Medicaid and ACA Enrollment Falls by More Than 5 Million in a Year

More than 5 million Americans lost health coverage through Medicaid or an Affordable Care Act marketplace plan in the span of a year, according to a report released this week by the advocacy group Protect Our Care and reviewed by NBC News. The numbers land well before the most consequential pieces of federal Medicaid policy have even taken effect.

<cite index="10-15">The number of people enrolled in Medicaid and Affordable Care Act plans fell by more than 5 million in the last 12 months, according to the new report from Protect Our Care.</cite> That figure combines two separate coverage streams that typically move independently of each other, which makes the simultaneous decline harder to explain away.

<cite index="10-17,10-18">The decline stems in part from the Trump administration's reconciliation bill, signed into law last July, and the expiration of enhanced ACA subsidies. The law includes nearly $1 trillion in Medicaid cuts over 10 years, and the subsidies expired in December after Republicans declined to extend them, leading to double- to triple-digit premium increases for millions of people.</cite>

The KFF Medicaid enrollment tracker, which draws on official state data, puts a more precise number on the Medicaid piece alone. <cite index="12-1,12-2,12-3">There were 74.3 million people enrolled in Medicaid and CHIP nationally as of the most recent count. Medicaid enrollment declined by 4.6 million, or 6%, from April 2025 through March 2026, and total enrollment has decreased in all states since April 2025.</cite>

<cite index="10-3,10-4">All but three states, Alabama, Missouri, and Montana, saw a decline in Medicaid and CHIP enrollment. The states that saw the largest declines were Indiana, Louisiana, Arizona, Rhode Island, and Delaware.</cite> For the ACA marketplaces, <cite index="10-5,10-6">enrollment fell by more than 10% in 12 states, with North Carolina, Ohio, West Virginia, Indiana, and Delaware seeing the largest drops.</cite>

Children's coverage is taking a hit, too. <cite index="12-15">Child enrollment in Medicaid and CHIP has decreased in all states from April 2025 through March 2026.</cite>

Health policy researchers say several forces are stacking on top of each other. <cite index="10-9">Miranda Yaver, an assistant professor of health policy and management at the University of Pittsburgh, said some of the Medicaid declines may reflect a chilling effect, in which eligible people, particularly legal immigrants or people with family members who are non-U.S. citizens, avoid enrolling or drop coverage because they fear immigration enforcement or deportation.</cite>

On the premium side, <cite index="11-10">the report found average monthly premium payments increased by about $65, while deductibles rose by more than $1,000.</cite> That's a significant hit for working families who don't qualify for substantial subsidies but can't absorb a four-figure jump in their annual deductible.

What makes this moment particularly sharp for clinicians and health systems is that the biggest policy changes haven't arrived yet. <cite index="10-7,10-8">Many of the changes to Medicaid have yet to take effect, with the most consequential provision, Medicaid work requirements, set to begin in most states in January. Nebraska implemented the new work rules in May, and Montana is expected to follow next month.</cite>

<cite index="14-12,14-13">In June, CMS announced guidance on the new work rules that could make it harder for people to qualify for medical exemptions. Yaver noted that "the CMS rules that have been proposed certainly go farther than HR 1 and will almost assuredly result in more dramatic coverage losses than the CBO projected."</cite>

The CBO's projection, set before the law passed, was sobering enough on its own. <cite index="10-20">The nonpartisan agency estimated there would be roughly 15 million more uninsured people by 2034 due to the Medicaid cuts and expiring subsidies.</cite> The 5-million mark in under a year tracks ahead of that trajectory.

<cite index="14-23,14-24">Lawrence Gostin, director of the O'Neill Institute for National and Global Health Law at Georgetown University, called the coverage losses "an entirely predictable consequence of the multilayered cuts and restrictions on eligibility" and warned that it "will cost Americans in lost lives and economic distress."</cite>

For nurses, physicians, and administrators in safety-net hospitals and community health centers, these aren't projections on a spreadsheet. They're the patients showing up in the ED with conditions that went unmanaged because coverage lapsed. That pattern tends to cost everyone more, and the tab is still climbing.

Sources cited:
- NBC News (https://www.nbcnews.com/health/health-news/medicaid-aca-enrollment-falls-5-million-new-report-finds-rcna351157)
- KFF Medicaid/CHIP Monthly Enrollment Tracker (https://www.kff.org/medicaid/medicaid-enrollment-and-unwinding-tracker/)
- CMS March 2026 Medicaid & CHIP Enrollment Data Highlights (https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights)