For three years during the COVID-19 pandemic, people did not have to go through any kind of renewal process to stay on Medicaid.

That changed in April, and now every state is winnowing its rolls — some much more quickly than others. Texas reported disenrolling 82% of its Medicaid recipients it had processed through May, while Wyoming shed just 8% of its rolls, according to an analysis by KFF, a health policy research organization.

At least 3.7 million people have lost Medicaid, including at least 500,784 Texans in just the first month, according to reports from 41 states and the District of Columbia that KFF analyzed. And 74% of people, on average, are losing coverage for "paperwork reasons," says Jennifer Tolbert, director of state health reform at KFF. She described some of those reasons.

"They didn't get the renewal notice in time. They didn't understand what they needed to do," says Tolbert. "Or they submitted the documents, but the state was unable to process those documents before their coverage was ended."

Dramatic growth, now unwinding

Medicaid grew dramatically during the pandemic. Just a few months ago — in March — the number of people on Medicaid was 93 million. That's about 1 in 4 people in the U.S. on Medicaid, which is the government health program for people with low incomes and for some with disabilities.

Medicaid is jointly funded by states and the federal government, and each state manages its own program. That's what accounts for the wide variation in how states are handling what has been called the Great Unwinding.

Tolbert says they don't have all the information to understand exactly what's driving the dramatic state-to-state variation.

"We can see it, but we don't exactly know what's behind it," she says.

Of course, some people are losing Medicaid coverage because they don't qualify anymore — they may have a new job that offers health insurance, or they may make too much money to qualify now.

Losing your coverage is known as a "qualifying event," and it means people can sign up for different health insurance — either from an employer or on HealthCare.gov — without having to wait for open enrollment. Also, many people who can't get health insurance from work will qualify for a plan with a very low monthly payment from HealthCare.gov.

Tolbert notes that some people who were wrongly cut off Medicaid will quickly reenroll — but even losing coverage briefly can be very disruptive and stressful if you're sick or can't get your medicine.

Lost in translation

Communication hurdles may account for some people getting wrongly kicked off Medicaid.

In Arkansas, for instance, advocates noticed a problem in the northwest corner of the state with a community of people who are from the Marshall Islands originally. The state had translated renewal documents, but the wrong message seemed to be getting through, says Keesa Smith, who now works at the nonprofit Arkansas Advocates for Children and Families and formerly worked for the state's Department of Human Services.

"The documents that DHS had had translated into Marshallese actually came off as being very aggressive," says Smith, who was speaking at a webinar with the Center for Health Journalism at the University of Southern California. "The one thing that did translate was that these individuals had done something drastically wrong."

KFF estimates that as many as 24 million people will lose Medicaid over the next year.