Since the beginning of the COVID-19 pandemic, states have kept people continuously enrolled in Medicaid in exchange for enhanced federal funding. Largely due to these changes, KFF estimates that Medicaid enrollment will increase to 95 million, an increase of over 30% from enrollment in February 2020. The Medicaid continuous enrollment provision will end on March 31, 2023, and states will then begin disenrolling people who are no longer eligible or who are unable to complete the renewal process even if they remain eligible. We have estimated that Medicaid enrollment could drop by 5 to 14 million people over the coming year as states unwind continuous enrollment. As states prepare for the end of the continuous enrollment provision, a survey from December 2022 found that 62 percent of adults in Medicaid-enrolled families were not aware of upcoming renewals.

To help inform the implementation of the unwinding of the continuous enrollment provision, we conducted 5 virtual focus groups in late January and early February, shortly after federal legislation set an end date for the continuous enrollment provision. Groups included 39 adults who self-identified as having Medicaid coverage for themselves or had children enrolled in Medicaid across 12 states to learn about their experiences with Medicaid, awareness of the end of the continuous enrollment provision, experiences applying for and renewing coverage, and accessing care. We also explored the challenges they might face if they were to lose Medicaid coverage. Participants included a mix of adults by gender, race/ethnicity, age, length of time enrolled on Medicaid, and work and family status. Two groups were conducted in Spanish. KFF worked with PerryUndem Research/Communication to conduct the focus groups. Individuals who were able to participate in our groups needed to know that they were enrolled in Medicaid coverage, have two hours of time, a quiet space, a computer, and internet. These characteristics alone may not fully represent many Medicaid enrollees, so findings may not be generalizable to the entire Medicaid population. See Appendix Table 1 for demographic details about the participants. Key findings from our groups include the following:

• Many participants experienced worsening health and financial stability during the pandemic, but Medicaid was important in helping them access needed health care that was affordable.
• Awareness that Medicaid coverage had been protected during the pandemic was limited and most were not aware that disenrollments could start in April.
• All said that they would try to renew Medicaid coverage and participants said they want to hear about what to expect through multiple communication modalities and from different sources to ensure they would not miss an opportunity to renew coverage.
• Many participants were worried about losing Medicaid coverage because it would have negative implications for their health and finances. While some worried that they may no longer be eligible due to a change in income, many individuals worried about losing coverage even if their economic circumstance did not change. Under normal operations, people who are no longer eligible are disenrolled from Medicaid; however, a large number of people could be disenrolled in the coming year because of the continuous enrollment provision that has been in effect. Most said they would look for other coverage if they were no longer eligible for Medicaid, but expressed concerns that other coverage would not be affordable.

Key Themes

Experience with Medicaid and the Pandemic

Participants said Medicaid enables them to access health care services and medications for themselves and their children. Those with serious chronic health conditions and other health and mental health needs said having Medicaid means they can get medications and regular doctor’s visits to manage their conditions. In some cases, they say Medicaid coverage has meant access to life-saving treatments, surgeries and therapy services. While some participants noted problems accessing certain services, including dental care, most said Medicaid covers the services they need. Parents in the groups especially valued being able to access preventive and primary care, treatment for more serious conditions, and mental and behavioral health services for their children. A common theme expressed by participants was the peace of mind from knowing that they can get the care they need without having to worry about how they will pay for it. Several participants described getting Medicaid when they became pregnant and the importance of the coverage during their pregnancies and once their children were born.

Because I have a chronic disease, which is diabetes, and I have to go [to the doctor] every six months. Sometimes, with regular insurance, you have to pay a copay, and now, Medicaid pays for it. I take advantage of that. – 56-year-old, Hispanic male (Spanish-speaking), Arizona

I mean [Medi-Cal] does cover a lot, you know. I have to take a lot of medication now so, all my medications are covered, all my doctor visits. Before when I was uninsured, I didn’t even bother going to the doctor. So, once I went, I found out all these things that were wrong with me. So, it definitely helped. – 32-year-old, Asian male, California

It’s for my kids, obviously, but my son has asthma. It’s really important to me that he has insurance. He’s had two asthma attacks, where I’ve had to take him to urgent care, or to the emergency room at the hospital. I didn’t have to worry about how I was going to pay for that visit or all the services that they were going to provide. – 50-year-old, Hispanic female, Tennessee

In recent years, many participants had ongoing health and financial challenges, some of which were exacerbated during the pandemic. The pandemic was hard for many participants. Several lost jobs early in the pandemic and while some managed to find other full-time work, others were cobbling together part-time gig work or still not working. Many got sick with COVID-19; some said they had lingering side effects and one person reported developing long-COVID. Recent inflation pressures were adding to financial concerns for some participants. Several said buying food and paying for normal expenses has gotten harder and some were forced to move because they could no longer afford their rent. These health and financial challenges made affordable coverage through Medicaid even more valued than prior to the pandemic for a number of enrollees.

I’m customer service, I work with the general public and a lot of people in San Diego do take public transportation, so I have to be out there and on top of that, I ended up getting COVID. So that kind of screwed everything. I have COVID long haul now, so now my hours are all depending on how my body feels…sometimes I get 40 hours, sometimes I get 15, 20 hours. I don’t have set hours anymore because now with COVID it just, my income goes up and down. – 51-year-old, Hispanic male, California

Gig work just means that it’s penny to penny, paycheck to paycheck if you will. And like somebody mentioned earlier, you know, one week you’ve got 40 hours of work, the next week you have 20… can’t plan well. And so having the security of the Medicaid is everything. – 39-year-old, White female, Oregon

I don’t know, I have gotten into therapy over the last year and a half or so and I don’t know that I would be doing as well overall if I hadn’t and I wouldn’t be able to afford therapy or all the handful of medications I take every morning, if not for this [Medicaid]…- 42-year-old, White male, Michigan

Knowledge of the Continuous Enrollment Provision

Among focus group participants, awareness that Medicaid coverage had been protected during the pandemic was limited. Some states seem to have done a better job of communicating that coverage was being continued because of the pandemic, including Arizona, California, Colorado, and Texas, where some participants reported receiving notices saying their coverage had been renewed because of the pandemic. At the same time, other participants in these states and in other states claimed not to know about the provision, and most were unaware disenrollments would resume soon.

[I learned I had been automatically renewed] by a letter that I received. It was around November, saying that they renewed me again without me doing anything because of COVID, based on what they said in the letter. – 56-year-old, Hispanic male (Spanish-speaking), Arizona

It was in my portal, and they also sent me a letter in the mail to let me know that my kids had another year of Medicaid due to COVID-19. – 35-year-old, Hispanic female (Spanish-speaking), Texas

I was not informed of that by the State of Michigan. Seems like they, seems like it would, that should be something that could come out in one of the many letters they send. –  42-year-old, White male, Michigan

I think it’s [continuous enrollment] a good thing just because the cost of insurance. I mean if you have regular insurance nowadays you have the deductibles, you have, there’s still a lot of out-of-pocket costs and everything costs so much now that pharmaceuticals are going sky high. –  63-year-old, Black female, Arizona

Although most participants did not know that disenrollments in their states could begin as early as April 1, 2023, all said they would seek to renew their coverage although some were worried that they are at risk of losing coverage, especially as inflation concerns and health issues persist. All participants wanted to keep their coverage and planned to take steps to renew. While most participants had not heard that their states would be resuming disenrollments soon, some reported receiving a notice with this information or seeing it in their online account. Several participants who had changed jobs, gotten promotions, or increased their hours were worried they might lose coverage. Some were worried about losing coverage even if nothing changed in their economic circumstances. Many said they would seek help in trying to retain coverage if needed, from local assistance organizations, the local Medicaid/social service office, or from friends and family.

