As states prepared to end a pandemic-era promise earlier this year that everyone on Medicaid could keep their health coverage, the Biden administration sought to quell fears that millions of people would become newly uninsured. A policy favorite of the president’s – Affordable Care Act insurance marketplaces – would offer a haven for people losing Medicaid because their incomes had grown too high to qualify, his aides pledged.

Yet in the months since the culling began within the nation’s largest public insurance program, the insurance marketplaces selling low-cost, private health plans so far are serving a surprisingly small role as a backstop for 2 million people across the country dropped from the safety-net coverage because they no longer are eligible.

Interviews with insurance exchanges, enrollment coaches, and health-care advocates in 10 states, plus leading health policy experts, suggest the administration’s prediction of a smooth transition from Medicaid to the marketplaces is a reality in a few states – but a myth in other parts of the country.

“The whole system has seized up,” said Sara Rosenbaum, a health law and policy professor at George Washington University. In places where the bureaucracy of Medicaid renewals is proving especially choppy, “the marketplaces are unable to process applications.”

The slow embrace of these alternate health plans is having ripple effects on consumers and the health-care system alike, with some people jettisoned from Medicaid having gaps in coverage, while clinicians and hospitals discover some of their patients have no means of paying their bills.

An undertaking of unprecedented scale playing out in every state, the unwinding marks the return of Medicaid’s usual renewal process, with low-income people having to demonstrate annually that they qualify for the public health insurance program, a joint responsibility of the federal government and states. Renewals were suspended for three years during the coronavirus pandemic, causing Medicaid caseloads to balloon. States were allowed to resume removing people from Medicaid rolls starting in April, and they phased in their unwinding, with most planning to complete the process over 12 months.

The ground-level effects vary considerably, from state to state.

In Virginia, cases often are sent over from the state’s Medicaid agency without essential information about whether income had caused recipients to be ruled ineligible for the public insurance system for the poor, according to Rosenbaum, who volunteers there to help people transition to ACA health plans. And confusion among consumers is rampant, she said, because notices sent to Medicaid beneficiaries who are being dropped “do such a poor job explaining anything, people just don’t know what to do.”

When volunteers, such as herself, try to call the Medicaid agency for information about a case, Rosenbaum said, “we can’t get anyone on the phone in Virginia. These states are overwhelmed.”

The Virginia Department of Medical Assistance Services did not respond to repeated requests for comment.

Even in states doing everything they can to ease the transition from Medicaid, only a small fraction of consumers eligible for marketplace health plans have enrolled.

Two states are chipping in their own money to help pay insurance premiums for ACA plans, with New Mexico covering the first month and Rhode Island the first two months if people’s earnings are below certain limits. The idea is to help consumers leaving Medicaid rolls acclimate to health plans that, depending on a consumer’s income, can come with a monthly fee.

In addition, Rhode Island is one of four states taking the additional step of automatically enrolling in ACA plans some people purged from Medicaid and then asked if they wanted the coverage. And New Mexico’s exchange, BeWellnm, is mounting an outreach campaign with more than 450,000 calls, texts, and emails so far urging consumers to sign up if they’re about to be dropped from Medicaid.

Even under such best-case scenarios, about 16 percent of those in Rhode Island and 9 percent in New Mexico removed from Medicaid because their income exceeds eligibility thresholds have adopted ACA coverage, those states’ most recent figures show.

In other states, Medicaid agencies and the insurance marketplaces are more disjointed. Under federal rules, notices informing consumers they no longer qualify are supposed to include information about how to contact an ACA insurance exchange. Health-care advocates say that, in some states, those notices can be unclear or, on occasion, missing any mention of marketplace coverage.

The government requires Medicaid agencies to electronically transfer to marketplaces the cases of consumers who appear eligible for ACA coverage. However, some cases are transferred with outdated addresses or phone numbers, making it difficult for the exchanges or enrollment coaches known as navigators to reach people who might benefit.

Such bureaucratic hindrances are surfacing at the same time an unexpectedly large proportion of beneficiaries are being severed from Medicaid for paperwork reasons, rather than because of outright ineligibility. About one-fourth of 7.5 million people across the country cut off from Medicaid so far have been found ineligible, according to tracking by KFF, a health policy organization. For everyone else, the marketplaces either do not receive the case or lack income information to see whether a consumer qualifies for an ACA plan.

