When COVID-19 first hit the U.S. in the spring of 2020 and more than 20 million people lost their jobs, there was a real fear that many would also lose their health insurance and that the uninsured rate might skyrocket. 

Instead, the opposite happened. By early 2022, the uninsured rate had dropped to 8% — the lowest it’s ever been. That’s largely because of one major change to Medicaid. 

In March 2020, as everything was shutting down, “the federal government was trying to get fiscal relief to the states and help preserve health insurance coverage,” said Larry Levitt, executive vice president for health policy at KFF. So it offered states more money for Medicaid.

“In return for this extra money that the federal government gave to states, they required states to keep people continuously enrolled in Medicaid,” he said. “So in other words, during the public health emergency, no one could be kicked off Medicaid.”

That “continuous enrollment” provision has kept millions of people insured through the pandemic. In the last three years, the number of people on Medicaid and the Children’s Health Insurance Program, or CHIP, has risen by more than 23 million. As of March of this year, nearly 95 million people had coverage through the programs, which provide free or low-cost health insurance to low-income people. 

“The change was quite dramatic,” said Sara Rosenbaum at the Milken Institute School of Public Health at George Washington University. 

“If you normally would have lost Medicaid because you went back to work and earned a little more, you’d keep Medicaid. If you got to the end of your postpartum period, and you normally would have cycled off the program, you kept your Medicaid,” she said. “Children who aged out of the child eligibility category and weren’t eligible as young adults got to keep their Medicaid as if they were still children. So essentially, people stayed on the program for what became the three years of the pandemic emergency.”

But now that the Biden administration has declared the COVID public health emergency officially over, states have begun requiring everyone to re-certify their eligibility for Medicaid again and removing people from the rolls. As states work through that process at different speeds over the course of the next year or so, KFF estimates that about 17 million people could lose their health coverage — either temporarily or permanently. 

The biggest risk of people losing it permanently is in 10 states — “states that have chosen not to expand Medicaid coverage under the Affordable Care Act,” said Jennifer Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities. They have what’s called a coverage gap. “There’s a group of individuals whose income will be too high for Medicaid but too low for marketplace coverage.”

In every other state, everyone should be eligible for some kind of health insurance, through an employer, through the exchanges or through Medicaid — because millions will still qualify to remain on it. 

For those who don’t qualify for Medicaid anymore and don’t have an option for employer coverage, “there’s a very good chance that they will be eligible for affordable insurance on the marketplace,” Wagner said. “The trick there will be transitioning to the marketplace, because that can be kind of difficult.”

Nearly 30% of people on Medicaid said they wouldn’t know where to look for other coverage if they were no longer eligible for Medicaid, according to new research from KFF. And 15% said they would end up uninsured. 

Even those who are still eligible for Medicaid could lose coverage in the coming months.

“The estimates are that probably almost half the people who lose their coverage are not going to be losing coverage because they actually are no longer eligible, but because they somehow got lost in the system,” said Sara Rosenbaum at GW. 

That was always the case before COVID. Lots of people would lose coverage every year when it came time to recertify because they didn’t realize they had to, they had trouble with the paperwork or because of administrative backlogs or errors. 

It’s likely to be an even bigger issue this year. Many people aren’t aware that after three years of uninterrupted coverage, they’re now going to have to recertify. On top of that, Rosenbaum said that “many states are down staff, they’re underwater. The staff who remain are really overwhelmed with work. Because, of course, Medicaid is changing, food stamps are changing, SNAP is changing, cash welfare is changing, everything is changing. And eligibility workers have this huge job. I mean, just huge.”

Even temporary disruptions in health coverage can have major consequences for people. 

That’s the case for Daffany Payne, a single mom living in Little Rock, Arkansas, with her seven kids, who range in age from 3 to 15. All of them have been on Medicaid for the last few years, but earlier this month, after Arkansas started re-determining everyone’s eligibility, Payne got a letter saying that her youngest son, the 3-year-old, no longer qualifies.  

“I don’t know why yet,” she said. “Out of eight people in this family, just one child was denied his medical services. And he was supposed to be starting school.”

Now he can’t, because the school he was going to is for kids with developmental delays, and Medicaid was going to pay for it. 

Payne is hoping the denial was just a mistake. She’s planning to apply again, but she’s worried about her son getting sick in the meantime. Even if he does eventually get back on Medicaid, she’s afraid he will have already lost his spot at the school; they only hold it for 30 days. 

“It’s very hard to get kids into this program,” she said. “More than likely, he won’t be able to get in til probably next year around this time.”

Millions of people are going to be dealing with different versions of this in the coming months, as states work through the recertification process.

“If some of these estimates are right, we could see the biggest increase in the number of people uninsured of all time, from this all-time low,” said KFF’s Larry Levitt.  

“We had this period during a pandemic where our health insurance system worked as well as it ever has, and we came as close as maybe we will for quite some time to universal coverage. But that period’s coming to an end.”