It’s kind of caught me off guard a little bit. I haven’t received any notice about [the end of continuous enrollment] so, uh, at least now I know like, I need to get my documents together. I haven’t heard about it and I haven’t received any notification from Medicaid at all. – 36-year-old, White female, Ohio

Every time I go to my account with my information, everything is written there. Before you log in, the whole message is there. How after March 31st, you’ll need to reapply or renew your benefits – 31-year-old, Hispanic female, Texas

The only reason I’ve been able to stay on Medicaid is because of this [continuous enrollment provision]. And I think I make like a thousand dollars over the limit for being qualified, but like I said, I’m paycheck-to-paycheck regardless, so I’m actually really concerned about not qualifying once this happens. – 32-year-old, White female, Oregon

I mean honestly my concern is just not totally understanding exactly what will disqualify me, so it would be nice to know more about that…nothing has really changed, but I still don’t trust it. – 39-year-old, White female, Oregon

Communicating with Medicaid

Most participants said they choose to receive communication from the Medicaid agency in multiple ways, including mail, email, text, and through their online accounts, so they do not miss important information about their coverage. Regardless of the preferred method for receiving information, most participants expressed concern about not wanting to miss information from Medicaid. Some participants said they prefer email, but others said their inbox was so full they worried important information would get lost. Participants in some states said they receive text messages and reminders; however, rules about text messaging vary by state. Similarly, participants in some states said they could receive notices through their online accounts but not everyone said they had that option. Even if participants preferred receiving notices and information through their online accounts, they also wanted to receive renewal reminders through other modes in case they forgot to check their accounts.

I have all of that [email, text, mail communications] because you just have to be aware now because…they don’t care if you didn’t get it. If you missed it, that’s it, you’re done you got to redo it all over again. – 34-year-old, Hispanic female, Arizona

For me, [communication] by email [is best]. But at the same time, it makes me wonder if maybe I might not get some mail that’s important…You get it once or twice a year, but it’s crucial information, and I wouldn’t want to not get that information. – 45-year-old, Hispanic male (Spanish-speaking), California

While many participants said Medicaid notices are clear and understandable, others found communications confusing, and some said they do not read the whole document. Most participants said they always read the Medicaid notices because they generally contain important information about their coverage. However, some participants admitted that sometimes they do not read all of the notices, in some cases because they felt the information was duplicative and unnecessary. Most participants said the notices clearly described any actions they needed to take and provided deadlines for renewing coverage or scheduling appointments. Some participants said they felt like they got conflicting information through their notices and providers or caseworkers and had to call the agency to help sort things out. Spanish speaking participants said they were able to get notices in Spanish, though some said they preferred to get the notices in English because some of the terminology used in the Spanish translations was unfamiliar to them.

Yeah, the [Medicaid notices are] clear. When you apply, they give you the information in whatever language you want to receive them in, so for me, they’re clear. – 39-year-old, Hispanic female (Spanish-speaking), Colorado

I have received some [notices] in the mail and the envelopes is bigger than a normal envelope and in black and bold letters it says your Texas Benefits. So, I normally open those right away. And I’ve never had any issues understanding what directions, you know, they’re trying to give me, or if I need to do anything. Because usually if I have to send something back, they’ll send me an e-mail with the link. – 50-year-old, Hispanic female, Texas

Sometimes you get the notices you’re told on the phone, for example, you’re approved everything’s done, you don’t need anything, we’ve got everything we need. Then you get a notice in the mail that oh, I need all of these things that they just told you didn’t need. So now you’re confused…it is like kind of in circles…And then you call, you’ve got to wait a billion hours on the phone to get somebody through, then they don’t know what you’re talking about. – 34-year-old, Hispanic female, Arizona

As far as Spanish, I think they use a term very rigidly, not how someone would normally speak it or understand it. That’s why people who understand it easily in English maybe won’t understand it [in Spanish]. – 35-year-old, Hispanic male (Spanish-speaking), Missouri

Participants had mixed experiences with calling the Medicaid agency. Participants may call the Medicaid agency to discuss issues with current coverage or about renewals. Some participants reported very long wait times calling Medicaid while others said they were only on hold for just a few minutes, and a participant in Arizona said wait times had gotten better recently. Those who faced long wait times described the calls as stressful. Prior to the pandemic, when calls were related to renewal of coverage participants said they were nearly always able to get this issue resolved, although sometimes the calls took several hours. However, participants seemed to have less success getting questions about participating providers or how to access certain services answered.

So, I was on hold with the Ohio Medicaid office for four hours trying to get verified for mine and my husband’s Medicaid. Yeah it took me four hours to get through to talk to someone. – 36-year-old, White female, Ohio

Despite broad-based efforts in many states to conduct outreach, most participants said they had not been asked by their Medicaid agency to update their contact information to prepare for the unwinding of the continuous enrollment provision. While some participants said they had recently updated their contact information after moving, only a handful said they had received a message from their state asking them to do so. Among those who had updated their information recently, they described the process as straightforward. Some updated their information through their online account, while others called the Medicaid agency to provide the information. They also noted the importance of updating their contact information with their managed care organization (MCO) or primary care physician, which they did as a separate step.

In the letters that they send me, reminder letters, they always remind me when I make a change. The same when you call on the phone, they ask if you’ve changed your address, phone number, or email. Because those are the three ways that they contact you. If there’s any changes, you can do it over the phone, and they’ll change it for you right away. – 50-year-old, Hispanic female (Spanish-speaking), Tennessee

It was fairly easy [to update contact information]. I just went through the app and did it and then I had to go through all of the PCP… or I had to go through PCP and everybody else and updated it. It took a minute, but I got it done. – 35-year-old, Hispanic female, Michigan

When it comes to communications about the unwinding of the continuous enrollment provision, participants said they want to hear about what to expect through multiple communication modalities and from different sources. Given the significance of the potential impending changes to their coverage, participants wanted states to communicate directly about the changes in many ways, using mail, email, text, and though their online accounts—the same ways in which participants receive regular notices. Because these changes are so significant, several also said they would like a personal phone call telling them what to expect. When asked specifically about using text messages, some people said they thought it was a good way to communicate, while others worried about fraud and that some people might ignore the message. Participants stressed the importance of making sure people understand the urgency of the information. They wanted the information to clearly indicate what actions people need to take and when and they wanted it early enough that they would have time to take the necessary steps to renew their coverage. Beyond communications from the Medicaid agency, participants also wanted to hear information from their doctors, from the media, and through social media. Some mentioned advertising on billboards, buses, and other places where people would likely see the information.

