As Pandemic-Era Policies End, Medicaid Programs Focus on Enrollee Access and Reducing Health Disparities Amid Future Uncertainties: Results from an Annual Medicaid Budget Survey for State Fiscal Years 2024 and 2025
Introduction
Medicaid provides health insurance coverage to more than one in five Americans and accounts for nearly one-fifth of all U.S. health care expenditures. At the end of FY 2024 and heading into FY 2025, states were wrapping up the unwinding of the pandemic-related continuous enrollment provision and focused on addressing other key priorities including reducing long-standing health disparities (often exacerbated by the pandemic), improving access to behavioral health and long-term services and supports (LTSS), addressing enrollee social determinants of health, and implementing broader delivery system and value-based initiatives.
At the start of the pandemic, Congress enacted the Families First Coronavirus Response Act, which included a requirement that Medicaid programs keep people continuously enrolled in Medicaid in exchange for enhanced federal funding. As a result, enrollment in Medicaid and Children’s Health Insurance Program (CHIP) reached record highs, growing to 94 million enrollees, an increase of 23 million or 32% between February 2020 and April 2023. Medicaid enrollment growth along with enhanced subsidies in the Affordable Care Act (ACA) Marketplaces contributed to the lowest ever uninsured rate in 2022 and a stable uninsured rate in 2023.
The 2023 Consolidated Appropriations Act (CAA) ended the continuous enrollment provision on March, 31, 2023 and required states to begin the process of “unwinding” (i.e., resume historically typical eligibility redeterminations and disenroll individuals found to be no longer eligible for Medicaid). The CAA also phased down the enhanced federal matching funds through the end of 2023. Since the unwinding period began, millions of individuals have been disenrolled from Medicaid, but total net Medicaid and CHIP enrollment as of June 2024 remained over 8 million more than enrollment in February 2020, before the pandemic began. Though state unwinding timelines varied, all states except four completed unwinding renewals by August 2024.1 However, net enrollment trends remain uncertain and continue to evolve as states wrap up unwinding, re-enroll eligible individuals who may have lost coverage, process new applications, and, in some cases, expand eligibility.
This report draws upon findings from the 24th annual budget survey of Medicaid officials in all 50 states and the District of Columbia conducted by KFF and Health Management Associates (HMA), in collaboration with the National Association of Medicaid Directors (NAMD). (Previous reports are archived here.) This year’s KFF/HMA Medicaid budget survey was conducted from June through September 2024 via a survey sent to each state Medicaid director in June 2024 followed by a set of focus groups with Medicaid officials in different roles (directors, deputy directors, chief financial officers, and medical directors) from various states. Overall, 50 states responded by October 2024,2 although response rates for specific questions varied. The District of Columbia is counted as a state for the purposes of this report. Given differences in the financing structure of their programs, the U.S. territories were not included in this analysis. The survey instrument is included as an appendix to this report.
This report examines Medicaid policies in place or implemented in FY 2024, policy changes implemented at the beginning of FY 2025, and policy changes for which a definite decision has been made to implement in FY 2025 (which began for most states on July 1, 20243). Policies adopted for the upcoming year are occasionally delayed or not implemented for reasons related to legal, fiscal, administrative, systems, or political considerations, or due to CMS approval delays. Key findings, along with state-by-state tables, are included in the following sections: