The Great Medicaid Unwinding

THE NATION, Adam Gaffney, October 8, 2023

Millions of Americans lost their coverage earlier this year when a pandemic-era policy expired. The consequences are detrimental to the very practice of medicine.

Ronald Reagan’s ascent to the presidency delivered a swift kick to the nation’s poor—especially those who had the misfortune to get sick. His administration’s 1981 budget imposed deep cuts on Medicaid, adding to financial pressures on states to narrow eligibility and punting some 600,000 beneficiaries out of the program early in the decade. A 1983 study in The New England Journal of Medicine examined the health consequences of Medicaid cuts in California, where coverage was eliminated for 270,000 people. One study subject who lost coverage died of a brain bleed (she couldn’t afford the blood pressure-lowering medications that might have prevented it), another of a stomach ulcer (he spit up blood for 10 days before seeking care, fearing ER bills), and a third of a probable heart attack (he ran out of heart medications which he couldn’t afford to refill). This episode is of more than historic interest: We are now about six months into our own version of what experts are calling a great “Medicaid unwinding.”

In April, the pandemic-era “continuous coverage provision”—which compelled states to keep Medicaid beneficiaries continuously insured for the duration of the Covid-19 public health emergency, greatly boosting enrollment—expired. This has already led to the disenrollment of nearly 8 million beneficiaries from the program, with predictable results. For example, Patricia Jones, a 62-year old West Virginia woman with heart problems and a recent bloodstream infection, was recently dropped from Medicaid because the $1,765 a month she was getting in disability survivor’s benefits after her husband died in March was $149 too high to qualify, The Washington Post recently reported. (She has yet to find alternative coverage.) Experts predict that as many as 24 million enrollees might lose their coverage by the time the unwinding is done.

These giant numbers dwarf the coverage losses of the early 1980s, and widespread harm is sure to follow. But the so-called “Medicaid unwinding” isn’t as new as it may seem. Before the pandemic, large numbers of people lost Medicaid coverage every year, thanks to shifting eligibility at the margins and administrative snafus. This feature—inherent to many means-tested programs—has always compromised coverage and caused suffering for those who depend on this critical program. Such discontinuities in coverage are all too common in the fragmented American insurance system, and they undermine the very essence of what medical care can do.