I think that besides mail, e-mail also, but bold, the March 31st should be in bold, I mean it should be, something that really stands out to let you know, this isn’t just the standard mail that you get, this is really serious or important to pay attention to it. – 63-year-old, Black female, Arizona

A text message, if it’s something more informative in general for all people, I think a text message would be the easiest, and in a way that most or almost all people would learn about it. – 39-year-old, Hispanic female (Spanish-speaking), Colorado

I don’t think text message because it’s a really public thing. As opposed to email, which is something a little more private. The same thing with social media. I think that’s a bad idea. – 20-year-old, Hispanic female, (Spanish-speaking), New Jersey

I would say get it to the doctors, the PCPs themselves and have a general service message from them saying, hey, if you have any customers that are under these government funded programs… to go ahead and tell them specifically. – 39-year-old, White male, Arizona

Applying for and Renewing Medicaid

Many participants had applied for Medicaid online and described the process as easy. For most participants, the online application was easy to complete and did not take a long time. But some, particularly those who were applying based on disability, had to provide what they described as a lot of paperwork and experienced delays in having coverage approved. Many states have integrated the Medicaid application with other social service benefits, such as SNAP and TANF. A couple of participants said they were able to apply for Medicaid and SNAP at the same time and one participant said she got Medicaid when she applied for unemployment benefits during the pandemic.

I have been enrolled since June of this past year, when I was laid off from a job. But I recall the process being fairly, fairly easy actually to get coverage. – 29-year-old, Hispanic male, Oregon

I applied when I found out I was pregnant last year around May, and the process was very easy, I applied online and they contacted me pretty quickly and they sent out everything. – 21-year-old, Black female, Michigan

It’s never been hard for me to fill out an application or anything because the process is easy. Now, everything is online. – 50-year-old, Hispanic female, Tennessee

The process for applying for both me and my husband was extreme. Like they wanted so much paperwork and it took us about two months to finally get qualified for it. – 36-year-old, White female, Ohio

Participants described a range of experiences renewing their Medicaid coverage, but many said the process was simple, particularly during the past few years. While states have not been able to disenroll people from Medicaid, many states have been continuing to process renewals during the continuous enrollment period using ex parte (verifying eligibility through data matches) and through more traditional renewal processes. Many participants said their coverage had been auto-renewed—they described receiving a notice from the state saying their coverage had been renewed for another 12 months—while others described receiving a renewal packet or form in the mail or a notice to complete the renewal form online to maintain their coverage. Still others reported having to submit documentation to the state to confirm continued eligibility. Variation in participant experiences could be due to different renewal policies across states but could also result from different requirements depending on a person’s eligibility pathway. For participants who had to take steps to complete the renewal process, most said they received notices in advance of their renewal date giving them enough time to complete the forms. At least one person noted that if they didn’t respond to the initial notice, the state would usually follow up within another notice or renewal packet. Some who have had Medicaid for a longer time said the process to renew coverage has gotten easier over time.

Every year they sent me something before to sign, and it stated that for renewal, we just want you to go over the details and make sure nothing changed, or if something changed write it down and they have me just sign on paper. And then a couple years after that I started just getting auto renewal notices where they just sent you a piece of mail saying, oh you’ve been renewed and your MediCal is active through the next year. – 32-year-old, Asian male, California

[Medicaid] sent me the form at the beginning of December, and they give you a month. It said, “You have to fill out this form if there have been changes in your household.” I filled out the form, and it gave a deadline. I put the name and everything, and I sent it back. – 39-year-old, Hispanic female (Spanish-speaking), Colorado

When I had Medicaid for the first time…you had to go there, physically, to the office once a year, turn in all your paperwork, and not be missing anything…Recently, for me, it’s been a drastic change because everything is online…I find it super easy, compared to how it was in the past. – 46-year-old, Hispanic male (Spanish speaking), Florida

In managing renewals pre-pandemic, some participants shared that there was a time when they did not receive the renewal packets or notices sent through the mail and either lost coverage for a period of time or nearly lost coverage before renewing. In some cases, participants knew their coverage was about to lapse and contacted their case worker or called the Medicaid agency to complete the renewal over the phone or to request that the renewal information be resent. Other participants said they did not realize their coverage had been terminated until they went to the doctor’s office or hospital. Although participants in these groups did not experience adverse health effects during the gap in coverage, they described feeling stressed and anxious while they tried to get their coverage reinstated.

They’re supposed to send you the renewal packet at least one month in advance to give you time to fill all that out…Unfortunately, the packet never came through, I had to request a new packet, I missed my window. I ended up almost losing my health insurance until I asked my caseworker who…got me the renewal packet, a different one, and the new appointment date and requested an emergency appointment to renew, because just lapsing even a couple of days without insurance can be scary. – 51-year-old, Hispanic male, California

Risks and Challenges Tied to Potentially Losing Medicaid

If they no longer qualified for Medicaid, participants said they would look for coverage through the Marketplaces or possibly from their employer, but affordability was an overriding concern. Most were aware of the health insurance Marketplaces and said they would search for coverage there. Awareness of how to apply for coverage through the Marketplace was fairly high; however, many who previously had Marketplace coverage recounted having difficulty affording premiums and deductibles, even when they had more stable employment. Participants may not have been aware that they might be eligible for zero premium subsidies in the Marketplace since those enhanced subsidies became available in 2021 after many participants had already gained Medicaid coverage. Some said they could potentially obtain insurance through an employer, but worried premiums would not be affordable. Several said they would become uninsured, and some parents said they would forego coverage for themselves but would make sure they could get other coverage for their children. All participants expressed concern over the disruption that losing Medicaid would cause. Even if they could find affordable insurance, they worried about having to find new doctors, particularly for their children.

Yeah, I’d go [to the Marketplace] there to see what plan, and if the price would work for me each month, whether I can afford it. – 56-year-old, Hispanic male (Spanish-speaking), Arizona

I might just have to go through my job’s insurance program they have [if I lose Medicaid]. It’s super expensive but I probably wouldn’t even get insurance for myself. I would just get it for my kids. I just worry about my kids first. – 37-year-old, Hispanic male, Texas

I don’t think [there are other options]. I think when you lose Medicaid, there won’t be anything similar. I think there would be some type of coverage, but it would definitely be at a cost and not with the same coverage as Medicaid. – 39-year-old, Hispanic female (Spanish-speaking), Colorado

I feel like with the cost of everything going up, we’re just breaking even with paying rent and buying groceries. If we were to lose the Medicaid coverage and have to go back to the healthcare Marketplace and have to pay for medical needs, maybe we’ll cover our rent but we’re not going to be able to buy the same groceries. We’re going to have to stretch everything out. We’re not going to have a lot of personal money. It would definitely affect us. – 36-year-old, White female, Ohio

I’d have to go back to what I did before Medicaid. [Being uninsured] is difficult because me and everybody else go to the same free place to get help. So, there’s a long waiting list to get resources and things like that. You’re not guaranteed anything. At least with Medicaid you’re guaranteed you can get medical help. – 60-year-old, White female, Mississippi

Losing Medicaid would pose significant challenges for participants that they said would affect their health as well as their finances. Many participants are managing serious health issues for themselves, their spouses, or their children and losing Medicaid coverage would disrupt their access to care and ability to manage their conditions. They used terms like “terrifying” and “devastating” to describe how they would feel if they no longer had Medicaid. Participants also noted that losing coverage right now, with inflation still relatively high, would create additional financial burdens as they are already struggling to pay current expenses and would have a hard time affording new costs for health insurance. While some worried that they may no longer be eligible due to a change in income, many individuals worried about losing coverage even if their economic circumstance did not change as disenrollments resume for all enrollees over the next 12 to 14 months.

