As our nation approaches another sad milestone with nearly 5 million fewer children enrolled in Medicaid, we released a report looking at how states have responded to the challenge of the Medicaid “unwinding” process. With approximately half of the nation’s children enrolled in Medicaid, the stakes are very high for children and the providers who serve them.

Georgetown University CCF has been following the process known as the “Medicaid unwinding” very, very closely. We have focused intensely on how children have fared since the bipartisan Medicaid continuous coverage provision expired on April 1, 2023 . Our report examined state-by-state data for a comprehensive look at the unwinding through the end of 2023. Which states protected children in the process and which states acted hastily to disenroll large shares of children?

Just over four million (4.16m) fewer children were enrolled in Medicaid/CHIP through December 2023 according to the new report. This equates to a 10% national decline in child Medicaid/CHIP enrollment.

Federal researchers estimated that three-quarters of children who are enrolled in Medicaid will – or already have – lost coverage during the unwinding would remain eligible for Medicaid, but lose coverage for procedural or “red tape” reasons. Nationwide, a shockingly high 70% of individuals enrolled in Medicaid have lost coverage for procedural reasons. Procedural losses occur when the renewal process broke down in some way – perhaps the renewal letter got lost in the mail or a family had trouble with the paperwork, the state’s computer system is not checking eligibility correctly or the notices a state sends are too complicated to understand — especially for families for whom English may not be the parent’s first language.

Procedural denials are nothing new in Medicaid, but given the unique scale of this process, which impacts half of the children in the United States, the situation demands the political commitment and resources to make it work well.

And in states that have not picked up the Affordable Care Act Medicaid expansion to low-income adults, children are the largest group of Medicaid enrollees – so by definition in non-expansion states like Texas, Florida and Georgia, children and very poor parents – mostly women – are at the heart of who is losing Medicaid.

States had many choices about how quickly they moved to remove children from Medicaid enrollment and how they went about the process. To look at their performance we used administrative data that states report to the federal government to see where child enrollment declined most quickly in 2023.

So, what did we find with respect to state performance? Stark differences have emerged in state results. Most states have Medicaid declines but some have put a premium on moving slowly and carefully and have minimized these losses. In fact, seven states saw very little change in child Medicaid/CHIP enrollment (CT, DC, HI, ME, NC, OR, RI). Other states rushed to disenroll children from Medicaid, even though many of them likely remain eligible, with little regard to smooth transitions to a new coverage source. And bear in mind that no state was done with the unwinding process when this data was calculated.

• Texas, Florida, Georgia, and California saw the largest number declines in Medicaid/CHIP child enrollment, accounting for half of the total national decline. Texas alone accounted for more than one million of the total decline in children enrolled in Medicaid/CHIP followed by Florida (nearly 600,000), together these two states account for 38% of child Medicaid declines nationwide
• South Dakota, Montana, and Utah saw the largest percentage declines in their child Medicaid/CHIP population with 25% fewer children enrolled in Medicaid/CHIP than prior to the initiation of the unwinding process with Texas, Idaho, Arkansas and New Hampshire right behind. All of these states have declines of 20% or more.
• Eight states (MT, ID, SD, AR, NH, UT, AK, CO) disenrolled so many children in 2023 that they had fewer children enrolled at the end of the year than prior to the pandemic – this is a troubling finding given that the world was not a perfect place prior to the pandemic so this is not the yardstick states should be using. Montana’s child enrollment is already 15% lower than pre-pandemic – a very concerning distinction.

We are not able to break down this data by race and ethnicity, but it is important to note that in the past, children in families of color – Black and Latino families – have been more likely to experience coverage churn or gaps in coverage which is troubling. Additionally, several states with large numbers of American Indian children also have high rates of child Medicaid loss.

• On the bright side, 11 states and DC are in the process of pursuing a new policy to remake their eligibility systems and extend periods of continuous coverage to children at various ages with an emphasis on the critical early childhood development period of 0-6. This is a significant breakthrough to avoid red tape losses at renewal and gaps in coverage in the future.
• Two states (Kentucky and North Carolina) took an e14 waiver flexibility offered by the federal government and postponed their child renewals for 12 months.

How many of these children are uninsured?

We don’t know how many of these children are now uninsured or experienced a gap in coverage, but there are reasons to worry. Children may lose coverage and become uninsured during this unwinding process in one of two ways – either because they have become ineligible for Medicaid and are unable to successfully transition to a new source of affordable health coverage – or because they lose Medicaid for procedural reasons as described above.

There are a few places they could go for coverage if they are not eligible for Medicaid. Some have undoubtedly moved to employer-sponsored insurance and we don’t have data on that. But bear in mind that affordable dependent coverage (as opposed to coverage for the worker themselves) is hard to come by for low-wage workers. So this is a different question for children than it is for adults.

According to our analysis, new enrollment of children in the marketplaces and separate CHIP programs appears to be offsetting only a modest share of the net decline in total child Medicaid/CHIP enrollment. Growth in separate CHIP programs only accounts for 10% of the child Medicaid loss and enrollment in the federal and state Marketplaces, which have seen record growth, only account for 14% of the child Medicaid loss.

States with high numbers or rates of Medicaid enrollment declines should make efforts to reach out to families with trusted community-based partners to re-enroll eligible children and consider systems reform to make the process go more smoothly – often by automating the process as much as possible.

Any gap in coverage is a problem for families — and of course, the providers who see them. Being uninsured is bad for a child’s health and educational outcomes and exposes families to large medical bills that they cannot afford. Because states run Medicaid and CHIP, the nation’s Governors, and to a lesser degree their legislators, are ultimately responsible for how millions of children are faring during this process.

Texas pediatrician Dr. Kimberly Avila Edwards explained that this new report reflects the reality pediatricians across the country are experiencing firsthand as state leaders make policy decisions that impact their patient’s ability to maintain health coverage. “A child’s ZIP code should not determine whether they have access to care, but that is exactly what is happening to the millions of kids losing their vital coverage due to procedural issues like delayed paperwork and lost mail,” she said. “For our children, for our families, and for our communities: this has to stop.”

Well said Dr. Edwards.