Multiple Democratic lawmakers have claimed that 8 million Americans have lost healthcare coverage as a result of the Trump-backed budget reconciliation bill that passed a year ago, known as the One Big Beautiful Bill Act. But experts told us the enrollment declines seen to date are largely due to other factors — including other Trump administration policies.
Enrollment in Medicaid and the Affordable Care Act marketplace has indeed declined by about 8 million since the start of President Donald Trump’s second term. But most of the healthcare-related provisions of the OBBBA — which are eventually expected to cause millions of people to lose insurance — haven’t yet taken effect.
The decline in Affordable Care Act enrollment came after the expiration of more generous subsidies at the end of last year made premiums more expensive, leading many people to drop coverage. Democrats have sought to tie the expiration of those subsidies to other healthcare cuts in the OBBBA, but they were set to lapse whether or not that bill passed.
It’s less clear why Medicaid enrollment has fallen, but experts told us confusion over the OBBBA, fear of Trump’s immigration crackdown, pressure on states to address purported fraud, state-level restrictions and other factors could all be playing some role.
“We’re seeing this before the direct effects of H.R. 1 are kicking in,” said Joan Alker, a research professor at Georgetown University and director of the school’s Center for Children and Families, referring to the bill number of the OBBBA.
Under the OBBBA, states that expanded Medicaid to working-age adults will have to implement work requirements and more frequent eligibility checks, among other changes. The nonpartisan Congressional Budget Office has projected that the law’s Medicaid provisions will result in 7.5 million more people without health insurance by 2034.
The law also includes changes to ACA marketplace coverage, including tightening immigrant eligibility and heightening verification requirements, that CBO projects could result in an additional 2.1 million uninsured by 2034 — separate and apart from the impacts of the loss of enhanced subsidies.
Most of those provisions don’t take effect until late 2026 or next year, though Nebraska and Montana have implemented the work requirements early and a third state, Iowa, will do so Dec. 1.
Even so, multiple Democratic lawmakers used the one-year anniversary of the law’s passage earlier this month to claim or imply that the OBBBA has already thrown millions off of health insurance.
“The big, bad, terrible bill that they passed a year ago and are now celebrating has taken health insurance away from more than 8 million people,” Rep. Brad Schneider, a Democrat from Illinois, said July 6 on CNN. “And it’s expected that that number will continue to grow.”
Rep. Seth Magaziner, a Rhode Island Democrat, made a similar statement in a House floor speech a week earlier.
“Eight million Americans lost their health insurance,” he said. “Millions more have seen their health insurance premiums go up by hundreds and thousands of dollars. … Why? Because our Republican colleagues passed the big ugly bill last year that cut funding from health care in order to fund tax cuts for billionaires and big corporations.”
Democratic Sen. Elizabeth Warren of Massachusetts invoked the same figure in a July 2 Facebook post.
“This week marks one year of Donald Trump’s ‘Big Beautiful Bill,’” she said in the post. “8 million Americans have lost their health insurance while the world’s richest companies have received billions in tax handouts.”
Asked about that statement, a spokesperson for Warren’s office framed the expiration of the enhanced marketplace subsidies as part of the OBBBA and cited an analysis from the left-leaning advocacy group Protect Our Care. The group’s late June analysis said that 8 million people have lost coverage since early 2025.
“Donald Trump has made health care more expensive for millions of Americans, and his One Big Beautiful Bill is kicking millions more off of their health insurance while giving giant tax breaks to the ultra-wealthy,” the spokesperson said in a statement. “It’s Donald Trump and Republicans in Congress who are responsible for this health care crisis.”
(As we’ve previously written, independent analyses indicate most taxpayers in every income group will see some tax relief from the OBBBA, though the greatest benefits will accrue to the highest earners.)
Spokespeople for Schneider and Magaziner didn’t respond to requests for comment.
Measuring the Decline in Enrollment
The Protect Our Care analysis that Democrats have cited says enrollment in ACA marketplace plans fell by 4.2 million from February 2025 to February 2026, while enrollment in Medicaid and the related Children’s Health Insurance Program fell by 3.8 million over the same timeframe.
The group’s ACA estimate relies on preliminary enrollment data for February 2025. Using the finalized enrollment figure for that month produces a decline of 2.9 million (though that will likely increase as the 2026 data are updated, too).
But because Medicaid enrollment has continued to decline, the total estimate of 8 million remains basically accurate. According to data tracked by the nonpartisan health policy organization KFF, enrollment in Medicaid and CHIP fell by 5 million between February 2025 and March 2026.
It’s not clear how many of those people have since gained insurance from an employer or other source. According to early release estimates from the CDC’s National Health Interview Survey, the share of Americans without insurance in 2025 was up just slightly from 2024 — increasing by 0.1 percentage points.
But that was before the spike in premiums for 2026 plans on the ACA Marketplace. Experts told us it’s likely that at least some people who had those plans are now uninsured. Publications covering the healthcare industry have reported that major hospital systems are seeing a rise in uninsured patients this year, with the country’s largest for-profit hospital operator saying that patients who dropped ACA coverage have “migrated almost one for one” to not being insured.
As for what’s driving those declines, we’ll look at each program in turn.
Change in Subsidies Drives ACA Coverage Drop
When it comes to ACA coverage, experts said it’s pretty clear that the expiration of more generous subsidies — which had made premiums more affordable for people without job-based insurance — led many of those people to drop their plans.