I think it’d affect [me] in every way. Mentally because, obviously, losing a low-cost service and paying for something as costly as private insurance would affect you emotionally, financially. It’s really important right now to have that type of service like Medicaid. – 34-year-old, Hispanic male, Missouri

My baby has to be constantly going in for her checkups. She’s a little baby that’s seen every two months for her shots and everything. I worry because, if she didn’t have Medicaid, maybe I could refrain from going to the doctor. But her shots are a must, so just thinking that she won’t have insurance is something that worries me. – 39-year-old, Hispanic female (Spanish-speaking), Colorado

If it wasn’t for Medicaid, I wouldn’t be able to get the medication I need to function…I mean just to be able to get out of bed and spend time with family, be able to leave the house, I mean it is so important. And I’m scared for all these people because if they lose their Medicaid nine times out of ten, they’re going to be out there without insurance. – 51-year-old, Hispanic female, Texas

[When] my daughter was young we did not have insurance at all. I was a waitress and a single mom, and it was terrifying that I knew every time she got sick, I didn’t have money to take her to the doctor, so I just had to take her into the ER and just get a bill that I knew was going to go to collections because I couldn’t pay it….To being able to be on Medicaid where it’s like okay, you’re sick you need to go to the doctor, let’s go. It goes from this feeling of being like a burden on society and not feeling like you deserve even medical care, to feeling like, ‘Oh I’m a valid human being who I deserve to be able to receive care in this country that we’re in.’– 44-year-old, Black female, Oregon

He [her son] has surgery coming up, but then he also sees a behavioralist, he has childhood anxiety and some other things going on that we have been seeing her for a year, but we’re just really starting to dig in and get things figured out. So, he would lose all of that I feel like because even if I got something through the Marketplace, I don’t know that I would be able to afford to pay copays for all of his visits, because those would add up too. So, yeah it’s just terrifying. It would be devastating. – 39-year-old, White female, Oregon

Looking Ahead

After a three-year pause, states will resume Medicaid disenrollments beginning April 1. All current Medicaid enrollees will undergo a redetermination over the next 12 to 14 months, and unlike during the past three years, enrollees could be disenrolled if they are no longer eligible or if they do not complete the renewal process. While there are federal rules and guidelines about enrollment and renewal processes, how Medicaid enrollees will be affected will vary across states because of differences in renewal polices, outreach and communication strategies, and in the capacity of staff to handle the volume of renewals. State policy choices and how those policies are implemented will be important factors in how many still eligible enrollees are able to retain Medicaid or transition to other sources of coverage if they are not still eligible for Medicaid.

The lack of awareness that Medicaid coverage had been protected during the pandemic and that disenrollments could start in April suggests enhanced communication efforts from states, providers, and community-based organizations using multiple modes may be important. While participants in our focus groups were generally aware of the need to renew their coverage and intended to act in response to a renewal notice, continued state efforts to increase ex parte renewal (automatic renewals using available data) rates and to simplify the process when individuals need to take action to renew their coverage can help promote continuity of coverage for those who remain eligible for Medicaid. States can also adopt strategies to help those who are no longer eligible for Medicaid transition to other coverage options. However, some states may be concerned about the administrative resources required, as well as the costs associated with continued elevated Medicaid enrollment.

Although knowledge among participants about the availability of Marketplace coverage was high, concerns about the affordability of that coverage may prevent people from exploring their options, even though enhanced subsidies have made ACA coverage more affordable. Facilitating account transfers to the Marketplace for people whose Medicaid coverage is terminated and providing information on the availability of enhanced Marketplace subsidies could help increase the number of people who enroll in Marketplace coverage and avoid becoming uninsured.

Appendix

Access to medication abortion has emerged as a central issue following the Dobbs decision overturning Roe v. Wade. There is ongoing litigation in four federal cases about the FDA’s approval and regulation of mifepristone, one of the two drugs used in medication abortion. Mifepristone, approved by the FDA in 2000, has a long record of safety and effectiveness and has been used by more than 5 million people in the United States.

In the most watched case, Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration, the court could rule to invalidate the FDAs 23-year-old approval of mifepristone or potentially limit the distribution of this drug for abortion, even in states where abortion remains legal. The ruling could also limit the availability of misoprostol, the other drug used in the medication abortion regimen. While these cases focus on abortion, the outcome of the litigation could have broader impact on the FDA’s future authority to regulate a wide range of other drugs.

In advance of the decision, we’re sharing key KFF resources that explain the medication abortion landscape related to what’s at stake and how women could be affected.

The Availability and Use of Medication Abortion 

Examine medication abortion, how it is used and regulated, the role of the drug in self-managed abortions, and an analysis of the intersection of federal and state regulations affecting its provision and coverage.

Key Facts on Abortion in the United States

Answer key questions about abortion in the United States.

State Health Facts

Get up-to-date and easy-to-use health data for all 50 states, the District of Columbia, and the United States. The Women’s Health category includes indicators for abortion.

State Profiles for Women’s Health

Explore the latest national and state-specific data and policies on women’s health, including abortion policies.

KFF Health Tracking Poll: Early 2023 Update On Public Awareness On Abortion and Emergency Contraception

Study the results of our February KFF Health Tracking Poll, which found widespread public confusion about the medication abortion pill and whether abortion is legal at the state level.

Abortion Bans May Limit Essential Medications for Women with Chronic Conditions

Explore an analysis about the use of methotrexate and misoprostol; the majority of those who use these drugs are women who are not pregnant but have diagnoses for other chronic conditions and rely on these medications to manage their health.

Abortion in the U.S. Dashboard

Review a variety of resources about abortion in the United Sates and track state abortion policies and litigation following the overturning of Roe v. Wade. 

Trust in public health officials declined over the course of the pandemic, particularly among Republicans. Over the course of the pandemic, KFF polling has found a decline in trust of public health officials – most notably among Republicans. In 2022, majorities of Democrats continued to say they have at least a fair amount of trust in the CDC, the FDA, and Dr. Fauci, while less than half of Republicans had the same level of trust in public officials as they did at the beginning of the pandemic.

