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We’re over two years into the Medicaid disenrollment process.

How are things going? For patients? Physicians? States?

They could be better….

In this article, I break down how we got to Medicaid disenrollment, what the data shows, and what it means for patients, physicians, and the business of healthcare.

The Medicaid program has undergone a significant transformation over the past five years, largely due to the pandemic. “Continuous enrollment” was one of the key factors driving said transformation. I’ll provide you with a quick timeline of the events, which will help you better understand where we’re at now.

Congress passed The Families First Coronavirus Response Act (FFCRA) in March 2020, which enhanced Medicaid and CHIP coverage. This legislation provided states a 6.2% increase in the federal share of Medicaid spending with an important condition:

This meant that even if enrollees started to make too much income, which would otherwise disqualify them from Medicaid, they would maintain insurance coverage.

Medicaid/CHIP coverage then increased 25% from pre-pandemic to October 2022, providing 17 million eligible adults and children with insurance coverage.

The Consolidated Appropriations Act of 2023 set the FFCRA continuous enrollment provision’s end date for March 31st, 2023. But, instead of millions of Americans losing Medicaid/CHIP coverage at once—like falling off a cliff—continuous enrollment would be phased out—like skiing down a long green trail.

The federal government slowly decreased the federal match rate (the above-mentioned 6.2%) throughout 2023. However, states had to comply with specific rules that were also part of the FFCRA to continue receiving federal funding.

KFF estimated that Medicaid/CHIP might lose between 5% and 13% of its enrollees—5.3 million to 14.2 million people.

On May 22, Congress passed the "One Big Beautiful Bill," targeting $1.7 trillion in federal cuts. Nearly half comes from Medicaid and ACA Marketplace changes, saving approximately $793 billion over ten years according to CBO estimates.

Some of the key changes include:

These significant policy changes have led to substantial shifts in Medicaid enrollment, creating a ripple effect across the healthcare system. Let's examine how these changes are playing out in the data and what it means for healthcare access.

In February 2020—pre-pandemic—roughly 71.6 million people were enrolled in Medicaid and CHIP. That number swelled to a record 94 million by March 2023, thanks to continuous enrollment protections during COVID. For three years, states couldn’t disenroll anyone.

Since April 2023 (when unwinding began), over 25 million people have been disenrolled from Medicaid. 70% were dropped for procedural reasons. That means most people didn’t lose coverage because they were ineligible. They just didn’t complete paperwork, didn’t receive a notice, or couldn’t get through the red tape.

We’re now down to 78.1 million enrollees—still about 9% above pre-pandemic levels, but 17% below the 2023 peak. Child enrollment has dropped in 15 states. Adult enrollment is down in 8.

According to the latest American Community Survey, the U.S. uninsured rate rose from 11% in 2023 to 11.3% in 2024. That may seem small on paper, but it translates to nearly 100,000+ more adults without coverage. For children, the trend is even more alarming. The uninsured rate increased from 5.4% to 6.0%

And with the One Big Beautiful Bill ushering in more frequent eligibility checks, stricter documentation rules, and pending work requirements, the unwinding isn’t over—it’s just entering phase two.

Honestly, I don’t need spreadsheets to tell me what Medicaid disenrollment looks like. I see it in my patients. The look of confusion when they find out, often too late, that they’ll be kicked off of Medicaid.

Over 22 million Americans have already been dropped from Medicaid since the unwinding began. And most of them weren’t denied because they were ineligible. They were just procedurally lost, due to a missed form, a change of address, or a notice that never arrived.

Now, the One Big Beautiful Bill will exacerbate all of this.

It mandates more frequent eligibility checks, reverses simplification rules, and adds work requirements for expansion adults. These are just barriers built into the system. And from the frontlines, they look less like cost-saving measures and more like systematic off-ramps from care.

While the government boasts of cost savings from these stricter Medicaid requirements, no one is considering the actual costly ripple effects. Pushing patients off Medicaid doesn’t make them disappear, it just shifts the cost downstream (which we as a health system aren’t prepared for).

Uninsured patients still show up. But now they delay care, present sicker, and use more expensive resources like the ER. Hospitals, especially safety-net and rural ones, absorb more bad debt. Revenue cycles tighten. Preventive care falls off. Risk pools destabilize. Payers may win in the short term, but the system pays in the long run.

And, we physicians are stuck navigating the fallout.

If you want to reduce Medicaid spending responsibly, it starts with smart policy, not paperwork traps. Because if this trend continues, the real cost won’t just be measured in dollars, it’ll be in deteriorating health and widening inequities.

This is the new Medicaid reality. And unless something changes, it’s only going to get worse.

In summary, Medicaid has undergone a dramatic shift—from pandemic-era expansion to post-pandemic contraction. Over 25 million Americans have already been dropped, mostly due to administrative hurdles rather than true ineligibility. Now, with the One Big Beautiful Bill introducing stricter rules and looming work requirements, coverage losses are set to accelerate. More uninsured patients, more strain on the system, and more frontline fallout for physicians.

Revenue Cycle Management might sound like dry admin work, but it’s the reason patients get surprise bills, doctors spend hours on paperwork, and hospitals live or die by razor-thin margins.

If you want to understand why U.S. healthcare feels so broken, you have to understand the middleman that moves the money.

👉 Read more details here.

Every physician knows the drill: a patient shows up with a laundry list of concerns, and suddenly the “routine” visit isn’t so routine. Immediate issues take precedence, and those long-overdue screenings or vaccines get bumped to “next time.”

The problem is, “next time” often comes too late. Preventive care gaps pile up, patients remain unaware of what’s being missed, and clinicians are left juggling competing priorities under time pressure. It’s an inefficiency baked into how we run primary care—and the costs are real for patients, physicians, and the system.

But a new randomized trial in NEJM Evidence tested a surprisingly simple way to tackle this head-on. The results might not be what you expect…

👉 Full breakdown in my latest Inefficiency Insights article here.

AI Isn’t Coming for Your Job—It’s Coming for Your Paperwork

We spend nearly $5 trillion on healthcare every year—but up to 15% of that is wasted on administrative bloat.

Think: prior auths, claims, referral faxes, and inboxes full of chart reviews. Not care. Just the stuff around it.

AI may finally be the tool to automate that waste away.

But which AI tools are actually moving the needle? What’s hype vs. reality? And how close are we to fully automated workflows like dynamic scheduling, ambient documentation, and claims adjudication?

👉 Full breakdown in my latest Huddle+ article here.

We were trained to take care of patients. But no one ever taught us how the system actually works:

That’s why I built this course: How Healthcare Really Works.

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Reply to this email and I’ll send the details with the course syllabus.