Ninety Four Million People, One Deadline: The End of Continuous Coverage

When Continuous coverage was “unwound”, North Carolina performed better than most states overall. Its final disenrollment rate was among the lowest in the nation, while nationally Medicaid enrollment declined about 14% from March 2023 to May 2024. But this statewide figure obscures what happened in individual counties, particularly in rural communities where the administrative infrastructure for renewal outreach was thinnest.

County-level disenrollment data has not been publicly released by NC DHHS — meaning we cannot say with precision what percentage of Robeson County’s Medicaid enrollees lost coverage during the unwinding. That data gap is itself a policy problem, and this brief calls for its publication.

Even more were expected to join the rolls after expansion took effect — and 20% of the county’s residents were already uninsured, meaning those who fell off Medicaid had nowhere else to go. For Robeson County, which saw the biggest spike in enrollment relative to its size when expansion launched — more than 7,100 residents, or 10.5% of the county’s adult population, received coverage on December 1 — the scale of pre-expansion dependency tells us that even a modest disenrollment rate during the unwinding represented hundreds of families losing their only coverage pathway.

The Data at a Glance

The Procedural Disenrollment Problem

The defining feature of North Carolina’s unwinding was its high rate of procedural disenrollments — cases where people lost coverage not because they were ineligible, but because the renewal paperwork process broke down. From June through November 2023, 87% of all NC disenrollments were procedural. At its worst, the state was tied with Connecticut for the fifth highest share of procedural terminations among states reporting data.

Procedural disenrollments happen for predictable reasons:

• A DSS caseworker sends a renewal notice to an outdated address.
• A household receives the notice in English but speaks primarily Spanish or Lumbee.
• A family recognizes the official-looking letter but dismisses it as a potential scam.
• A 30-day response window expires.
• Benefits are automatically terminated.

Each of these failure points is individually avoidable. Together, in a county like Robeson — where residents are older, poorer, less digitally connected, and more linguistically diverse than the state average — they compound into a systematic exclusion of people who were both eligible and in need.

Five Months Without a Net

North Carolina’s Medicaid expansion passed in March 2023 — the same month continuous coverage ended. But expansion did not take effect until December 1, 2023. The result was a precise five-month window (July through November) during which:

• Disenrollments Peaked: Unwinding disenrollments were at their highest rate (19% of redeterminations in the pre-expansion period, vs. 12% overall).
• No Alternative Pathway: Expansion had not yet launched, so recently disenrolled residents had no new eligibility pathway.
• The Policy Gap: An estimated 20,183 residents were deemed ineligible under old rules but would have qualified under expansion.
• Overwhelmed Infrastructure: Rural DSS offices were simultaneously managing the highest volume of redeterminations in history.

"This was not a policy accident. It was a structural collision between the end of pandemic-era protections and the delayed implementation of expansion — and it landed hardest on the communities least equipped to absorb it."

Robeson County in the Eye of the Storm

Robeson County entered the unwinding period carrying every risk factor for procedural disenrollment at scale. With 63,549 Medicaid enrollees as of October 2023, the county’s DSS office faced one of the largest renewal workloads in North Carolina. Its poverty rate of approximately 28% means residents are more likely to have fluctuating incomes, seasonal employment, and addresses that change year to year.

Robeson’s Medicaid dependency is also deeper than almost anywhere else in the state. At 54% of residents enrolled before expansion, the county had almost no margin for coverage loss. The uninsured rate was already 20%, the county had no academic medical center, and marketplace plans were largely inaccessible.

The Lumbee Tribe adds a specific compounding vulnerability. As the largest Native American tribe east of the Mississippi without federal recognition, Lumbee tribal members are excluded from Indian Health Service benefits — making Medicaid their only coverage pathway.

The Day-One Enrollment Signal

When expansion launched on December 1, 2023, Robeson County had the highest adult enrollment rate in the state: 10.5% of adults — more than 7,100 residents — received coverage that day. Edgecombe (9.5%), Richmond (8.7%), and Anson (8%) followed.

This extraordinary day-one surge has been interpreted as a success story. It was also a distress signal. It tells us how many people had been waiting — and raises the question of how many of those 7,100 people had previously lost Medicaid during the unwinding and were returning to coverage.

The Re-enrollment Question: Did Expansion Close the Gap?

The aggregate state data suggests expansion helped significantly. Monthly procedural disenrollments fell 54% after December 2023. But aggregate improvement does not mean individual restoration. Three categories of people likely did not return:

1. Those who were disenrolled in July–November 2023, needed care during that gap, and experienced a health crisis.
2. Those who were procedurally disenrolled, lost confidence in the system, and did not attempt to re-enroll.
3. Those in the 20,183 who were deemed ineligible under old rules and expected to qualify under expansion, but lacked targeted outreach.

Work Requirements Are Coming

Federal legislation in 2025 introduced work requirements for the expansion population. Adults enrolled through expansion must now demonstrate employment, job training, or community service to maintain eligibility.

Work requirements function like procedural disenrollments on a scheduled basis. They require enrollees to document their status, navigate reporting systems, and comply with deadlines — exactly the administrative tasks that caused 87% of unwinding terminations in the first place.

The Cumulative Burden

Consider the Medicaid enrollment experience for a Robeson County resident who:

• Lost Medicaid during the unwinding in August 2023.
• Experienced a gap in care during the five-month pre-expansion window.
• Re-enrolled under expansion in December 2023.
• Must now demonstrate work compliance under new federal requirements.

This is a near-constant cycle of documentation, re-application, and eligibility uncertainty. Each dropout is a potential delay in cancer screening, a missed medication refill, or an untreated chronic condition.

Policy Recommendations

The following recommendations are administratively feasible, evidence-supported, and directly responsive to the barriers identified in this brief.

1. Publish County-Level Unwinding Analysis

NC DHHS should publish a retrospective analysis of unwinding disenrollments and subsequent re-enrollment rates by county.

2. Create Automatic Re-enrollment Protections

NC DHHS should request a CMS-approved state plan amendment or waiver authority to build automatic grace periods and re-enrollment pathways for residents navigating procedural issues.

3. Fund Permanent Navigator Infrastructure

In counties like Robeson, navigator services should be permanently funded through the state Medicaid plan and embedded in FQHCs and county health departments.

4. Invest in DSS Capacity in Rural Counties

Implementing work requirement verification without additional investment in DSS capacity is a formula for another wave of procedural disenrollments.

Conclusion

North Carolina’s Medicaid unwinding is officially over. Expansion arrived. But for some people, it arrived too late — and the system that was supposed to welcome them back has no formal record of what they went through to get there.

The unwinding revealed something important about how North Carolina’s Medicaid system works under pressure: it defaults to administrative correctness over coverage preservation. The recommendations in this brief are the minimum infrastructure needed to prevent the next gap from looking like the last one.