Confusion and belief in misinformation about COVID-19 is common. Misinformation about health care topics is nothing new, but social media, the polarization of news sources, and the pace of scientific development on COVID-19 all contributed to an environment that made it easier than ever for misinformation and deliberate disinformation to spread. In late 2021, nearly eight in ten adults said they had heard at least one of eight different false statements about COVID-19 and that they believed it to be true or were unsure if it was true or false. Unvaccinated adults were more likely to report believing COVID misinformation than those who are vaccinated.

Early gaps in COVID-19 vaccination rates between Black, Hispanic, and White adults were largely eliminated by the end of 2021. When COVID-19 vaccines first became publicly available in early 2021, Black and Hispanic adults were less likely than White adults to report being vaccinated. This gap reflected both difference in vaccine access, such as not having paid time off work to get vaccinated or not having a trusted place to get the vaccine, as well as concerns and questions about vaccine safety and side effects. Over time, as public health officials and community groups worked to provide access and offer answers to people’s questions, this gap narrowed and eventually closed. Recent surveys find that the share of Black and Hispanic adults who report being vaccinated is roughly equal to the share among White adults. In fact, the share of White adults who say they will “definitely not” get vaccinated has been higher than the shares among Black and Hispanic adults in most recent polls.

Partisanship played a strong role in self-reported public health behaviors. Since the beginning of the pandemic, KFF COVID-19 Vaccine Monitor surveys have found a strong relationship between partisanship and people’s willingness to take preventive actions to protect themselves and others from COVID-19. Democrats have been consistently more likely than Republicans to report wearing masks, social distancing, and getting vaccinated for COVID-19. Immunocompromised people, regardless of partisanship, are also among the groups most likely to report taking precautions.

The COVID-19 pandemic has had broad impacts beyond health. The pandemic has taken a heavy toll on adults and children over the last three years. Whether it comes to their education, work, finances, mental or physical health, many – regardless of race, ethnicity and income – have reported feeling the negative effects of the pandemic. Parents are particularly likely to say their children have been negatively affected, with more than six in ten saying the pandemic has had a negative effect on their children’s education and nearly as many saying the same about their children’s mental health. About half of all adults say that the pandemic has had a negative effect on their own mental health, while four in ten say the same about their physical health and their financial situation.

As we pass the three-year mark since the World Health Organization characterized the COVID-19 pandemic on March 11, 2020, data from the U.S. show that cases and deaths have remained relatively low through the second half of 2022, over 8 in 10 people (81%) had received at least one COVID-19 vaccination dose as of February 23, 2023, while only 17% of people ages five and older had received an updated bivalent booster dose. Over the course of the pandemic, racial disparities in cases and deaths have widened during variant surges and narrowed when cases and deaths fall. However, overall, Black, Hispanic, and American Indian and Alaska Native (AIAN) people have borne the heaviest health impacts of the pandemic, particularly when adjusting data to account for differences in age by race and ethnicity. While Black and Hispanic people were less likely than their White counterparts to receive a vaccine during the initial phases of the vaccination rollout, the disparities in the share that have received at least one COVID-19 vaccination dose have narrowed over time and reversed for Hispanic people. Despite this progress, a vaccination gap persists for Black people and Black and Hispanic people are about half as likely as their White counterparts to have received an updated bivalent booster dose.

This data note presents an update on the status of COVID-19 cases and deaths by race and ethnicity as of December 2022 and vaccinations by race/ethnicity as of February 2023, based on federal data reported by the Centers for Disease Control and Prevention (CDC).

What is the status of COVID-19 cases and deaths by race/ethnicity?

Racial disparities in COVID-19 cases and deaths have widened and narrowed over the course of the pandemic, but when data are adjusted to account for differences in age by race/ethnicity, they show that AIAN, Black, and Hispanic people have had higher rates of infection and death than White people over most of the course of the pandemic. 

Early in the pandemic, there were large racial disparities in COVID-19 cases. Disparities narrowed when overall infection rates fell. However, during the surge associated with the Omicron variant in Winter 2022, disparities in cases once again widened with Hispanic (4,404.9 per 100,000), AIAN (4,148.6 per 100,000), Black (3,029.4 per 100,000) people having higher age-adjusted infection rates than Asian (2,873.4 per 100,000) and White people (2,826.4 per 100,000) as of January 2022 (Figure 1). Following that surge, infection rates fell in Spring 2022 and disparities once again narrowed. During Summer 2022, there was a slight rise in infection rates with higher age-adjusted infection rates for Hispanic, AIAN, Black, and Asian people compared to White people. Between Fall/Winter 2022, infection rates fell across groups, but as of December 2022, the age-adjusted COVID-19 infection rates were highest for Hispanic people (488 per 100,000) and AIAN people (440 per 100,000). White and Asian people had the lowest infection rates at 313 per 100,000 and 329 per 100,000, respectively.

While death rates for most groups of color were substantially higher compared with White people early in the pandemic, since late Summer 2020, there have been some periods when death rates for White people have been higher than or similar to some groups of color. However, age-adjusted data show that AIAN, Black, and Hispanic people have had higher rates of death compared with White people over most of the pandemic and particularly during surges. For example, as of January 2022, amid the Omicron surge, age-adjusted death rates were higher for Black (37.6 per 100,000), AIAN (34.8 per 100,000), and Hispanic people (30.0 per 100,000) compared with White people (23.5 per 100,000) (Figure 1). Following that surge, disparities narrowed when death rates fell. As of December 2022, age-adjusted death rates were similar across groups at 4.4 per 100,00 for White people, 3.8 per 100,000 for AIAN people, 3.7 per 100,000 for Black people, 3.5 per 100,000 for Hispanic people, and 3.2 per 100,000 for Asian.

Despite these fluctuations in patterns of cases and deaths by race and ethnicity over time, total cumulative age-adjusted data show that AIAN and Hispanic people have had higher risk for COVID-19 infection and AIAN, Hispanic, and Black people have had higher risk for COVID-19 deaths compared with White people. As of December 28, 2022, cumulative age-adjusted data showed that AIAN and Hispanic people were about 1.5 times as likely to be infected with COVID-19 compared with White people (Figure 2). AIAN people were twice as likely as White people to die from COVID-19, and death rates for Hispanic and Black people were 1.7. and 1.6 times higher than White people, respectively. AIAN, Black, and Hispanic people also have had increased risk of hospitalization due to COVID-19 compared with White people.

What are COVID-19 vaccination and booster patterns by race/ethnicity?

While disparities in the uptake of at least one COVID-19 vaccination dose have narrowed over time and have been reversed for Hispanic people, they persist for Black people. KFF analysis shows that at both the federal and state level, there were large gaps in vaccination for Black and Hispanic people in the initial phases of the vaccination rollout, which narrowed over time and eventually reversed for Hispanic people. Despite this progress, a vaccination gap persists for Black people. According to the CDC, over 8 in 10 people (81%) had received at least one COVID-19 vaccination dose as of February 23, 2023, and race/ethnicity was known for 76% of people who had received at least one dose. Based on those with known race/ethnicity, about half (51%) of Black people had received at least one dose compared with 57% of White people, roughly two-thirds (67%) of Hispanic people, and over seven in ten Native Hawaiian and other Pacific Islander (NHOPI) (71%), Asian (73%), and AIAN (78%) people (Figure 3).

