Amid Unwinding of Pandemic-Era Policies, Medicaid Programs Continue to Focus on Delivery Systems, Benefits, and Reimbursement Rates: Results from an Annual Medicaid Budget Survey for State Fiscal Years 2023 and 2024


Nationwide, Medicaid provided health insurance coverage to more than one in five Americans in 2022 and accounted for nearly one-sixth of all U.S. health care expenditures. 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 through the end of the COVID-19 PHE, in exchange for enhanced federal funding. As a result, total Medicaid/Children’s Health Insurance Program (CHIP) enrollment grew substantially, peaking at 94.5 million people in April 2023, the month following the end of continuous enrollment – an increase of 23.1 million enrollees or 32.4% from February 2020. The uninsured rate also dropped. As of July 2023, total Medicaid/CHIP enrollment was 91.5 million.

The Consolidated Appropriations Act, 2023, signed into law on December 29, 2022, delinked the continuous enrollment provision from the PHE (ending it on March 31, 2023) and phased down the enhanced federal Medicaid matching funds through December 2023. States were given up to 12 months to initiate, and 14 months to complete, an eligibility renewal for all Medicaid- and CHIP-enrolled individuals following the end of the continuous enrollment requirement—a process commonly referred to as “unwinding.” The volume of redeterminations coupled with eligibility workforce shortages, systems issues, and enhanced outreach efforts present challenges for states in implementing the unwinding. Millions are expected to lose Medicaid during the unwinding, potentially reversing recent improvements in the uninsured rate, though not everyone who loses Medicaid will become uninsured. While states could begin disenrolling people starting April 1, 2023, many did not resume disenrollments until May, June, or July.

This report draws upon findings from the 23rd 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 2023 via a survey sent to each state Medicaid director in June 2023 and then a follow-up telephone interview. Overall, 48 states responded by October 2023,1 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 2023, policy changes implemented at the beginning of FY 2024, and policy changes for which a definite decision has been made to implement in FY 2024 (which began for most states on July 1, 20232). 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:

Executive Summary Delivery Systems

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