Beyond the Number: The Unseen Currents of Medicaid and the 80 Million Lives in the Balance

The Phone Call That Made the Numbers Real

The call came on a Tuesday afternoon.

It was a close family member, a woman who pieces together a living as a part-time caregiver for the elderly—a job with immense heart but no health benefits.

Her voice was tight with a specific kind of panic, the kind that comes from staring at a dense, jargon-filled letter from a government agency that holds your future in its hands.

The letter, she explained, seemed to be saying that her Medicaid coverage was about to be terminated.

For her, this wasn’t an abstract policy issue; it was a potential catastrophe.

Medicaid was the only way she could afford the medication that kept a chronic condition from spiraling out of control.

The confusion, fear, and sheer powerlessness in her voice that day transformed a headline I had read a dozen times—the “Medicaid unwinding”—from a distant, statistical event into a tangible, urgent crisis.

It was a stark reminder that behind the national enrollment figures and political debates, there are millions of individual, high-stakes dramas unfolding in kitchens and living rooms across America.

Answering the question “How many Americans are on Medicaid?” requires more than just stating a number.

It demands that we understand the turbulent currents of policy and economics that are shaping, and sometimes upending, the lives of tens of millions of our fellow citizens.

Part I: The Great Disruption: Why “How Many?” Is the Wrong First Question

To ask how many Americans are on Medicaid today is to ask for a snapshot of a tidal wave in motion.

The number itself, while important, is dangerously misleading if viewed in isolation.

It represents the surface of a turbulent sea, masking the violent currents of change that have reshaped the landscape of American public health in just a few short years.

To understand the present, we must first comprehend the unprecedented disruption that preceded it.

The Pandemic Flood: A Historic Surge

Before the COVID-19 pandemic, the Medicaid system had a relatively stable baseline.

In February 2020, approximately 71.4 million people were enrolled in Medicaid and the Children’s Health Insurance Program (CHIP).¹

But as the pandemic swept across the nation, a critical policy decision was made.

The Families First Coronavirus Response Act included a “continuous enrollment provision.” In exchange for enhanced federal funding, states agreed to pause most Medicaid disenrollments for the duration of the public health emergency.¹

This provision acted like a powerful dam, holding back the normal outflow of people who would have lost coverage due to small income changes or procedural issues.

Simultaneously, the economic shock of the pandemic created a massive new inflow, as millions lost jobs and the employer-sponsored insurance that came with them.³

The result was a historic surge in enrollment.

Over the next three years, the number of people covered by Medicaid and CHIP swelled by 23 million—a staggering 32% increase—reaching a record high of 94.3 million people by the spring of 2023.¹

The Unwinding Drought: Opening the Floodgates

The end of the continuous enrollment provision on March 31, 2023, marked the beginning of the next dramatic chapter: the “unwinding.” States were required to undertake the monumental task of redetermining the eligibility of every single one of those 94 million enrollees over the following 12 to 14 months.¹

The dam broke, and the outflow began.

The drop was as precipitous as the rise.

In just over a year, national enrollment plummeted.

As of May 2024, the most recent comprehensive data available, total enrollment had fallen by approximately 13 million people from its peak, settling around 81 million.³

In a single year, the unwinding wiped out more than half of the coverage gains accrued during the entire three-year pandemic period.

Program Milestone	Date	National Medicaid/CHIP Enrollment
Pre-Pandemic Baseline	February 2020	71,446,354
Peak Pandemic Enrollment	March 2023	94,349,705
Post-Unwinding (Latest Data)	April 2025 (Preliminary)	78,382,471

Source: KFF analysis of CMS data ¹

The Illusion of a Stable Lake: The Flawed Mental Model

Simply looking at these three numbers—the start, the peak, and the current level—is like measuring the depth of a lake without understanding the rivers that feed it or the outlets that drain it.

It tells you what happened, but not how or why.

This static view creates a dangerous illusion of a system returning to normal, when in fact the system itself has been fundamentally altered.

The current enrollment of roughly 78-81 million is still significantly higher than the pre-pandemic baseline of 71 million.¹

This simple fact reveals that the unwinding was not a reset.

The pandemic acted as a massive enrollment event, bringing in many people who were already eligible for Medicaid but had not previously signed up.¹

Furthermore, several states, including Oklahoma, Missouri, South Dakota, and North Carolina, expanded their Medicaid programs during or immediately after this period, permanently enlarging the pool of eligible individuals.¹

The unwinding was therefore not a return to an old equilibrium, but a chaotic and painful recalibration of a much larger, more complex system.