Overall, few people have received the updated bivalent booster vaccine dose, and Black and Hispanic people are about half as likely as White people to have received this booster so far. The updated bivalent boosters protect against both the original virus that causes COVID-19 and the BA.4 and BA.5 Omicron variants. These boosters became available for people ages 12 years and older on September 2, 2022, and for people ages 5-11 years old on October 12, 2022. The CDC recommends that people ages 5 years and older receive one bivalent booster at least 2 months after their last COVID-19 vaccine dose. The CDC reports that, overall, 17% of people over age five have received the updated bivalent booster vaccine dose as of February 23, 2023, with race/ethnicity data available for 90% of recipients. Based on those with known race/ethnicity, 21% of eligible Asian people had received a bivalent booster dose, higher than the rate for White people (16%). Rates were slightly lower for eligible AIAN (14%) and NHOPI (11%) people, while eligible Black (9%) and Hispanic 8%) people were about half as likely as their White counterparts to have received the bivalent booster dose (Figure 3).

Discussion

While disparities in cases and deaths have widened and narrowed over the course of the pandemic, age-adjusted data show that AIAN, Black, and Hispanic people have had higher rates of cases and death compared with White people over most of the course of the pandemic and that they have experienced overall higher rates of infection, hospitalization, and death.

Data point to significantly increased risks of COVID-19 illness and death for people who remain unvaccinated or have not received an updated bivalent booster dose. During the initial vaccine rollout, Black and Hispanic people were less likely to receive vaccines than their White counterparts. However, disparities in the uptake of at least one COVID-19 vaccination dose have narrowed over time and reversed for Hispanic people, though they persist for Black people. Despite this progress in initial vaccination uptake, overall uptake of the updated bivalent booster dose has been slow so far, and eligible Black and Hispanic people have been about half as likely to have received an updated booster than their White counterparts.

Overall, these data show that although the pandemic has contributed to growing awareness and focus on addressing racial disparities, they persist, reflecting the underlying structural inequities that drive them. The findings highlight the importance of a continued focus on equity and efforts to address inequities that leave people of color at increased risk for exposure, illness, and death as well as to close gaps in access to health care, as COVID-19 recovery continues.

On March 11, 2020, the World Health Organization (WHO) first characterized COVID-19 as a “pandemic,” stating, “We have rung the alarm bell loud and clear.” As we mark three years since then, here are 10 key data points that illuminate the challenges, and progress, made to date. All data provided are as of Feb. 28, 2023, unless otherwise noted.

1,095

The number of days elapsed between March 11, 2020, to March 11, 2023

March 11, 2023 marks 1,095 days since WHO first characterized COVID-19 as a pandemic.  Even prior to that date, on January 30, 2020, the WHO had already declared COVID-19 to be a “Public Health Emergency of International Concern” (PHEIC)  and the U.S. government declared COVID-19 to be a “Public Health Emergency” (PHE) on Jan. 31, 2020. The U.S. PHE has been renewed every 90 days since, although the Biden administration recently announced that the PHE will end on May 11, 2023.

6,859,093

Global number of COVID-19 deaths to date*

Since the pandemic began, there have been almost 7 million reported COVID-19 deaths worldwide. This is likely an underestimate, as many COVID deaths have gone unreported and uncounted. Estimates using excess death calculations place the true toll at closer to 15 to 20 million, or even more.

1,115,637

U.S. number of COVD-19 deaths to date

Since the start of the pandemic, more than 1.1 million of all reported COVID-19 deaths have been in the United States.

758,390,564

Global number of COVID-19 cases to date

There have been more than three-quarters of a billion confirmed COVID-19 cases to date, likely a fraction of the true number of SARS-CoV-2 infections, the virus that causes COVID. An accurate and up-to-date picture of where and how much the virus is transmitting has been challenging given limited testing, imperfect surveillance and reporting systems, and other factors.

103,268,408

U.S. number of COVID-19 Cases to date

More than a hundred million COVID-19 cases have been reported in the U.S. to date.

71%

Share of global population vaccinated against COVID-19

Overall, seven in 10 people worldwide have received at least one dose of a COVID-19 vaccine, and 65% have been fully vaccinated. However, much smaller shares have received a booster shot. In low-income countries, fewer than three out of 10 people have received at least one dose of a vaccine.  More information on vaccine coverage is available here.

81.2%

Share of U.S. population vaccinated against COVID-19

As of February 23, about 8 in 10 people in the U.S. have received at least one vaccine dose and 69.3% have been fully vaccinated against COVID-19, but the share who have received the updated booster, among those eligible, remains quite low, at just 17.2%.

671,582,379

Total number of vaccine doses administered in the U.S.

In the two years since COVID-19 vaccines have become widely available, over 671 million doses have been administered in the U.S., for a population that stands at approximately 330 million.

683,700,000

Number of vaccine doses delivered by the U.S. government for global use

In 2021, the U.S. government pledged to donate over 1 billion doses of COVID-19 vaccines to countries in need. As of February 2023, the U.S. had delivered over 680 million of these doses, and is the largest government donor to COVID-19 vaccination efforts.  The difference between total vaccines pledged and those delivered largely reflects increasing supply and falling demand for COVID-19 vaccinations globally.

Five

Number of named variants of concern

SARS-CoV-2 evolves and changes as it spreads over time, which has sometimes given rise to new “variants of concern”, or genetic changes in the virus with potentially harmful implications for public health. Since the original version of the virus emerged, WHO has identified 5 different variants of concern: Alpha, Beta, Gamma, Delta, and Omicron (the dominant global variant now in circulation).

*Case and death numbers used here are based on reports, and do not account for undercounts including in countries with very large populations, such as India and China.

Jen Kates, Senior Vice President and Director of Global Health and HIV Policy at KFF, describes the state of global health three years into the COVID-19 pandemic.

In a months-long project, KFF’s Kaiser Health News correspondent Brett Kelman joined forces with CBS News National Consumer Investigative Correspondent Anna Werner to investigate an unregulated dental device that is at the heart of numerous accounts of pain and disfigurement.

At least 10,000 dental patients have been fitted with the fixed Anterior Growth Guidance Appliance (“AGGA”), which costs about $7,000. The device resembles a retainer, is typically worn for several months, and uses springs to apply pressure to the front teeth and upper palate, according to the patent application filed by the inventor of the device.

In videos of the inventor training dentists, he says the pressure can expand a patient’s jaw, which he cites as the key to making people more beautiful and curing common ailments like sleep apnea and TMJ. But dental specialists interviewed by KHN and CBS News said that based on their experiences with former AGGA patients the device pushed teeth out of position and sometimes left them loose and weak.

At least 20 patients have filed lawsuits in the past three years claiming the device — which has not been reviewed by the Food and Drug Administration — left them with flared teeth, damaged gums, exposed roots, or erosion of the bone that holds teeth in place. The inventor and other defendants have denied liability in all the lawsuits.

