- Medicaid enrollment fell by 1.6 million from Jan–Jul 2025, reflecting post‑pandemic unwinding and heightened eligibility redeterminations.
- OBBBA cuts, work requirements, and administrative hurdles risk pushing more low‑income people uninsured and disrupting care access.
- Expiration of enhanced ACA subsidies could raise premiums ~20%, compounding coverage losses and straining vulnerable families and providers.
As President Donald Trump’s second term barrels toward its first anniversary, a stark reality is emerging in America’s health care landscape: Medicaid rolls have shrunk by 1.6 million people in just the opening six months, according to fresh data from the Kaiser Family Foundation (KFF).
The drop, from 72,011,017 enrollees in January 2025 to 70,356,307 by July, signals the end of pandemic-era expansions and the dawn of aggressive reforms under the administration’s “One Big Beautiful Bill Act” (OBBBA).
But with enhanced Affordable Care Act (ACA) subsidies set to expire at year’s end, health policy experts are sounding alarms over a potential surge in the uninsured rate that could hit low-income families hardest.
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The unwinding of Medicaid — a process mandated by federal law after the COVID-19 public health emergency lifted in 2023 — accelerated under Trump, who has championed state flexibility and work requirements as keys to “program integrity.”
Enrollment ballooned during the crisis, from 64.5 million in February 2020 to a peak of 95.4 million by March 2023, as states kept eligible people on the rolls to ensure continuity of care.
Now, as routine eligibility redeterminations resume, millions are being screened out, many due to procedural hurdles like outdated paperwork or shifts in income.
“This process helps states make sure that only those who are eligible and need the program continue to receive benefits, support program integrity and ensure taxpayer dollars are used responsibly,” the Centers for Medicare & Medicaid Services (CMS) told Newsweek in a statement.
The agency emphasized that during the pandemic, “millions of people remained on Medicaid, even when their income or circumstances changed,” leading to longer-than-usual coverage periods.
Yet, the numbers paint a sobering picture.
A June 2025 report from the National Center for Health Statistics documented a more than 2 million increase in the uninsured population between 2023 and 2024, coinciding with the early waves of unwinding.
Lindsey Leininger, a professor of business administration and director of the Center for Health Care at Dartmouth College, described the initial impacts as “modest so far, which suggests that many people were able to find alternative coverage.”
She noted that overall Medicaid enrollment “remains almost 10 percent higher than before the pandemic,” offering some reassurance amid the turbulence.
But Leininger cautioned against complacency: “Several states have experienced very large enrollment declines, in some cases as much as 15 percent below pre-pandemic levels. It is hard to believe they did not leave more people uninsured.”
In rural heartlands and urban low-income pockets alike, the fallout is palpable — from shuttered clinics in Maine to layoffs at California’s Lucile Packard Children’s Hospital, where 87 jobs were cut in October citing “regulatory headwinds and significant budgetary consequences.”
Looming Cuts and Work Mandates: A Recipe for Disruption?
The OBBBA, signed into law earlier this year, embeds deeper changes that could amplify these losses.
The Congressional Budget Office projects roughly $1 trillion in Medicaid reductions over the next decade, shifting costs to states and introducing work requirements starting in 2027 — mandating at least 80 hours per month for expansion enrollees.
Proponents argue this fosters self-reliance; critics see it as a barrier-laden trap.
Paul Shafer, a professor of health law, policy and management and co-director of the Medicaid Policy Lab at Boston University, painted a grim forecast.
“We have already cut 17 million people from Medicaid and CHIP since the peak in April 2023 and this only stands to get worse,” Shafer said.
“Work reporting requirements, more frequent paperwork, and fears related to immigration enforcement will push many more out of the program. When combined with the expiration of the enhanced subsidies for Marketplace coverage, we can anticipate a considerable jump in the uninsured rate in the coming years.”
Shafer highlighted the human toll: “Without health insurance or feeling the budget crunch of more expensive premiums, people will go without the care and medications that they need.
This could create a vicious cycle where those who are already struggling most end up going without or delaying care — seeing their health get worse, which then can lead to avoidable health issues with even higher costs to treat and impacts on people’s lives.
People with lower incomes, chronic conditions, those who struggle with health literacy and so-called administrative burdens — like paperwork — are ones who will certainly suffer in this environment.”
Leininger echoed the concern, focusing on “churn” — the disruptive cycling in and out of coverage.
“Insurance transitions often force patients to change doctors or prescriptions because networks and formularies differ across plans,” she explained.
“Consider a parent of a child with special needs receiving care at an academic medical center. These centers typically accept Medicaid and are at the forefront of complex pediatric care. Losing Medicaid and moving to a lower-cost employer plan with a narrow network can reduce access to crucial specialists and treatments. These are real losses for very vulnerable families.”
Looking ahead, “many of us in the Medicaid community are worried about the combined effect of looming work requirements and broader program cuts,” Leininger added.
“We have decades of evidence showing that increasing administrative red tape leads to lower Medicaid enrollment, and work requirements in particular create rolls and rolls of red tape to implement and enforce.
I value program integrity… but in this context that goal comes at a very high cost for low-income families who are already doing their best to navigate a complicated system.”
ACA Subsidies on the Brink: Premiums Poised to Spike 20%
Compounding the Medicaid squeeze is the impending sunset of Biden-era enhanced tax credits for ACA marketplace plans, which expire December 31 without congressional action.
These subsidies, which covered premiums for over 90% of enrollees in 2025, have fueled record sign-ups — 24 million this year alone.
Their lapse could drive national average increases of around 20%, slamming small-business workers, retirees and students hardest.
The Trump administration’s response?
A proposed two-year extension laced with guardrails: income caps at 700% of the federal poverty level, minimum premium payments and options to redirect credits into health savings accounts for lower-tier plans.
But the rollout has stalled amid GOP infighting, with Senate Republicans divided over abortion-linked restrictions and the wisdom of propping up “Obamacare.”
President Trump, in a November Truth Social post, urged sending subsidy funds “directly to the people so they can purchase their own, much better, health care.”
Yet, as of early December, no formal proposal has landed on Capitol Hill.
Senate Finance Committee Ranking Member Ron Wyden, D-Ore., decried the chaos in a monthly report: “Trumpcare is gutting Americans’ health care,” citing clinic closures like Maine Family Planning’s three sites in October, blamed on Medicaid cuts.
A bipartisan push led by Rep. Brian Fitzpatrick, R-Pa., aims to bridge the gap with a temporary extension tied to reforms, but time is short. Open enrollment ends January 15, and a Senate vote could come as early as December 9.
Broader Reforms: Drug Prices and Transparency in Focus
Not all Trump health moves spell contraction.
An executive order in May slashed drug prices via “most-favored-nation” pricing, aligning U.S. costs with lower international rates.
February’s transparency mandate requires point-of-service price data, empowering consumers.
And in a win for rural providers, HHS Secretary Robert F. Kennedy Jr. revoked a nursing home rule in December, projecting $25 billion in savings by easing regulatory burdens.
Still, these tweaks feel like bandages on a hemorrhaging system.
As Shafer put it, the push for market-driven fixes risks “exacerbated racial and socioeconomic inequities in health care access,” especially in a wobbly economy where job-tied insurance falters.
For the 1.6 million who’ve already lost Medicaid — and the millions more teetering — the new year looms as a referendum on reform.
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