Full Breakdown
Medicaid and ACA Enrollment Plunge by Over 5 Million Amid Policy Shifts
6/23/2026, 1:28:29 AM
Enrollment Drop Hits Over 5 Million
In the 12 months through June 2024, enrollment in Medicaid and CHIP fell by about 3.8 million and ACA marketplace enrollment dropped by roughly 1.2 million, a loss of over 5 million people. The decline follows years of steady growth that had lifted ACA enrollment to a record 22 million.
Policy Shifts Behind the Decline
Donald Trump’s “big, beautiful” bill, signed July 2023, mandates nearly $1 trillion in Medicaid cuts and let enhanced ACA subsidies expire in December 2023. It adds Medicaid work-requirement rules for most states in January 2025; Nebraska began enforcement in May, Montana will follow.
Numbers and State Trends
Overall loss exceeds 5 million (3.8 M Medicaid/CHIP, 1.2 M ACA). ACA enrollment fell >10 % in twelve states, especially North Carolina, Ohio, West Virginia, Indiana and Delaware. Medicaid/CHIP declines appeared in all but Alabama, Missouri and Montana; the largest drops were in Indiana, Louisiana, Arizona and Delaware. The CBO projects 15 million more uninsured by 2034 due to the cuts and subsidy expiration.
Key Figures & Groups
Protect Our Care, led by executive director Brad Woodhouse, issued the report. Georgetown’s O’Neill Institute director Lawrence Gostin and University of Pittsburgh health-policy assistant professor Miranda Yaver supplied analysis. CMS and Georgetown’s Center for Children and Families provided enrollment data.
Official Statements
The administration framed the Medicaid cuts as a fiscal-consolidation measure. The CBO’s estimate of 15 million future uninsured reflects its analysis. In June 2024 CMS issued guidance tightening eligibility for medical exemptions under the new work-requirement rules.
Criticism & Opposition
Scholars called the losses “a predictable consequence of the multilayered cuts and restrictions on eligibility.” Yaver warned of a “chilling effect” deterring legal immigrants. Woodhouse described the gap as an “affordability crisis” shifting costs to taxpayers.
Conflicting Reports & Gaps
Some analysts say part of the decline may reflect eligible people moving to employer-based coverage, but the scale suggests substantial loss. The report does not track downgrades to weaker plans or future dropouts from unaffordable premiums, likely understating the crisis.
Verbatim Quotes
- “We’re already at 5 million,” — Brad Woodhouse, Executive Director, Protect Our Care
- “People who lack coverage get sicker sooner and they die earlier,” — Brad Woodhouse, Protect Our Care
- “This was an entirely predictable consequence of the multilayered cuts and restrictions on eligibility,” — Lawrence Gostin, Director, O’Neill Institute, Georgetown University
- “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,” — Miranda Yaver, Assistant Professor, University of Pittsburgh
What Lies Ahead
Medicaid work requirements will start in most states in January 2025; Nebraska shows enrollment impacts. CMS’s new guidance may further tighten medical exemptions. Experts expect continued declines and greater strain on hospitals serving uninsured patients, prompting calls for legislative fixes or renewed subsidies.