The joint KHN-CBS News investigation aired on “CBS Mornings” in two installments, on March 1 and March 2. A digital version of the story, which includes embedded video of the TV segments, appears on kffhealthnews.org and cbsnews.com. This is the first investigative project stemming from a broader editorial partnership between CBS News and KFF.

“A hallmark of KHN’s investigative journalism is that we illuminate systemic flaws in American health care,” said KHN Publisher David Rousseau, the executive director of journalism and technology at KFF. “This investigation shows no one was watching.”

“This is a great example of reporters teaming up to expose a problem that can impact the health and finances of everyday Americans,” said Shawna Thomas, Executive Producer of CBS Mornings. “By partnering with Kaiser Health News, we’re able to expand the depth of our health care and consumer coverage.”

The editorial partnership also features regular appearances by Dr. Céline Gounder, KHN’s senior fellow and editor-at-large for public health, on all of CBS News’ platforms, as well as stories, segments, and specials drawing upon reporting from across KHN’s newsroom and bureaus. It includes the popular “Bill of the Month” series, in which KHN Editor-in-Chief Elisabeth Rosenthal appears regularly on “CBS Mornings” to discuss surprising medical bills and what they tell us about the health care system. (“Bill of the Month” is a collaborative investigative project of KHN and NPR.) And it now includes the KHN Health Minute, a weekly feature for CBS News Radio stations that will help millions of listeners understand how  developments in health care delivery and policy affect them.

For the dental device story, KHN and CBS News journalists interviewed 11 dental patients who said they were harmed by the AGGA device — eight of whom have active lawsuits concerning the device — plus attorneys who represent or have represented at least 23 others.

In every case, the patients said they mistakenly assumed the device would not be for sale unless it was proven safe and effective. Dental experts said, based on their experience with former AGGA patients, that patients can suffer tens of thousands of dollars in damage to their mouths.

According to a KHN and CBS News review of the FDA’s device database, the AGGA does not appear to be on the radar of the agency, which is responsible for regulating medical and dental devices in the United States. A manufacturer is supposed to register devices with the FDA, and those that pose even a moderate risk to a patient can be required to go through a pre-market review to check if they are safe and effective. The manufacturer of the AGGA said in a court document it has no record of communicating with the FDA about the device before beginning to make or sell it, and claimed that the device is exempt from premarket review under an exemption for dental labs.

About KFF and KHN

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis, Polling and Survey Research and Social Impact Media, KHN is one of the four major operating programs at KFF. KFF is an endowed nonprofit organization providing information on health issues to the nation.

About CBS News and Stations

CBS News and Stations brings together the power of CBS News, 28 owned television stations in 17 major U.S. markets, the CBS News Streaming Network, CBS News Streaming local platforms, local websites and cbsnews.com, under one umbrella. CBS News and Stations is home to the nation’s #1 news program 60 MINUTES, the CBS News Streaming Network, the first 24/7 digital streaming news network, the award-winning broadcasts CBS MORNINGS, CBS SATURDAY MORNING, the CBS EVENING NEWS WITH NORAH O’DONNELL, CBS SUNDAY MORNING, CBS WEEKEND NEWS, 48 HOURS and FACE THE NATION WITH MARGARET BRENNAN. CBS News and Stations provides news and information for the CBS Television Network, CBSNews.com, CBS News Radio and podcasts, Paramount+, all digital platforms, and the CBS News Streaming Network, the premier 24/7 anchored streaming news service that is available free to everyone with access to the internet. The CBS News Streaming Network is the destination for breaking news, live events, original reporting and storytelling, and programs from CBS News and Stations’ top anchors and correspondents working locally, nationally, and around the globe. CBS News’ streaming services, across national and local, amassed nearly 1 billion streams in 2022. Launched in November 2014 as CBSN, the CBS News Streaming Network is available on 30 digital platforms and apps, as well as CBSNews.com and Paramount+. The service is available live in 91 countries. CBS News and Stations is dedicated to providing the highest-quality journalism under standards it pioneered and continues to set in today’s digital age. CBS News earns more prestigious journalism awards than any other broadcast news division.

A new KFF analysis estimates that enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) will have grown by 23.3 million enrollees, to nearly 95 million, by the end of March. That is when the federal continuous enrollment provision expires, and states can resume disenrollments, which have been paused since February 2020. Millions of beneficiaries are expected to be disenrolled over the next year, and the new estimates illustrate the extent to which enrollment could decline and who will be most affected.

Over half of the 23.3 million enrollment increase is among low-income adults under age 65 (56%), and nearly one-third is among children. According to the KFF estimates, the increase in low-income adults includes 8.9 million (38%) in the Affordable Care Act (ACA) Medicaid expansion group and 5.8 million (25%) other adults (mostly low-income parents) who do not qualify for Medicaid based on disability. Estimated enrollment increases have been smaller for adults eligible based on disability or age (1.3 million) and for CHIP enrollees (0.2 million).

It is expected that the groups that experienced the most growth due to the continuous enrollment provision—ACA expansion adults, other adults, and children—will see the largest enrollment declines.

The increase in enrollment is concentrated in a small number of states with large populations and, consequently, large Medicaid programs. Our analysis shows that California, New York, Texas, Florida, and Illinois account for over one-third of the increase in Medicaid/CHIP enrollment. Because Texas and Florida have not adopted the ACA Medicaid expansion, children and other adults account for higher percentages of enrollment gains in those states.

Growth rates in Medicaid/CHIP enrollment vary considerably by state, ranging from 22 percent in Connecticut to 81 percent in Oklahoma. States that implemented Medicaid expansion after 2020 (Oklahoma, Missouri, Nebraska, Utah, and Idaho) have particularly high enrollment growth.

The number and share of individuals who will be disenrolled across states is expected to vary, but studies estimate that between 5 percent and 17 percent of current enrollees might lose Medicaid coverage. (A previous KFF analysis estimates that between 5.3 million and 14.2 million people will lose Medicaid coverage during the unwinding of the continuous enrollment provision.)

As states start to resume renewal procedures for all current Medicaid enrollees, there is substantial uncertainty as to how much of the Medicaid enrollment growth during the pandemic will be sustained, how many people will transition to other coverage, and how many people could end up uninsured. Our recent analysis of coverage outcomes after disenrolling from Medicaid or CHIP found that nearly two-thirds of people experienced a period of uninsurance. Policies to smooth the transition from Medicaid to other coverage sources could reduce that rate as the Medicaid continuous enrollment period unwinds.

The analysis uses a combination of enrollment data from the Centers for Medicare and Medicaid Services (CMS) Performance Indicator Project (PI data), Medicaid claims data (T-MSIS data), and some state-specific data. (A detailed explanation of the methods is available in the paper.) While our estimates are based on the best available public data on states’ Medicaid and CHIP enrollment, they will likely differ somewhat from data maintained by individual states because we use modeling and assumptions to project enrollment through March 2023 and to allocate states’ adult enrollment across eligibility groups.

