The number of people enrolled in Medicaid and Affordable Care Act plans fell by more than 5 million over the past year, according to a new report from the advocacy group Protect Our Care. The decline stems from President Donald Trump's "big, beautiful" reconciliation bill — signed into law last July — and the expiration of enhanced ACA subsidies that expired in December after Republicans declined to extend them.
The legislation includes nearly $1 trillion in Medicaid cuts over 10 years. When the enhanced subsidies lapsed, millions of enrollees faced double- to triple-digit premium increases for their health plans.
Health policy experts had warned that these two changes would significantly reduce health coverage in the United States. The Congressional Budget Office, a nonpartisan federal agency, estimated last year that there could be roughly 15 million additional uninsured people by 2034 due to the Medicaid reductions and expiring subsidies.
The findings are based on enrollment data from the Centers for Medicare & Medicaid Services and an analysis of Medicaid figures by the Georgetown University Center for Children and Families. The report found that Medicaid and Children's Health Insurance Program enrollment fell by about 3.8 million people since last June, while ACA plan enrollment declined by roughly 1.2 million.
What the Left Is Saying
Brad Woodhouse, executive director of Protect Our Care, said the enrollment decline marks a significant shift in coverage trends. "We're already at 5 million," Woodhouse said. "This is going to get worse." He warned that people who lose insurance often delay or forgo care until their conditions become more serious. "People who lack coverage get sicker sooner and they die earlier," he said. "People put off going to the doctor or they can't even afford to go to a doctor, so they put off getting any care until they're sicker than they would have been otherwise."
Lawrence Gostin, director of the O'Neill Institute for National and Global Health Law at Georgetown University, called the enrollment decline an entirely foreseeable outcome. "This was an entirely predictable consequence of the multilayered cuts and restrictions on eligibility," Gostin said. He added that the policy changes would result in significant human costs. "It will cost Americans in lost lives and economic distress."
Woodhouse also pointed to broader fiscal implications. He said treating uninsured patients ultimately increases costs for taxpayers. "It just all contributes to this affordability crisis that the American people are faced with," he said.
What the Right Is Saying
Before this year's enrollment declines, ACA enrollment had been rising steadily for several years and reached a record 22.3 million sign-ups last year. Some Republican supporters of the legislation have argued that the Medicaid cuts were necessary to address federal spending concerns and put the program on a more sustainable path.
The reconciliation law's proponents have emphasized provisions designed to promote workforce participation through Medicaid work requirements, which are set to begin in most states in January. Nebraska has already implemented the new rules, and Montana is expected to follow next month. Supporters have said such requirements encourage self-sufficiency and can help connect beneficiaries with employment opportunities.
Health policy experts from varying perspectives have noted that some portion of the enrollment decline may reflect people transitioning to job-based insurance rather than losing coverage entirely. This transition effect complicates assessments of how many individuals have genuinely lost access to health care.
What the Numbers Show
The enrollment figures come from Protect Our Care, an advocacy group, and draw on data from CMS as well as analysis by Georgetown University's Center for Children and Families. According to the report: Medicaid and CHIP enrollment fell by approximately 3.8 million people since last June, while ACA plan enrollment declined by about 1.2 million.
All but three states — Alabama, Missouri, and Montana — saw a decline in Medicaid and CHIP enrollment. The states with the largest declines were Indiana, Louisiana, Arizona, Rhode Island, and Delaware. For ACA plans, enrollment fell by more than 10% in 12 states, with North Carolina, Ohio, West Virginia, Indiana, and Delaware experiencing the most significant drops.
The CBO's projection of roughly 15 million additional uninsured people by 2034 represents a baseline estimate made before some policy changes took full effect. Medicaid work requirements are set to begin in January for most states, and CMS guidance announced in June could make medical exemptions harder to obtain — changes that experts say may drive further enrollment declines.
Before this year, ACA enrollment had been climbing for several years, reaching 22.3 million sign-ups last year. Medicaid enrollment surged during the Covid-19 pandemic but began declining in 2023 after states rolled back pandemic-era protections.
The Bottom Line
The 5-million-person decline represents one of the largest contractions in U.S. health coverage in recent memory. The two primary drivers — federal Medicaid cuts and expired ACA subsidies — are expected to continue pushing enrollment downward as remaining provisions of the reconciliation law take effect.
Medicaid work requirements, set to begin in most states in January, represent the next major phase of change. Experts say these rules could accelerate coverage losses beyond current levels. CMS guidance released in June could further restrict medical exemptions available under the new requirements.
Watch for state-level implementation data as Nebraska's early rollout and Montana's upcoming adoption provide early indicators of how work requirements affect enrollment. Congressional budget analysts will also update their projections as more policy changes take hold, which could revise the 15-million uninsured estimate upward or downward.