage. The KFF Survey of Medicaid Unwinding includes about two-thirds (64%) of adults who were enrolled in Medicaid prior to the start of the unwinding process and say they took action last year to try and renew their Medicaid coverage.

Notably, those who received notice about the need to re-enroll appear to have been spurred to action as more than three in four (78%) of those who remember receiving information about confirming, renewing, or re-enrolling in Medicaid say they took action to try and renew their coverage. In contrast, just three in ten (29%) of those who did not recall receiving information say they took action to renew their Medicaid coverage.

Most of those who took some type of action to renew their coverage found the process easy. About two-thirds (65%) of enrollees who tried to renew their coverage say they found the Medicaid renewal process to be “very easy” or “somewhat easy.” Nonetheless, about one-third (35%) of enrollees who tried to renew their coverage found the process difficult. More specifically, about three in ten say gathering and submitting the documents (29%) and figuring out what documents were needed to complete enrollment (28%) were either “very difficult” or “somewhat difficult.” Additionally, about one in four (23%) enrollees who tried to renew their coverage say filling out the necessary forms was at least somewhat difficult.

Enrollees are split on whether they found the experience stressful or not. Overall, half (48%) of those who took action to try to renew their coverage say they found the process to be at least somewhat stressful, similar to the share (52%) who say it was “not too stressful” or “not at all stressful.”

Those who have previously renewed their Medicaid are more likely than those for whom this is a new experience to say they remember receiving information about re-enrolling in Medicaid (79% vs. 57%) and to say they took action to renew their Medicaid coverage (75% vs 42%). However, prior experience with the renewal process does not necessarily translate to an easier or less stressful experience trying to renew their coverage.

About a third of both groups, those who had previously participated in renewal and those who had not, say the renewal process during unwinding was difficult (35% vs. 33% respectively) and about half of both groups say the process was stressful (48% and 49% respectively).

A Majority of Pre-Unwinding Enrollees Who Tried To Renew Their Medicaid Coverage Experienced Problems

About six in ten (58%) adults who were enrolled in Medicaid prior to unwinding and tried to renew their coverage last year say they experienced at least one problem when doing so (37% of total enrollees). The most commonly reported problem was long wait times on the phone (44%), followed by not knowing what documents were needed to complete re-enrollment (26%), trying to submit forms but being told the documents were incomplete (25%), and submitting renewal materials or forms but being told that they were not received or not processed (24%). Additionally, 14% of pre-unwinding enrollees who tried to renew their Medicaid coverage said they did not have reliable internet access to complete forms online, rising to 19% among those with household incomes under $20,000, to 19% among rural residents, and to 23% among those who say they are in fair or poor physical health.

Enrollees who say they experienced a problem when trying to renew their coverage are more likely to say the renewal process was difficult with a slight majority saying the process was “very” (11%) or “somewhat” (42%) difficult. Additionally, two-thirds (66%) of those who experienced a problem when trying to renew their coverage found the process to be at least somewhat stressful.

Among enrollees who tried to renew their coverage, 28% say they got help with the Medicaid renewal process, including about a third of enrollees who are in fair or poor health (34%). The most common source of help was from a Medicaid case worker or Navigator (19%), while fewer say they received help from a friend or family member (7%), from a Medicaid health plan (5%), or from a doctor or health care provider (3%).

Additionally, about one in six (17%) of those who didn’t get help say they wanted assistance (8% of total enrollees). This was most commonly reported by pre-unwinding enrollees who experienced problems when trying to renew their coverage. About three in ten (29%) pre-unwinding enrollees who experienced problems when trying to renew their coverage say they wanted but did not get help with the process.

Those in Non-Expansion States Are More Likely To Report Being Asked To Submit Proof of State Residency When Attempting To Renew Medicaid Coverage

As part of the process to redetermine Medicaid eligibility, states may require people to submit various types of information. Overall, about three in four (77%) enrollees who tried to renew their Medicaid coverage say they were asked to submit proof of income or financial assets as part of the renewal process and about half (54%) say they were asked to submit proof of residency in their state.

Pre-unwinding enrollees in non-expansion states are much more likely than those in expansion states to say they were asked to submit proof of residency in their state (73% vs. 51%). States are required to first check available data sources to confirm ongoing eligibility. However, if they are unable to obtain information via electronic sources, they may require enrollees to submit documentation confirming income or residency. States may also accept self-attestation of certain information.