In the Consolidated Appropriations Act, 2023, signed into law at the end of 2022, Congress set an end to the Medicaid continuous enrollment provision on March 31, 2023 and phased down the enhanced federal Medicaid matching funds through December 2023. 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 during the COVID-19 public health emergency in exchange for enhanced federal funding. As a result, enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) has grown substantially compared to before the pandemic, contributing to declines in the uninsured rate which dropped to the lowest level on record in early 2022. But, millions of people could lose coverage when the continuous enrollment provision ends, reversing recent gains in coverage.

This analysis estimates Medicaid enrollment growth by state and eligibility group between February 2020, before the pandemic, and March 31, 2023, at the end of the continuous eligibility period. These estimates can help paint a picture of the overall number and composition of enrollees who may risk coverage loss after the continuous enrollment provision ends. Prior to the continuous enrollment period, typical patterns of enrollment included disenrollments throughout the year. Some enrollees disenroll and then re-enroll within a short period of time (or “churn” in and out of Medicaid). The continuous enrollment provision halted disenrollment and churn, resulting in overall program growth. While states will need to conduct renewals for all enrollees, understanding the overall growth in enrollment and the composition of that growth can help inform understanding the range of potential outcomes as the continuous enrollment unwinds. How individual states implement the unwinding will affect the ultimate loss of coverage.

We use a combination of enrollment data from the Centers for Medicare and Medicaid Services (CMS) Performance Indicator Project (PI data), Medicaid claims data (T-MSIS data), and some state-specific data to inform the analysis (see Methods for a detailed explanation of the methods used in this analysis). While our estimates are based on the best available public data on states’ Medicaid and CHIP enrollment, they will likely differ somewhat from data maintained by individual states because we use modeling and assumptions to project enrollment through March 2023 and to allocate states’ adult enrollment across eligibility groups.

Distribution and Rates of Enrollment Growth By Eligibility Group

By the time the continuous enrollment period ends, we estimate that enrollment in Medicaid and CHIP will have grown by 23.3 million enrollees; nearly two-thirds of the enrollment increase is among low-income adults under age 65 (63%) and nearly one-third is among children (Figure 1, tab 1). The increase in low-income adults includes 8.9 million (38%) adults in the Affordable Care Act (ACA) Medicaid expansion group and 5.8 million (25%) other adults (mostly low-income parents) who do not qualify based on disability. Estimated enrollment increases have been smaller for adults eligible based on disability or age (1.3 million) and for CHIP enrollees (0.2 million).

Adults are experiencing the highest rates of enrollment growth during the continuous enrollment period (Figure 1, tab 2). There are very low rates of growth in CHIP, likely because the continuous enrollment provision does not apply to separate CHIP programs and some children may be moving from CHIP into Medicaid. Several factors contribute to the variation in growth rates among Medicaid eligibility groups. First, several states newly expanded Medicaid under the ACA during the continuous enrollment period resulting in high enrollment growth in those states. Adult groups and children typically experience higher rates of churn, which is when enrollees disenroll and then re-enroll within a short period of time and may occur due to temporary changes in income or administrative barriers during renewal that may result in a lapse in coverage even if an individual remains eligible for Medicaid. A recent KFF analysis found that churn rates for children more than doubled following annual renewal, signaling that many eligible children lose coverage at renewal. By halting disenrollment, the continuous enrollment provision has also halted this churning among Medicaid enrollees. People who qualify based on age or disability are historically less likely to churn on and off Medicaid as they are more likely to live on fixed income and therefore, less likely to experience changes in eligibility.

Distribution and Rates of Enrollment Growth By State

The increase in enrollment is concentrated in a small number of states with large populations and consequently large Medicaid programs. Our analysis shows that California, New York, Texas, Florida, and Illinois account for over one-third of the increase in Medicaid/CHIP enrollment (Figure 2, tab 1). Because Texas and Florida have not adopted the ACA Medicaid expansion, children and other adults account for higher percentages of enrollment gains in those states (Appendix Table 1).  

Growth rates in Medicaid/CHIP enrollment vary considerably by state (Figure 2, tab 2). Rates range from 22% in Connecticut to 81% in Oklahoma. States that implemented Medicaid expansion after 2020 (Oklahoma, Missouri, Nebraska, Utah, and Idaho) have particularly high enrollment growth. Beyond Medicaid expansion, several factors may contribute to variation including:

• Churn rates prior to the pandemic (states with higher rates of churn would be likely to have faster growth on account of the continuous enrollment provision),
• The economic effects of the pandemic (in states where more people are out of work, enrollment growth may be faster), and
• State policies to conduct outreach about coverage (states that increased outreach efforts during the pandemic are likely to experience faster growth).

Looking Ahead to Unwinding

We estimate Medicaid/CHIP enrollment will reach nearly 95 million in March 2023, with enrollment growth since February 2020 accounting for one in four enrollees (Appendix Table 1). While the number of Medicaid enrollees who may be disenrolled during the unwinding period is highly uncertain, studies estimate that between 5% and 17% of current enrollees might be disenrolled. Earlier KFF analysis estimates that between 5.3 million and 14.2 million people will lose Medicaid coverage during the unwinding of the continuous enrollment provision. These projected coverage losses are consistent with, though a bit lower than, estimates from the Department of Health and Human Services (HHS) suggesting that as many as 15 million people will be disenrolled.

It is expected that the groups that experienced the most growth due to the continuous enrollment provision—ACA expansion adults, other adults, and children—will experience the largest enrollment declines. In states that haven't expanded Medicaid, many low-income parents and new mothers will be most at risk of losing coverage. HHS estimates that of those disenrolled, 6.8 million will likely still be eligible. Many children may remain eligible even if their parents are no longer eligible because most states’ income limits for children are considerably higher than for adults, and many adults eligible based on disability or age (65+) may remain eligible if they are living on fixed incomes.

Actual enrollment outcomes will vary across states depending on an array of state policy decisions including how states prioritize renewals and efforts to conduct outreach and enrollment assistance. These policies can help ensure that those who remain eligible for Medicaid are able to retain coverage, and that those who are no longer eligible can transition to other sources of coverage, particularly the ACA marketplace. Our state-by-state estimates of enrollment gains by eligibility group can help illustrate how many people are at risk of coverage loss (for enrollment increases by state and eligibility group see Appendix Table 1). As states start to resume renewal procedures for all current Medicaid enrollees, there is substantial uncertainty as to how much of the Medicaid enrollment growth during the pandemic will be sustained, how many people will transition to other coverage, and how many people could end up uninsured. Because a large share of people are covered by Medicaid, including an analysis that shows that over half of all children are covered by Medicaid and CHIP, declines in Medicaid coverage could directly impact the number of uninsured. Our recent analysis of coverage outcomes after disenrolling from Medicaid or CHIP found that nearly two-thirds of people experienced a period of uninsurance. Policies to smooth the transition from Medicaid to other coverage sources could reduce that rate as the Medicaid continuous enrollment period unwinds.

Appendix Table