Research Report State Variation in Medicaid and CHIP Unwinding for Children and Adults as of November 2023
Analyses of Enrollment Relative to Earlier Projections and Key Policy Choices
Matthew Buettgens, Jameson Carter, Jessica Banthin, Jason Levitis
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Between April 2020 and March 2023, there was record-high Medicaid enrollment growth of more than 20 million people, a result of the continuous coverage requirement passed by Congress under the Families First Coronavirus Relief Act. Congress passed legislation to end this requirement effective March 31, 2023, and allowed states to resume the Medicaid eligibility redetermination process, also known as Medicaid “unwinding.” A December 2022 Urban Institute brief estimated that 14.8 million people on net would lose Medicaid or Children’s Health Insurance Program (CHIP) coverage after all eligibility redeterminations were completed. In this report, we compare net disenrollment (total disenrollment less new enrollment or reenrollment) through November 2023 for our sample of nearly all states with our estimated total disenrollment to assess the extent of the unwinding and its correspondence with several policy choices by individual states.


According to monthly enrollment reports, enrollment in Medicaid and CHIP declined by about 9 million people from April through November 2023. Many observers are concerned that states are moving too fast and that many enrollees could lose coverage for procedural reasons even though they remain eligible. Other observers argue that slowing down the unwinding leaves ineligible people on the rolls at an unnecessary cost to both state and federal budgets. Concern has been particularly high for children, given the potential consequences of coverage gaps and early problems during automatic redetermination processes in 29 state systems that disproportionately impacted children.


Our main findings are the following:

  • Nationwide, aggregate net disenrollment as of November 2023 was at 60.5 percent of projected total disenrollment throughout the unwinding for our sample of nearly all states.
  • Behind the national total, we find tremendous diversity among states: 19 states had net disenrollment of 50 percent or less of our projected total net disenrollment, while eight states had already disenrolled more people than 100 percent of our projected total net disenrollment.
  • The net disenrollment rate was much higher for children than adults nationwide, largely because some states had exceptionally high child net disenrollment. Total net disenrollment among children was 84.2 percent of the expected total, while total net disenrollment among adults was 50.7 percent of our estimates. Seven states had adult net disenrollment greater than 100 percent of expected disenrollment, while 12 states had child net disenrollments that exceeded that threshold. This means current Medicaid enrollment levels in these states are below the historical trend.
  • States that publicized their intention to complete the unwinding in less than 12 months, states that obtained few federal waivers to streamline renewal, and states that prioritized the renewal of those likely to be ineligible all had notably higher overall net disenrollment rates relative to other states. States with any of these three characteristics had net child disenrollment over 120 percent of our projections on average.


For this analysis, we used the most recently available monthly Centers for Medicare & Medicaid Services Medicaid/CHIP enrollment reports through November 2023 to compute net disenrollment and compared these estimates with previous research using the Urban Institute’s Health Insurance Policy Simulation Model to project net disenrollment in Medicaid and CHIP during the unwinding.

Research Areas Health and health care
Tags Medicaid and the Children’s Health Insurance Program 
Policy Centers Health Policy Center
Research Methods Microsimulation modeling