The sheer velocity of this change—millions losing coverage month after month—created a secondary crisis of confusion and fear, as experienced by my family member.

A primary driver of this was “procedural disenrollment,” a bureaucratic term for a human tragedy where eligible individuals lose their health coverage not because they no longer qualify, but because they get lost in a maze of paperwork, missed mail, or confusing online portals.⁶

This reveals a critical vulnerability in the system: its inability to handle massive, rapid change without inadvertently harming the very people it is designed to serve.

Part II: The Watershed: A New Framework for Understanding Medicaid

To truly grasp the forces shaping the lives of the tens of millions of Americans on Medicaid, we must discard the static “lake” model and adopt a more dynamic and accurate one: Medicaid as a vast and complex watershed.

This framework moves beyond a single number and allows us to see the program as a living ecosystem, defined by constant movement and powerful, often invisible, forces.

• Inflows (The Tributaries): These are the many streams that feed the Medicaid reservoir. People flow into the program for a multitude of reasons that reflect the unpredictable nature of life: a layoff from a job, a reduction in work hours, a new baby, a disabling accident, a pregnancy, or aging into eligibility. These inflows represent the program’s essential function as a responsive safety net.
• Outflows (Evaporation and Rivers to the Sea): These are the channels through which people leave the program. Some of these outflows are natural and expected, such as when a person gets a new job with good health benefits. But a significant portion of the outflow is due to systemic inefficiencies—water lost unnecessarily. This includes procedural disenrollments and people losing coverage because of small, temporary spikes in income.
• Undercurrents (Churn): This is a powerful, invisible, and deeply inefficient force within the watershed. Churn is the cycle of enrollees being swept out by the outflow currents, only to be pulled back in by the inflow currents a short time later.⁷ It represents profound instability, causing gaps in care for individuals and creating massive administrative waste for the system.
• Geography (The Landscape): The American Medicaid watershed is not a single, uniform body of water. Its landscape is shaped by 50 different sets of state policies, creating a patchwork of vastly different environments. Some states have built deep, stable reservoirs with broad eligibility and robust systems (expansion states). Others maintain shallow, fast-draining riverbeds with restrictive rules (non-expansion states). This state-level geography is the single most important factor determining the size and stability of the program within a given region.

By adopting this watershed framework, we can move from asking the simple question of “how many” to exploring the much more important questions of who, why, and how.

Part III: Mapping the Watershed: The Forces Shaping American Health Coverage

Using our new watershed framework, we can now map the key features of the Medicaid landscape.

This allows us to move beyond a single, national number to a rich, multi-dimensional understanding of the populations served, the policies that govern them, and the inequities that persist within the system.

The Headwaters: Who Can Drink from the Stream?

The ultimate source of the entire watershed is eligibility.

The rules governing who can access Medicaid determine the potential size and scope of the program.

These rules are a complex interplay of federal minimums and state-level decisions.

Federal law requires states to cover certain mandatory eligibility groups, which include low-income children, qualified pregnant women, and individuals receiving Supplemental Security Income (SSI) due to disability.⁸

The Affordable Care Act (ACA) of 2010 then created a major new optional pathway: the expansion of Medicaid to nearly all non-elderly adults with household incomes at or below 138% of the federal poverty level (FPL).⁸

Eligibility is determined by both financial and non-financial criteria.

The primary financial test for most applicants is based on Modified Adjusted Gross Income (MAGI), a standardized methodology designed to be consistent across states and programs.⁸

Non-financial criteria include being a resident of the state and being a U.S. citizen or a qualified non-citizen.⁸

State-specific examples show how these rules play out in practice.

In Florida, for instance, the state defines distinct income limits for parents, children, and pregnant women ¹¹, while North Carolina provides a detailed chart showing how monthly income thresholds vary by family size for different groups.¹²

This complex reality of eligibility stands in stark contrast to the many myths and misconceptions that cloud public understanding of the program.

Dedicated Feature: Myths vs. Facts About Medicaid Beneficiaries

Correcting widespread misinformation is critical to having an informed public debate about Medicaid’s role and function.

