Medicaid and ACA Enrollment Decline
Recent data reveals that the number of individuals enrolled in Medicaid and Affordable Care Act (ACA) plans has dropped by over 5 million in the last year, according to a new report from the advocacy group Protect Our Care.
This decline can be attributed in part to legislative changes enacted by President Donald Trump last July, along with the end of enhanced ACA subsidies. The new legislation is projected to cut nearly $1 trillion from Medicaid over the next decade. Meanwhile, the expiration of subsidies in December, following Republican resistance to extend them, has led to significant premium hikes for many.
Health policy experts had foreseen that these changes would greatly reduce health insurance coverage across the country. The Congressional Budget Office estimates that, if trends continue, around 15 million more people could be uninsured by 2034 due to these cuts and subsidy expirations.
Brad Woodhouse, the executive director of Protect Our Care, noted, “We’re already at 5 million. This is going to get much worse.”
Experts pointed out that while some decrease in enrollment might stem from a shift to employer-sponsored insurance, the significant size of the drop implies that many likely lost their health coverage entirely. Lawrence Gostin from Georgetown University commented, “This was a completely predictable outcome of multiple layers of cuts and restrictions on eligibility. Americans will lose their lives and suffer economically.”
It’s not unusual for individuals who’ve lost their health insurance to delay or forgo necessary medical treatment, sometimes waiting until their conditions worsen. Woodhouse remarked, “People who are uninsured get sick sooner and die sooner. They either postpone going to the doctor or they simply can’t afford it, waiting until it’s much worse.”
The report’s findings were derived from an analysis of two years’ worth of ACA enrollment data alongside Medicaid data from the Georgetown University Center for Children and Families. Enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) has decreased by approximately 3.8 million since last June, while ACA enrollment has fallen by around 1.2 million.
Following a trend of steady increases, registered ACA enrollment reached a record high of 22.3 million last year before declining in 2023 as states began to roll back protections established during the pandemic. The report shows declines in Medicaid and CHIP enrollment across all but three states—Alabama, Missouri, and Montana—with the most pronounced losses occurring in Indiana, Louisiana, Arizona, Rhode Island, and Delaware.
ACA plans also experienced enrollment reductions of 10% or more in 12 states, particularly in North Carolina, Ohio, West Virginia, Indiana, and Delaware.
Changes to Medicaid are still emerging, with significant provisions like work requirements set to begin in January for most states. Nebraska has already put in place new work regulations, and Montana is expected to follow shortly.
Miranda Yarber, an assistant professor of health policy and management at the University of Pittsburgh, suggested that some of the decline in Medicaid enrollment might be influenced by a chilling effect, where eligible individuals—especially legal immigrants—hesitate or decline to enroll due to fears about immigration enforcement.
Yarber warned that if more states implement Medicaid work requirements, the decline would worsen. Recent CMS guidelines could complicate qualification for medical exemptions, adding barriers to access.
“The proposed CMS rule certainly goes further than H.R.1 and will almost certainly result in coverage losses that are more dramatic than CBO predicted,” Yarber stated.
She expressed that she wasn’t surprised by the drop in ACA enrollment, as many enrollees reported experiencing “sticker shock” during the previous year’s open enrollment period. She added that the actual impact of these changes might be even more pronounced, as the numbers don’t capture people opting for lesser coverage or dropping their insurance entirely due to rising costs.
“This is a glimpse of much more to come,” she concluded.
Woodhouse added that the burden of treating uninsured patients ultimately falls on U.S. taxpayers, saying, “It all just contributes to this affordability crisis that Americans are facing.”