Overall, Black and Hispanic adults are much more likely than White adults to say they were asked to submit proof of residency in their state as part of the Medicaid renewal process. Majorities of Black (71%) and Hispanic (60%) enrollees say they were asked to submit proof of state residency, compared to fewer White enrollees (42%) who say the same.

One in Five Pre-Unwinding Enrollees Say They Were Disenrolled from Medicaid at Some Point Since the Beginning of the Unwinding Process

One in five (19%) pre-unwinding enrollees say they lost their Medicaid coverage at some point since April 1, 2023 – even as some have successfully re-enrolled in the program. Being disenrolled was more common among younger enrollees (under the age of 50), and not surprisingly, among those who experienced problems during the renewal process. In Medicaid expansion states, 13% enrollees with a household income under $20,000 – most of whom are likely still eligible for Medicaid coverage – say they were disenrolled at some point since the start of unwinding.

Notably, three in ten (30%) pre-unwinding enrollees say they found out they were disenrolled when they were informed by a doctor, medical provider, or pharmacist.

Disenrollment Led to Increased Health Worries, Skipped Care

Whether or not they were able to re-enroll in Medicaid, disenrollment from Medicaid had a disruptive effect on those who experienced it. Seven in ten (70%) adults who were disenrolled from Medicaid during the unwinding process say that they became uninsured when they lost their Medicaid coverage, while three in ten say they already had another form of health coverage in place.

Losing Medicaid coverage led to worries about their own health. Three in four (75%) of those who became uninsured say that they were at least somewhat worried about their physical health and six in ten (60%) say they were worried about their mental health when they lost their Medicaid coverage. This includes about four in ten who say they were “very worried” about their physical health (43%) or their mental health (37%).

In addition, about one in five (21%) enrollees who took action to renew their Medicaid coverage (13% of total enrollees) say they skipped or delayed getting needed health care services or prescription medications when attempting to renew their coverage. The share who say they skipped or delayed needed health care when attempting to renew their coverage increases to more than half (56%) of those who say they lost their Medicaid coverage at some point since the start of unwinding.

A Quarter of Those Who Were Disenrolled Are Now Uninsured, Costs Top Concerns of Those Who No Longer Have Medicaid Coverage

As the Medicaid unwinding process continues, about half (47%) of those who were disenrolled from Medicaid last year are now currently enrolled in Medicaid coverage. Prior to the pandemic, about 41% of Medicaid enrollees who were disenrolled eventually re-enrolled in coverage. More than a quarter of those who were disenrolled are now insured with a different form of coverage including 16% who have employer-sponsored insurance, 9% who have Medicare, and 8% who have purchased their own insurance through the ACA marketplace. One in four (23%) of those who were disenrolled are currently uninsured.

Overall, a large majority (83%) of enrollees say they currently have Medicaid coverage while 8% say they are now uninsured, and 8% say they no longer have Medicaid coverage, but have some other type of health insurance, including 4% who say they are now covered by employer-sponsored insurance, 2% who say they are now covered by Medicare, and 2% who are now covered by a self-purchased Marketplace plan.

About one in eight Hispanic adults (13%), and one in ten women (10%) and enrollees between the ages of 18 and 49 (10%) say they are now uninsured. The share of pre-unwinding enrollees who are now uninsured increases to 17% among those living in non-expansion states. In expansion states, 6% of pre-unwinding enrollees with household incomes of less than $20,000 – a group that should largely still be eligible for Medicaid – say they are currently uninsured.

Those With Other Forms of Coverage Rate Their Current Coverage Worse Than Medicaid on Out-of-Pocket Costs, Though Many Say New Coverage Is the Same or Better When It Comes to Access

Most enrollees who now have another form of health coverage say their current insurance is “about the same” or in some cases, “better” than Medicaid when it comes to health care access. For example, most rate their current coverage about the same (58%) as Medicaid when it comes to the ability see a doctor or health care provider when they need to, while one in five (20%) say their current coverage is better. Similarly, a plurality (39%) say their current coverage is about the same when it comes to the services covered while about one in four (26%) say their current coverage is better. Yet, some say their access to covered services (34%) and ability to see health providers when needed (22%) are worse with their current coverage than they were with Medicaid.