Congress initially passed the increased subsidies in 2021, later extending them through the end of 2025 as part of the Inflation Reduction Act, as we’ve explained before. Because of that, many lower-income people became eligible for plans with no or very low cost premiums, while middle-income people earning more than four times the federal poverty level gained access to subsidized coverage for the first time.
Enrollment in ACA marketplace plans reached record highs as a result, rising from 10.4 million in 2019 to around 22 million in 2025, according to finalized February enrollment figures.
Last year, with the enhanced subsidies set to expire, Democrats pushed for extending them — the central issue in last fall’s government shutdown — but Republicans in Congress declined to do so.
“It wasn’t so much what was in the One Big Beautiful Bill Act as much as what was not in, which was the continuation of the enhanced subsidies that had been enacted during the Biden administration,” Michael Gusmano, a professor of health policy at Lehigh University, told us.
KFF had estimated premiums would more than double on average without the enhanced subsidies, if people stayed on their 2025 policies. In practice, once some enrollees dropped coverage and others switched to higher-deductible plans, net premiums rose by 58% on average.
The Trump administration has claimed that the decrease in enrollment was entirely due to its efforts to root out fraud. Gusmano and other experts told us that’s highly implausible. While some degree of fraud exists in every program, they said there’s no evidence of anything near the scale the administration is claiming, and things federal officials have pointed to as indicative of fraud — such as enrollees who don’t have any claims for medical services in a given year — have more innocuous explanations.
“It seems extremely unlikely to me that the enrollment drop would be ‘entirely’ due to that phenomena, and I don’t think the administration has offered any clear evidence of that,” Ben Sommers, a health economist at Harvard who held senior policy roles at the Department of Health and Human Services under Biden, told us in an email.
Sommers pointed to research he did with colleagues showing the enhanced subsidies lowered the uninsured rate.
“So the gains under the enhanced subsidies certainly had real people gaining insurance, and some of those people are now losing coverage,” he said.
Reasons for Medicaid Decline Still Murky
As for the decline in Medicaid enrollment of 5 million people since early 2025, experts we spoke to offered several possible explanations — although some cautioned that we won’t have definitive answers to that question until we get more detailed data.
Tim McBride, a professor at Washington University in St. Louis who closely tracks Medicaid policy, said confusion over the OBBBA could be one reason that enrollment has declined already. Some people may mistakenly believe they’re no longer eligible for Medicaid.
“I think this is just kind of anecdotal, we don’t know for sure, but people may be thinking that the bill has gone into effect when it really hasn’t,” he said.
Other likely factors include the Trump administration’s immigration crackdown deterring some lawfully present immigrants or children of immigrant parents from enrolling, and continued procedural issues with the annual renewal process, McBride said. Renewals were paused during the pandemic before resuming in 2023.
Those three issues are what he tends to hear about from groups that help people sign up for health coverage, he said.
Alker, the Georgetown professor, noted that the decline in Medicaid and CHIP enrollment includes a sharp drop in the number of children covered — down by at least 2.1 million between January 2025 and May of this year, according to data tracked by the Center for Children and Families.
Alker said a major reason for that is probably a “chilling effect” caused by the administration’s immigration policies. Many children who are U.S. citizens and eligible for Medicaid or CHIP live in households with one or more noncitizen parents.
“Those families are absolutely terrified to be interacting with the federal government right now for obvious reasons, including the fact that for the first time ever, the Trump administration announced that they would share Medicaid data with ICE,” or Immigration and Customs Enforcement, she said.
Alker also cited the Trump administration’s deep cuts to healthcare navigator programs — which help people find and sign up for health coverage — along with confusion over shifting eligibility rules and states enacting more stringent policies of their own.
Michael Sparer, a professor of health policy who directs Columbia’s Center for Public Health Systems, said what happened during Trump’s first term is instructive. Even in the absence of major legislative changes, he said, the administration pursued regulatory changes and encouraged states to adopt more restrictive policies that resulted in Medicaid enrollment declining by several million in the years before the pandemic.
“You obviously have also seen some states, as they did during the first administration, try to make it a little more complicated and difficult to sign up and/or renew your eligibility for Medicaid,” he said.
The pressure the Trump administration is putting on certain states to clamp down on purported Medicaid fraud — including the recent announcement that it would withhold more than $1 billion in Medicaid funds from Minnesota and California — could also be having some effect, said Frank Thompson, an emeritus professor at Rutgers University who remains affiliated with the school’s Center for State Health Policy.
That could be leading state Medicaid administrators to increase verification requirements to cut down on errors, at the expense of making it harder for some people who actually qualify to get benefits.
“The Trump administration has pursued a form of what I would call punitive partisan federalism, where in the campaign against waste, fraud and abuse in Medicaid, it has gone to unprecedented lengths to penalize states that it believes have high rates of fraud,” he said. “And it’s being done, by all the evidence, in an acutely partisan manner.”
But, he cautioned, these are just “working hypotheses” for now.
Jennifer Tolbert, the director of state health policy and data at KFF and deputy director of the organization’s Program on Medicaid and the Uninsured, echoed that last point during a webinar on Medicaid policy this month.
“I don’t think we actually know yet,” she said. “Part of the problem is we can see data on overall enrollment numbers. But what we don’t have yet is more detailed data to indicate who is losing coverage.”
For example, more detailed information could show whether coverage losses are coming from particular groups, such as immigrants or people with certain incomes.
“We simply don’t know that yet, and it will probably take a little bit of time for the data that we need to kind of get underneath these numbers to be available,” Tolbert said.
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