As officials from the Biden administration and states planned for the massive review of Medicaid rolls – known as unwinding – the fate of people losing such coverage was a major consideration.

President Biden has long been a fervent proponent of expanding access to health coverage and now is a candidate for reelection. For both reasons, his administration is eager to avoid any spike in uninsured Americans as the unwinding proceeds. The insurance marketplaces, created under the 2010 Affordable Care Act, are designed for people who cannot get affordable health benefits through a job. That law created federal subsidies that help most of those on such health plans with the monthly premiums. The subsidies were recently improved by Congress – a change the president cites often.

While administration officials never expected the insurance marketplaces to be a haven for everyone losing Medicaid, they are “an incredibly important component” of the unwinding, said Ellen Montz, deputy administrator and director of the Center for Consumer Information and Insurance Oversight, a part of the Health and Human Services Department responsible for many aspects of the ACA.

Montz said her agency has “used every tool in the toolbox that we can find” in working with Medicaid agencies, state insurance departments, enrollment coaches, and insurance brokers to connect people removed from Medicaid with ACA exchanges.

“Unfortunately, coverage transitions between Medicaid . . . and the marketplace are not automatic,” Montz said. “They take time and effort and, importantly, active engagement from a consumer to enroll in that marketplace coverage.”

Until now, federal officials have refused to release data showing how many people leaving Medicaid have an ACA plan. Once they do, the initial figures – expected at the end of this month – will lag, covering the unwinding’s first two or three months.

So far, according to KFF, about 2 million people have been ruled ineligible for Medicaid – as opposed to the millions more who have lost benefits because of paperwork issues. Knowing exactly how many extra people are becoming uninsured will take considerable time – with census data a year from now beginning to tell the official story. Nor is it clear how many of the ineligible no longer needed that coverage because they have gotten health benefits through work.

And exchange directors point out that marketplace health plans could become more popular over time.

What is clear is that people dropped from Medicaid rolls find themselves in vastly disparate circumstances, depending on where they live.

In Albuquerque, Lorraine Martinez, 62, became seriously ill about five years ago with lupus, two other autoimmune diseases, and a slow-growing kidney cancer in addition to long-standing liver problems. As she became less able to work, and finally stopped, she relied on savings from a busy career doing administrative work. In spring 2021, she applied for Medicaid and disability benefits. The disability application has still not been decided, but Medicaid paid for her doctors, medicines, and scans.

“Medicaid was critical,” Martinez said. “I was blessed with it.”

In April, her savings gone, she began drawing early Social Security benefits. It came at a cost: She turned out to be $61 a month above the income threshold for Medicaid. “I was totally panicked,” she said, not knowing how she would afford monthly infusions to treat her lupus, costing $2,000 each – more than her monthly income – if she had to pay for them herself.

She received an email announcing enrollment events by BeWellnm, the state’s ACA marketplace, for people losing Medicaid. At an event at a public library, she received help applying for a health plan, Ambetter, run by the same insurance company that provided her Medicaid coverage. She qualified for the marketplace plan without a monthly premium.

Her new coverage began Sept. 1, the day after her Medicaid ended. She worried whether it would cover her infusions. It does.

About 1,500 miles to the east, just outside Charleston, W.Va., Patricia Jones is also 62 and began getting Medicaid nine years ago, when her husband, a plumber with heart and lung trouble, received disability benefits. He died in March. Weeks later, a letter arrived saying she needed to renew her Medicaid. A notice from the West Virginia Department of Health and Human Resources, dated June 26, said her income exceeds the eligibility limit. She gets $1,765 a month in disability survivor’s benefits – $149 too much. Her Medicaid ended five days later.

The four-page notice says nothing about the ACA marketplace, even though federal rules say it should. Her daughter-in-law phoned the state health department and reached a supervisor to ask what Jones could be eligible for. “He basically told me she didn’t have any options,” Brandi Jones, the daughter-in-law, recalled. “It was nerve-racking because of all her health conditions.”

Before her Medicaid ended, Patricia Jones saw a cardiologist every few months for an uneven heart rhythm and a leaky valve. She saw an infectious disease doctor because a blood infection in an arm traveled to her knee, which then needed to be replaced. She still is on an anti-bacterial medicine – one of 15 prescription drugs she needs. “I can’t afford to pay nobody,” she said. She discovered that a Charleston clinic, Health Right, would provide her with all but three of her medicines for free.

