As states prepare to implement the newly passed federal Medicaid work requirements, the lessons learned from the COVID-19 Public Health Emergency (PHE) Medicaid unwind offer a critical blueprint. Beyond the technical and administrative challenges of redeterminations, the unwind process underscored a deeper truth: community trust, culturally responsive outreach, and proactive engagement are essential to preserving coverage for eligible individuals. With millions at risk of losing Medicaid due to new work requirement policies, states must prioritize building meaningful connections with enrollees—particularly with communities historically marginalized by health systems.
The Medicaid unwind revealed the consequences of fragmented communication strategies and administrative churn. Enrollees frequently lost coverage not because they were ineligible, but because outreach failed to reach them. Between 15% and 50% of renewal notices were returned to states as undeliverable. To mitigate this, some states innovated by embracing modern communication methods, such as text messages, emails, and direct phone calls. States like Maine and Louisiana demonstrated that outbound calls and personalized contact could help thousands of households complete their renewals. Going forward, these practices should be expanded—not just as logistical tools, but as part of a broader effort to build trust and foster relationships with Medicaid members, particularly those facing language barriers, housing instability, or past discrimination in health care settings.
Robust community engagement will be the key marker of success in implementing Medicaid work requirements. Many enrollees who will be subject to these requirements are already connected to programs like SNAP and TANF, which have similar provisions. State agencies must partner with local organizations, workforce commissions, and Departments of Labor to create seamless, integrated systems that support enrollees through these new processes. But the infrastructure alone isn’t enough. States need to engage trusted community leaders, community-based organizations, direct care providers, and grassroots advocates to help explain the rules, navigate reporting obligations, and address fears about losing coverage. Outreach must be tailored—accounting for language needs, cultural contexts, and the lived experiences of people who have faced systemic barriers to care.
Managed Care Organizations (MCOs) also have a critical role to play in community engagement. With 80% of Medicaid expansion beneficiaries enrolled in MCOs, these organizations are well-positioned to assist states in maintaining contact with members, educating enrollees about new requirements, and identifying those at risk of disenrollment. MCOs should be contractually encouraged or required to partner with community-based organizations to conduct outreach and facilitate real-time updates to contact information, employment status, and exemptions. This collaboration can help prevent care disruptions and maintain the stability of health care systems that serve vulnerable populations.
Equity must remain at the forefront of these efforts. During the unwind, Black, Hispanic, American Indian, and Alaska Native individuals, as well as people with disabilities, disproportionately lost Medicaid coverage due to administrative barriers. To avoid repeating this harm, states must invest in strategies that center the voices of enrollees themselves. Transparent data reporting, including disaggregated data by race, ethnicity, disability, and geography, will help states monitor for unintended consequences and adjust interventions as needed.
Ultimately, the implementation of Medicaid work requirements will test the resilience and compassion of public health infrastructure. It is not simply a policy exercise—it is a community health imperative. By embracing lessons from the unwind, centering community trust, and forging authentic partnerships with the organizations closest to the people Medicaid serves, states can minimize unnecessary coverage loss and protect access to care for those who need it most.