Texas has removed about 1.8 million people from its Medicaid health coverage program over the past two years, according to data from KFF, a nonprofit health policy research and news organization. This is one of the largest coverage losses in the country since pandemic-era protections ended. The speed and scale of the process have drawn national attention, especially with children making up most of those dropped.
During the COVID-19 emergency, a federal rule prevented states from removing people from Medicaid. That rule ended in March 2023. Texas, like other states, began checking eligibility again through a process called “unwinding.” Texas removed most of the 1.8 million people in the first year of that review.
Most Removals Were Bureaucratic, Not Based on Eligibility
Texas removed most people not because they became ineligible for health coverage, but only due to missing paperwork or procedural issues. Nearly 1.4 million Texans lost coverage this way. That includes children, pregnant women, and people with disabilities. Research suggests that about 30% of those who lost coverage remain uninsured.
Children suffered the most from these administrative failures. Texas has removed more than 1 million children from Medicaid. More than any other state. Worsening the state’s already high uninsured child rate. These children make up 65% of those dropped from coverage, even though children typically qualify for Medicaid at higher income levels and face fewer eligibility restrictions.
One reason for the high number of procedural removals is that Texas relied very little on automatic renewals. These automatic renewals use existing government data to confirm eligibility without requiring paperwork from recipients. Initially, Texas handled fewer than 5% of cases this way. By late 2024, the rate reached only 13%, well below the national median of 56%.
Why Texas Saw Steeper Declines
Texas experienced a rate of decline faster than other large states like Florida, California, and New York. Together, these four states accounted for 36% of total Medicaid enrollment nationwide and subsequently made up 31% of the coverage losses during the unwinding period.
The steeper drops in Texas result from several factors beyond population size. Timothy McBride, a professor of public health at Washington University, told media outlets this comes from “higher poverty rates, especially in Florida and Texas, fewer good jobs that offer health insurance, and a higher percentage of nonwhite persons, especially in Florida, Texas, and California.” All these groups are more likely to rely on Medicaid when private coverage isn’t available. Without employer-sponsored insurance, more Texans turned to Medicaid during the pandemic, creating a larger pool of enrollees subject to the unwinding process.
State and Federal Roles in the Process
Federal guidance required Texas to review eligibility for 6 million people in one year. A spokesperson for the Texas Health and Human Services Commission shared that when the state removes people from coverage, it is “committed to ensuring that those qualified for benefits receive them.” The state worked closely with the Centers for Medicare & Medicaid Services throughout the public health emergency and the Medicaid unwind process.
State officials said they followed federal rules while meeting regularly with federal partners. Still, the state later admitted that 95,000 people had been wrongly removed, including more than 30,000 children who should have been moved to CHIP. CHIP is the Children’s Health Insurance Program that covers families earning too much for Medicaid.
Texas had one of the most aggressive approaches to unwinding. Five states had disenrollment rates over 50%, and Texas was among them. Between March 2023 and March 2025, enrollment in the state dropped from 5.9 million to just over 4.1 million. The decline was so steep that Texas ended up as one of only nine states nationwide where enrollment fell below pre-pandemic levels.
Consequences for Health and the Medicaid System
The coverage loss has made healthcare access harder for many people. Over half of those dropped from Medicaid skipped or delayed medical appointments during the renewal process. For people with chronic illnesses or mental health conditions, these delays can lead to serious outcomes and higher personal costs. McBride said this can mean “delays in seeking needed medical care leading to worse outcomes, lack of prevention, which is especially problematic if they have chronic conditions, bad mental health and financial outcomes, and higher medical debt since they have to pay for more out of pocket.”
Although most people eventually kept or regained coverage, about 8% of pre-unwinding enrollees are now uninsured. In Texas, this includes hundreds of thousands of people who may now rely on emergency rooms for care or go without it altogether.
Texas also faces a growing backlog. By March 2024, average processing times reached nearly three months, with more than 200,000 applications awaiting review. Health policy experts warn of additional challenges ahead. Texas has seen major growth in its health insurance marketplace in recent years as federal subsidies increased, but upcoming projected decreases in those marketplacesubsidies could lead to further coverage losses.
Federal Concerns Over Child Coverage Loss
Nine states, including Texas, account for 60% of children who lost Medicaid. Federal officials have raised concerns and urged these states to use every available tool to keep eligible children covered. Even after the unwinding, Texas continues to have the highest uninsured rate in the country. The loss of coverage is adding pressure to a system already stretched thin.
As premium tax credits expire, up to 1.7 million more Texans could lose marketplace coverage. The state that removes people from Medicaid at one of the highest rates in the country now faces widening coverage holes and growing pressure on its health systems, all while the number of uninsured continues to rise in Texas.
For many families, the issue is no longer whether they qualify for coverage. It is whether they can stay in the system long enough to receive the care they need.
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