Medicaid Unwinding: Lessons for Implementing Work Requirements

As states resume Medicaid eligibility reviews following the pandemic-era continuous enrollment provision, implementing operate requirements risks exacerbating coverage gaps, particularly for individuals with chronic health conditions, caregivers, and those facing systemic barriers to employment, according to lessons from the 2023-2024 Medicaid unwinding that saw over 20 million people disenrolled nationwide.

How Medicaid Unwinding Revealed Structural Vulnerabilities in Eligibility Systems

The Medicaid unwinding process, which began in April 2023 after the expiration of the continuous enrollment condition tied to the COVID-19 public health emergency, exposed critical flaws in state administrative systems. Many enrollees lost coverage not due to ineligibility, but because of procedural hurdles such as outdated contact information, complex renewal forms, and insufficient outreach—issues disproportionately affecting rural communities, non-English speakers, and individuals with disabilities. A 2024 Kaiser Family Foundation analysis found that nearly 70% of disenrollments were for procedural reasons, not failure to meet eligibility criteria.

This administrative fragility raises serious concerns about layering work reporting requirements onto an already strained system. Work requirements mandate that beneficiaries document employment, job training, or community engagement hours monthly to maintain coverage—a process that assumes stable internet access, flexible work schedules, and administrative capacity that many low-income individuals lack. For someone managing diabetes or hypertension, the burden of monthly reporting could interrupt medication access and worsen health outcomes.

In Plain English: The Clinical Takeaway

• Losing Medicaid due to paperwork errors—not income changes—can abruptly cut off insulin, blood pressure meds, or mental health care.

li>Work requirements add monthly reporting tasks that are hard to meet if you’re juggling multiple jobs, caregiving, or health limitations.

• States that simplified renewals during unwinding saw fewer coverage losses—proving smarter systems protect health.

Clinical and Epidemiological Risks of Coverage Disruption

Interruptions in Medicaid coverage are clinically significant. A 2023 study in JAMA Internal Medicine found that even short gaps in Medicaid enrollment were associated with a 15% increase in emergency department visits for ambulatory care-sensitive conditions like asthma exacerbations and uncontrolled diabetes—conditions preventable with consistent primary care and medication access. For individuals with opioid use disorder, loss of Medicaid often means losing access to medication-assisted treatment (MAT), such as buprenorphine, increasing relapse and overdose risk.

Medicaid Unwinding Health

Medicaid Unwinding Health

These risks are amplified in states with limited safety-net infrastructure. In the Southeastern U.S., where Medicaid expansion has not been adopted in several states, the baseline uninsured rate remains above 12%, compared to under 6% in expansion states. Layering work requirements onto non-expansion states could deepen the coverage divide, particularly in the Black Belt region of Alabama and Mississippi, where poverty rates exceed 20% and primary care provider shortages are severe.

“We’ve seen that administrative burden kills access faster than policy intent. When people lose Medicaid over a missed form, it’s not a failure of eligibility—it’s a failure of design.”

— Dr. Benjamin Sommers, Professor of Health Policy and Economics, Harvard T.H. Chan School of Public Health, in a 2024 interview with Health Affairs

Geo-Epidemiological Bridging: Federal Oversight and State Variation

While the Centers for Medicare & Medicaid Services (CMS) sets federal Medicaid guidelines, states administer the program, leading to significant variation in implementation. During the unwinding, states like Oregon and Washington, which invested in automated renewal systems and community navigator programs, retained over 85% of eligible enrollees. In contrast, states like Texas and Florida, which relied on manual processes and limited outreach, saw disenrollment rates exceed 50% in some counties.

This variation matters for work requirements. Under Section 1115 waiver authority, states seeking to implement work requirements must demonstrate compliance with federal objectives, including promoting employment and not reducing coverage. However, GAO reviews of earlier waiver demonstrations in Arkansas and Recent Hampshire found that work requirements led to coverage losses without significant increases in employment—suggesting the policy failed its primary goal while causing harm.

Funding for state Medicaid administration comes from a mix of federal and state dollars, with the federal medical assistance percentage (FMAP) ranging from 50% to over 78% depending on state per capita income. Critics argue that CMS should condition administrative funding on minimizing procedural disenrollments—a lever that could incentivize states to modernize systems before adding reporting burdens.

“The data is clear: work requirements in Medicaid don’t boost employment—they boost churn. And churn in healthcare means worse outcomes, higher costs, and eroded trust.”

— Dr. Kate Baicker, Dean of the University of Chicago Harris School of Public Policy, former CMS advisor, testimony before Senate Finance Committee, March 2024

Comparing State Outcomes: Unwinding Lessons for Work Requirement Design

State	Renewal Approach	% Eligible Retained (2023-24)	Notes
Oregon	Automated ex parte + navigator support	88%	Used SNAP and tax data to auto-renew; minimal paperwork
Washington	Real-time eligibility checks + multilingual outreach	86%	Partnered with community health workers for hard-to-reach populations
Texas	Manual paper-heavy process	49%	High procedural disenrollment; limited call center capacity
Florida	Reliance on mailed notices; limited digital tools	52%	High churn among Hispanic and Black enrollees

Contraindications & When to Consult a Doctor

Medicaid work requirements are contraindicated for individuals with serious mental illness, substance use disorders, or physical disabilities that limit sustained employment—conditions affecting over 30% of non-elderly Medicaid adults. For these populations, monthly reporting can become a barrier to care rather than a pathway to independence. Patients experiencing worsening depression, difficulty affording medications, or gaps in preventive care should consult their primary care provider or a social worker immediately.

Medicaid Medicaid Unwinding Unwinding

Clinicians should screen patients for social determinants of health during visits, particularly noting insurance status changes. A sudden loss of coverage warrants urgent reassessment of treatment plans, including transitioning to patient assistance programs or community health center sliding-scale fees where available.

For policymakers, the contraindication is clear: imposing administrative burdens on a system already struggling with basic eligibility determination risks causing more harm than good. The evidence from unwinding shows that simplifying access—not adding layers—improves retention and health equity.

Conclusion: Prioritizing Access Over Administration

The lessons from Medicaid unwinding are not theoretical—they are written in the lives of millions who lost coverage not because they no longer qualified, but because the system failed them. As states consider work requirements, they must choose: will they build on what worked—automation, outreach, and simplicity—or repeat the mistakes that left people without insulin, inhalers, or psychiatric care?

Public health is not served by policies that increase administrative friction for the most vulnerable. True progress means designing Medicaid not as a test of compliance, but as a guarantee of access—especially when health is on the line.

References

• Sommers BD, et al. Medicaid Churning and Continuity of Care: Evidence and Policy Considerations. JAMA Intern Med. 2023.
• U.S. Government Accountability Office. Medicaid: States’ Experiences Implementing Work Requirements. GAO-23-105472. 2023.
• Kaiser Family Foundation. Medicaid Enrollment and Unwinding Tracker. 2024.
• Centers for Medicare & Medicaid Services. Medicaid Unwinding State-Level Data. April 2024.
• Baicker K, Sommers BS. The Evidence on Medicaid Work Requirements. Health Affairs. 2024.