Although wound care is not recognized officially as a medical specialty or subspecialty, it is crucial for hundreds of patients in nursing facilities or long-term care. Wound care medicine focuses on treating lingering injuries or those that do not heal, including foot and venous stasis ulcers, surgical wounds, and deep pressure sores. These injuries are considered silent killers in nursing homes, as untreated sores and wounds can quickly lead to infection and even death in nursing home patients, the majority of whom are elderly and immunocompromised. For these patients, the importance of Medicaid coverage cannot be understated; it is not only a bastion of American public health, but also their lifeline.

“A significant portion of my patients in these nursing homes are African-American and Latinx-American from nearby neighborhoods with limited healthcare access. As a result, Medicaid becomes one of the only things that allows for their nursing centers to pay for treatments for diabetic or vascular conditions, including my services in addressing wounds,” according to Uchechukwa Osadebe, MD—a wound care physician at some of New York City’s most notable nursing homes and long-term care facilities, including Ditmas Park Nursing in Brooklyn, Beth Abraham Center in The Bronx, and at NYC Health + Hospitals/McKinney in Brooklyn.

Based on the Centers for Medicare and Medicaid Services (CMS.gov), over 90.8 million Americans, including over 1.2 million nursing home residents, were enrolled in Medicaid as of 2022. During the COVID-19 pandemic, these enrollees were protected under Medicaid through the Families First Coronavirus Act, which ensured continued coverage through the public health emergency (PHE) and paused any disenrollment. However, one month before Congress ended the COVID-19 PHE on May 11, 2023, millions of Americans lost their Medicaid coverage due to mass “unwindings” conducted by states to reevaluate their eligibility.

During this unwinding process, over 25 million people were disenrolled, and these affected Americans disproportionately, with several Midwestern states experiencing over double the disenrollment rate as other states. Of the millions of disenrolled Americans, 73% were due to procedural reasons rather than ineligibility. These reasons include missed deadlines, language barriers, digital access issues, and failure to complete renewal forms—factors that disproportionately affect racial minorities more than other groups of low-income Americans. Indeed, a recent study led by Northwestern University in 2024 revealed that Black and Hispanic Americans were twice as likely to be disenrolled due to procedural and administrative issues during the

post-COVID unwinding period as white Americans. The disparities in post-COVID disenrollment are especially relevant because nursing homes, hospice, or home care are mainly funded through Medicaid. Furthermore, emergency Medicaid provides lifesaving coverage for the undocumented and immigrants who are ineligible due to being undocumented or having lived in the United States for less than five years.

With all of the uncertainty due to the current Trump administration, especially the GOP’s proposed $2.3 trillion cuts to mandatory spending and Medicaid funding, it is paramount to understand how disenrollment has affected low-income Americans, predominantly Black and Hispanic Americans, and what can be done to restore this medical care to them. Many changes can be instituted at the state level to address the problem of procedural disenrollments and protect Medicaid for underserved communities. To begin, states can take advantage of Medicaid Section 1115 waivers, which are individual states’ guidelines for testing new methods for delivering and paying Medicaid services passed under section 1915 of the Social Security Act. These waivers can be considered policy amendments that can pilot new initiatives or test out significant changes to state Medicaid policies. Within these proposed Section 1115 waivers, states should propose automatic re-enrollment or grace periods for procedural disenrollments. As an alternative to automatic re-enrollment, these 1115 waivers can also propose continuous eligibility models, which have been enacted in Oregon and protect coverage for enrollees who experience a change in family size or income.

Procedural disenrollments highlight the flaws in Medicaid’s administrative infrastructure and policies at both the state and federal levels, thus confirming the racial and socioeconomic disparities in healthcare access post-pandemic. Especially under the current administration, Medicaid disenrollment contributes to worse health outcomes, increased burdens across America’s hospitals and care facilities, and overall greater financial strain. These protective policies and amendments to current Medicaid legislation, especially through utilizing Section 1115 waivers, are the means by which the United States can mitigate future disenrollment, especially for procedural reasons.