The unwinding lesson that rarely makes the summaries is about eligibility logic. In 2023, 29 states turned out to be running renewals at the household level instead of the individual level, and about 420,000 people, many of them children, lost coverage before anyone caught it. The work requirement rules carry far more branching than that. Exclusions have to be checked person by person before activity is considered, medical frailty depends on a 12-month claims lookback, and the parent of a 13-year-old is treated differently from the parent of a 14-year-old. All of it is being built quickly, against a rule that's still being litigated. Expect a defect of that kind to surface somewhere in 2027, and the states that find their own will be in a far better position than the ones that hear about it from CMS.
The second weak point is the mailbox. Nebraska's losses are mostly non-response, and non-response usually starts with returned mail, outdated addresses and notices nobody opens. Paper is still the legal default, and CMS assumes 75% of enrollees will never opt into electronic notices. The rule does give states an opening, though. Every outreach notice has to go out through a minimum of two channels, which can include text, phone or the member's online account. Most states will treat that second channel as a compliance requirement but in fact, it's one of the most useful tools states have for proactive communication.
States have some experience to draw on here. At least 15 states texted enrollees during the unwinding, several for the first time, and the results were mixed. Florida's texts caused panic, partly because of poor translations. Digital outreach works when it gets the same care as the notice itself: plain language, real translation, testing with actual members. It also works better as a sequence than as a single message—a text before the letter arrives, a reminder before the deadline, and a call from the health plan when neither gets a response.
Timing matters as well. Current enrollees are first checked at their first renewal on or after January 1, so once notice periods and disenrollment timing play out, the first real wave of losses lands between February and April. States are heading into that window with less capacity than they had in 2023. The longest average peak call wait time in any state during the unwinding was 72 minutes. In the first quarter of 2026, Hawaii's was 193.
