One Big Beautiful Bill Not (Yet) Driving ACA, Medicaid Declines

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.