Medicaid and the Great Unwinding: The Administrative Presidency Meets Federalism

In the context of America's fragmented health insurance system, federal policy makers frequently turn to Medicaid to temporarily assist the blameless victims of societal crises. In this vein, the COVID pandemic triggered passage of major legislation that led Medicaid enrollments to soar. The end of the public health emergency presented the Biden administration and state Medicaid programs with the daunting task of implementing the "great unwinding"-redetermining eligibility for millions of enrollees. This article describes the core strategies the Biden administration employed to induce state implementing agents to minimize inappropriate Medicaid disenrollments during the unwinding. Preliminary data suggest great variation in state responses to the Biden strategic initiatives. On balance, however, the Biden administrative presidency appears to have made headway in nudging states toward more take-up-friendly renewal processes. The article also discusses the implications of the great unwinding for more general efforts to enhance Medicaid participation rates.