She reapplied for Medicaid and was turned down a second time because of her income. Then, she got help from a clinic staffer to apply again. “Same old thing,” she said. She was rejected a third time, with no mention of any other path to insurance coverage.

Jones would like to go back to her cardiologist, to check the valve, to see whether her heartbeat is in rhythm. She said that at Health Right, which serves an important community need but struggles to provide medical specialists, she has been told she might get in to see a heart doctor in about a year.

Sarah Young, West Virginia’s deputy Medicaid commissioner, said notices denying Medicaid recently have begun to include recommendations to contact the ACA insurance exchange if a case is transferred automatically to the marketplace. But a case is not always transferred for a variety of reasons, Young said, including if a person does not appear eligible for an ACA plan or if income information on their Medicaid application was incomplete.

West Virginia is one of 30 states that rely on a federal ACA marketplace, which uses the enrollment website HealthCare.gov. In those states, no state agency is keeping tabs on how many former Medicaid beneficiaries have been joining ACA plans – unlike tracking by similar marketplaces run by 20 states and the District of Columbia.

To help with the transition from Medicaid to the federal marketplace, HHS officials recently created a program in which the state agencies forward to HealthCare.gov the cases of people ruled ineligible for Medicaid. Those cases are then farmed out to navigators and a federal contractor who are supposed to contact those losing Medicaid and help them apply for an ACA plan.

“Does it work perfectly, no, [but] I’ve been very excited,” said Julia Holloway, director of navigator services for Affiliated Service Providers of Indiana, which is participating in the program to help people get an ACA plan. She said her group has received about 5,400 referrals, calling each up to three times. It has had 2,500 appointments to discuss marketplace coverage. She did not say how many have picked a plan.

In North Carolina, Nicholas Riggs, a Legal Aid attorney and director of that state’s navigator consortium, said in August that the number of referred cases was “coming in at a trickle” of a few hundred. More recently, he said some people losing Medicaid have begun to contact navigators on their own and that the transitions to marketplace health plans were still slow but starting to pick up.

“There’s still too much chaos with this,” said Jodi A. Ray, director of Florida’s largest navigator group, Florida Covering Kids & Families. Many referred cases have missing or wrong phone numbers and addresses, she said, so a lot of the mail her group sends out is returned. Plus, the notices from the state’s Medicaid agency denying coverage “are just horrific,” Ray said, without clear information about how to apply for an ACA health plan.

States that run their own ACA insurance exchanges have an advantage, because they can design their approaches to help people losing Medicaid convert to different coverage.

Rhode Island and three other states – California, Maryland, and Massachusetts – have automatic enrollment into ACA health plans for certain consumers, offering a choice of whether to keep a plan or jettison it.

Perhaps no state is trying harder than California, where Medi-Cal, the state’s version of Medicaid, and Covered California, the insurance exchange, share a common enrollment and eligibility system. When consumers are found ineligible for Medicaid, the two issue a joint letter saying the state wants to keep them insured. Covered California selects a health plan, estimates the cost, and tells people to reply whether they want it – or a different plan. “Everything is there waiting for them,” said Jessica Altman, Covered California’s executive director.

For July, the most recent month with data available, almost 37,000 cases were transferred to the exchange, and nearly 11,000 of them included clear enough information for automatic enrollment in a health plan. But when it came time to begin paying monthly premiums, just over 3,000 consumers kept their plans.

Like Altman in California, Russell W. Cook, executive director of Nevada’s Silver State Health Insurance Exchange, wants to understand why more people aren’t buying health plans. Early on, he said, a technical glitch prevented phone numbers transferred from Nevada’s Medicaid agency from being recognized by the marketplace’s software. That was fixed in July, and, since then, 10 marketplace employees have been making calls to encourage sign-ups. Cook said he has found “a lot of people are understandably leery when a government agency calls them, so we need to be delicate.”

From July to August, the proportion of eligible people getting health plans rose slightly – from about 3 percent to slightly more than 4 percent, or just over 500 Nevadans out of more than 12,000 referred from the Medicaid agency.

“It’s an extraordinarily difficult problem to solve,” Cook said. “That’s what we are seeing on the ground.”

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