Not unexpectedly, when it comes to comparing the cost of coverage, majorities of pre-unwinding enrollees who now have another form of insurance are more critical about the costs associated with their current coverage. Two-thirds (67%) of these adults say the out-of-pocket costs of their current coverage are worse compared to Medicaid. Similarly, two in three (65%) say the monthly premiums they pay for their new coverage are worse when compared to Medicaid. The costs associated with Medicaid, including co-pays and premiums, are generally nominal, and connected to a recipient’s income.

Over half of previous Medicaid enrollees who have another form of coverage report difficulty affording monthly premiums and out-of-pocket costs. About six in ten (59%) say it is at least “somewhat difficult” for them to afford the out-of-pocket costs associated with their current coverage – which include co-pays and deductibles. A slight majority (54%) report difficulty affording their monthly premiums.

Costs Are a Barrier to Obtaining Health Insurance for Some Who Lost Medicaid

Among pre-unwinding Medicaid enrollees who are now uninsured (8%), more than half (54%) say that they have not gotten another form of health insurance because of the cost. Additionally, about one-third (36%) say they are still trying to get Medicaid coverage. About one in four (27%) are not aware of other insurance options, which may indicate an information gap on alternative coverage options during their transition from Medicaid. Additionally, about one in five of those currently uninsured say they have been too busy to find alternate health coverage (22%). Many of the uninsured may be unaware that the ACA marketplace offers income-based premium subsidies for those without access to affordable employer coverage.

Many Enrollees With Other Forms of Coverage or Who Are Now Uninsured Cite Concerns Over Paying for Health Care

Enrollees who now have other non-Medicaid coverage are less likely than those who retained their Medicaid coverage to express worry about affording some basic expenses, however they are more likely to say they worry about health care costs and bills. For example, at least three-quarters of those who now have non-Medicaid insurance (76%) or who are now uninsured (78%) say they are worried about affording the cost of health care services, while fewer than half (47%) of those who still have Medicaid express this concern. Large majorities of those who have other coverage (75%) or who are uninsured (79%) are worried about unexpected medical bills, compared to six in ten of those who remain on Medicaid (60%). Those who now have other forms of coverage are about twice as likely as those who still have Medicaid to say they are worried about affording their monthly health insurance premium (50% vs. 26%). (Some enrollees who still have Medicaid also have additional coverage through employers or Medicare, which may have more costly monthly premiums). Additionally, enrollees who are now uninsured (70%) or who have other coverage (50%) are much more likely than those who remain on Medicaid (33%) to say they are worried about affording prescription drugs.

Those Who Were or Still Are on Medicaid Rate It Positively

Overall, a majority of enrollees rate Medicaid positively. About three-quarters (77%) of adults who were enrolled prior to the start of unwinding rate their experience with Medicaid as “excellent” (34%) or “good” (43%). About one in four give Medicaid a negative rating of either “fair” (19%) or “poor” (4%).

Majorities across racial and ethnic groups, including at least three in four Black enrollees (77%), Hispanic enrollees (79%), and White enrollees (79%) rate Medicaid positively. Additionally, ratings are consistently positive across both Medicaid expansion states (79%) and in non-expansion states (71%).

Losing Medicaid seems to be driving some perceptions of the program with more than a third of those who are now uninsured giving Medicaid a negative rating, likely reflecting some frustration with having lost their coverage.

Past KFF research has shown that Medicaid enrollees often have worse self-reported health status and therefore are more likely to be higher users of health care services. It is also well-documented that high health care users are often more critical of their insurance coverage. But overall, Medicaid enrollees give Medicaid positive ratings on most cost and access measures. At least six in ten pre-unwinding enrollees rate their Medicaid insurance as “excellent” or “good” when it comes to the quality of medical providers available to them (70%), the amount they have to pay out-of-pocket to see a doctor (68%), the amount they have to pay to fill a prescription (68%), and the availability of providers covered by Medicaid (62%). Over half (56%) of pre-unwinding enrollees say Medicaid insurance is “excellent” or “good” when it comes to the specialists that are covered. About half (46%) say the same about mental health providers and services that are covered, though about a quarter (26%) say the mental health aspect doesn’t apply to them since they don’t use these services. Across some of the measures asked about, a notable share say the question didn’t apply to them mostly due to them not accessing this type of service.