Common Myth	The Reality (with Data)
Medicaid is for people who don’t work.	Fact: This is one of the most pervasive myths. In reality, nearly 70% of non-disabled adults covered by Medicaid are in working families. Many are employed in low-wage sectors like retail, hospitality, and caregiving, where jobs often do not include employer-sponsored health insurance.13
You have to be completely destitute to qualify.	Fact: While Medicaid is a needs-based program with strict income and asset limits, the rules are complex. Certain assets, like a primary home (up to a certain value), a car, and personal belongings, are typically exempt. Furthermore, legal strategies known as “spend-downs” can allow individuals, particularly those facing catastrophic long-term care costs, to structure their finances to meet eligibility requirements.15
Medicaid will take your house.	Fact: The state does not seize a person’s home when they enroll in Medicaid. The home is generally an exempt asset, especially if a spouse or dependent child lives there. The issue that causes confusion is “Medicaid Estate Recovery,” a federal requirement for states to attempt to recoup the costs of long-term care from a recipient’s estate after they have died. This process can often be managed or mitigated with proper legal planning.15
Medicaid provides substandard care.	Fact: This is demonstrably false. Numerous studies confirm that Medicaid coverage leads to improved health outcomes, increased access to preventive care, and better management of chronic conditions compared to being uninsured. The benefits package is often more comprehensive than many private plans, particularly for services like long-term care and support for individuals with disabilities.13

The Main Rivers: The Core Populations Medicaid Sustains

The streams flowing from the headwaters of eligibility converge into the main rivers of the watershed—the major populations that rely on Medicaid for their health and well-being.

As of the latest preliminary data for April 2025, the roughly 78.4 million people enrolled nationally are split between two main programs: 71.1 million in Medicaid and 7.3 million in the Children’s Health Insurance Program (CHIP).¹

Demographically, these enrollees are composed of 40.1 million adults (52%) and 37.2 million children (48%).¹

This represents a significant and troubling shift from the pre-pandemic era.

In February 2020, children made up the slight majority of enrollees at 51%.¹

The reversal of this ratio points to a critical failure within the unwinding process.

While adult enrollment remains more than 20% higher than it was before the pandemic, child enrollment has plummeted back to near pre-pandemic levels, standing only 5% higher nationally.³

In a staggering 15 states, child enrollment has actually fallen

below what it was in February 2020.¹

This decline has occurred alongside a documented increase in the national uninsured rate for children.³

This is not merely a statistical fluctuation; it is a five-alarm fire for public health.

Children typically have higher income eligibility thresholds for Medicaid and CHIP than adults do, meaning they should be more protected from losing coverage, not less.

The data strongly suggest that children are the unintended victims of the administrative chaos of the unwinding.

When parents, who may themselves be losing coverage or struggling with the paperwork, fail to navigate the complex renewal process, their children lose coverage along with them.

This is a profound policy failure hidden within the aggregate numbers, with potentially devastating long-term consequences for a generation of vulnerable children.

The Great Divide: How State Expansion Creates Different Worlds

The single most dramatic feature of the Medicaid watershed’s geography is a state’s decision to expand its program under the ACA.

To date, 41 states and the District of Columbia have expanded Medicaid to low-income adults, while 10 states have not.⁵

This decision creates two fundamentally different realities for low-income Americans.

The impact on coverage is stark.

In 2019, the uninsured rate for non-elderly adults in expansion states was 9.8%, while in non-expansion states it was nearly double, at 18.4%.²²

This gap is driven by a “coverage gap” in non-expansion states, where millions of adults earn too much to qualify for traditional Medicaid but too little to receive subsidies to buy private insurance on the ACA marketplace.

Furthermore, expansion states have significantly higher “take-up” rates, meaning a larger percentage of those who are eligible actually enroll—88% in expansion states compared to just 78.7% in non-expansion states.²³

The state-by-state enrollment data from the pandemic and unwinding period vividly illustrates this divide.

States that recently expanded, like North Carolina, saw enrollment surge by 54% over the pre-pandemic baseline, as the expansion took full effect during this period.

In contrast, many non-expansion states, and even some early expansion states with restrictive administrative practices, have seen enrollment fall back to or even below pre-pandemic levels.¹

State	Medicaid Expansion Status	Feb 2020 Enrollment	Mar 2023 Enrollment	Apr 2025 Enrollment	% Change (Feb 2020-Apr 2025)
United States	N/A	71,446,354	94,349,705	78,382,471	10%
North Carolina	Expansion State (2023)	1,987,192	2,821,399	3,061,048	54%
South Dakota	Expansion State (2023)	114,339	142,669	148,806	30%
California	Expansion State (2014)	11,590,601	14,285,643	13,334,947	15%
Texas	Non-Expansion State	4,249,561	5,913,584	4,142,168	-3%
Florida	Non-Expansion State	3,514,586	5,348,633	4,015,130	14%
Montana	Expansion State (2016)	258,958	321,296	218,040	-16%
Arkansas	Expansion State (2014)	864,334	1,087,844	820,916	-5%

Source: KFF analysis of CMS data.¹

Note: Florida’s increase despite non-expansion status reflects large pandemic-era growth that has not yet fully unwound.

Arkansas and Montana show net decreases due to aggressive unwinding procedures.

A common argument against expansion is that it diverts resources from “more deserving” populations like children or individuals with disabilities.

The data refutes this claim in spectacular fashion.

A stunning and counter-intuitive finding is that expansion states don’t just spend more on the new adult group; they spend significantly more per enrollee on all eligibility groups.

For example, 2021 data shows that per-enrollee spending for individuals with disabilities was nearly 2.5 times higher in expansion states ($25,170) than in non-expansion states ($10,494).

For children, expansion states spent nearly $2,000 more per child ($6,001 vs. $4,295).²⁴

This suggests a “virtuous cycle.” States that demonstrate the political will to expand Medicaid likely have a broader commitment to a robust public safety Net. This translates into higher provider payment rates (attracting more doctors), more comprehensive benefits, and better-funded administrative systems that make it easier for people to enroll and stay enrolled.

The massive infusion of federal funds for the expansion group (initially 100%, now 90%) also frees up state dollars that can be reinvested into strengthening the entire program, lifting all boats in the reservoir.

The Hidden Channels: Race, Ethnicity, and Navigating the System

The currents of the Medicaid watershed do not flow the same way for everyone.

For communities of color, the program is both a vital lifeline and, at times, a source of systemic friction.

People of color are disproportionately represented in the Medicaid population.

While making up about 46% of the total U.S. non-elderly adult population, they account for over 60% of Medicaid beneficiaries.²⁵

The program is therefore an indispensable tool for reducing long-standing racial and ethnic disparities in health coverage and access to care.²⁶

However, the unwinding process has threatened to reverse years of progress.

The most critical finding from recent research is that the disparity appears not just in who is eligible, but in who can successfully navigate the bureaucracy.

A 2024 analysis found that Black and Hispanic adults were approximately twice as likely as their White counterparts to report losing Medicaid coverage because of an inability to complete the renewal process.²⁶

This is a procedural failure, not an eligibility failure.

It points directly to the systemic barriers that disproportionately affect communities of color: language barriers for those with Limited English Proficiency, the digital divide making online portals inaccessible, unstable housing that leads to missed mail, and a legacy of historical distrust that can make interacting with government agencies a fraught experience.

The problem is not the person, but the process.

It is a stark illustration of how systemic inequities are embedded in the very administrative channels of the watershed, creating hidden currents that can pull vulnerable people under.

It is also important to note that analysis in this area is often complicated by significant data quality issues in state reporting of race and ethnicity data, which can be incomplete or inconsistent.²⁸

Part IV: The Broken Levees: Understanding Churn and Coverage Instability

Within the Medicaid watershed, there is a powerful, destructive, and largely invisible undercurrent: churn.

Churn is the cycle of an enrollee losing coverage, only to re-enroll a few months later.⁷

This is not a marginal issue; it is a major design flaw that affects roughly one in ten Medicaid beneficiaries annually and destabilizes the entire system.⁶

The Mechanics of Churn

Churn is driven by two main factors that are inherent to the lives of low-income Americans and the structure of the program itself:

1. Income Volatility: The lives of many low-wage workers are characterized by fluctuating income. Irregular hours, seasonal work, or a small amount of overtime can push a family’s monthly income just over the rigid eligibility limit for a month or two, causing them to lose coverage before their income drops again and they re-qualify.⁶
2. Procedural Barriers: As seen during the unwinding, the single biggest driver of disenrollment is “procedural” reasons. Eligible individuals lose coverage simply because they fail to navigate the complex renewal bureaucracy. A renewal notice might be sent to an old address, a form might be too confusing to fill out correctly, or a deadline might be missed by a few days.⁶

This reveals a fundamental mismatch.

The Medicaid system, with its rigid monthly income checks and complex paperwork requirements, was largely designed for a mid-20th-century economy of stable, 9-to-5 jobs with predictable weekly paychecks.

It is profoundly ill-suited to the realities of the 21st-century low-wage labor market.

Churn is not a personal failing of the enrollee; it is a predictable and systemic failure of an outdated administrative architecture.

The Human and Systemic Cost

The consequences of this instability are severe.

For individuals, even a temporary gap in coverage can be devastating.

It disrupts relationships with trusted doctors, interrupts medication regimens for chronic conditions like diabetes or asthma, and leads people to forgo necessary preventive care.⁷

For the system, churn is incredibly wasteful.

States spend significant administrative resources disenrolling an individual, only to spend more resources processing their re-application a few months later.

The estimated administrative cost of a single churn cycle is between $400 and $600 per person.⁶

This is money that provides zero value to the health of the beneficiary and could be better spent on actual care.

The Policy Fixes: Repairing the Levees

The most effective and widely endorsed policy for combating churn is 12-month continuous eligibility.

This policy, which as of 2024 is mandatory for children, allows an individual to remain enrolled for a full year regardless of short-term income fluctuations.⁷

It essentially builds stronger levees around the enrollee, protecting them from being swept away by the chaotic currents of income volatility.

Extending this protection to adults would be the single most impactful step states could take to reduce churn, improve health outcomes, and increase administrative efficiency.

Part V: The Broader Ecosystem: Medicaid’s Impact on the Entire Landscape

The Medicaid watershed does not exist in a vacuum.

Its health, size, and stability have profound and far-reaching effects on the entire American socioeconomic landscape, acting as both a bulwark against poverty and a powerful engine for state economies.

A Bulwark Against Poverty

Medicaid is one of the nation’s most effective, if underappreciated, anti-poverty programs.³³

While it doesn’t provide cash, it provides something just as valuable: protection from the catastrophic medical expenses that are a primary driver of financial ruin in the United States.

In a single recent year, out-of-pocket health care spending pushed over 10.5 million Americans into poverty.³⁴

By covering these costs, Medicaid acts as a financial shield.

Research shows that Medicaid reduces the overall poverty rate by 3.8 percentage points.

Its impact is even more pronounced for children, for whom it reduces the poverty rate by a staggering 5.3 percentage points, and for communities of color, where it reduces poverty rates by 6.1 percentage points for Hispanics and 4.9 percentage points for African Americans.³³

For the families it covers, Medicaid is not just a health program; it is a core pillar of economic security.

An Engine for State Economies

Debates about Medicaid are often framed around its “cost” to state budgets.

This framing is fundamentally flawed and ignores the program’s role as a major driver of state economic activity.

This economic impact stems from its unique joint financing structure.

For every dollar a state invests in its Medicaid program, the federal government contributes a matching amount, known as the Federal Medical Assistance Percentage (FMAP).³⁶

This federal match, which on average is 57% and is even higher (90%) for the ACA expansion population, means that state spending on Medicaid has a powerful “multiplier effect.” It injects a massive infusion of federal dollars into a state’s economy that would not exist otherwise.³⁶

These dollars don’t just sit in a government account; they flow through the economy.

They pay the salaries of doctors, nurses, and home health aides.

They allow hospitals, especially in rural areas, to keep their doors open.

These healthcare workers then spend their income at local businesses, supporting jobs in other sectors and generating state and local tax revenue.³⁸

Because of this multiplier effect, cutting Medicaid spending is not a simple savings.

A $1 cut in state Medicaid funding does not save the state $1.

It results in the loss of that state dollar plus the corresponding federal matching dollars, leading to a much larger contraction in total economic activity, job losses, and reduced tax revenue.³⁶

Therefore, viewing Medicaid as a pure “expense” is economically shortsighted.

The data overwhelmingly support reframing Medicaid as a strategic “investment.” It is an investment that yields a significant return to the state in the form of a healthier, more productive workforce, a more stable healthcare sector, and a stronger, more resilient local economy.³⁸

Conclusion: From Turbulent Rapids to a Stable Reservoir

I think back to that Tuesday afternoon phone call.

After days of stressful calls to the state helpline, my family member was able to resolve her issue.

Her renewal paperwork had been processed incorrectly—a classic case of near-procedural churn.

She kept her coverage.

But the experience left a scar, a lingering anxiety about the fragility of the system she depends on.

Her story is one of millions.

The answer to “how many Americans are on Medicaid?” is not a single number.

It is a dynamic, ever-changing story of roughly 80 million individual lives interacting with a vast and complex system.

Viewing this system as a watershed—with its constant inflows and outflows, its powerful undercurrents of churn, and its diverse geography shaped by state policy—is the only way to move beyond the headlines and grasp the reality on the ground.

The challenge for policymakers is not simply to count the people in the water.

It is to manage the watershed itself.

It is to repair the broken levees of churn with policies like 12-month continuous eligibility.

It is to ensure the geography of state policy promotes stability and equity, recognizing the profound benefits of Medicaid expansion.

And most importantly, it is to shift the public narrative from one of “cost” to one of “investment,” acknowledging that the health of this vital ecosystem—this great American watershed—is inextricably linked to the economic security, physical well-being, and fundamental health of our nation as a whole.

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