The Trump administration’s Medicaid overhaul will reverse historic gains in health coverage.
President Trump and his Republican backers have been determined to gut the Affordable Care Act (ACA) and expanded Medicaid coverage ever since his first term in office. This year he is finally getting his way, putting the health of tens of millions of Americans at risk.
Racial minorities and the chronically ill will be the most harmed.
A year ago, Congress passed the so-called One Big Beautiful Bill Act, putting in place onerous new eligibility requirements for Medicaid coverage, including work requirements. Medicaid enrollees ages 19 to 64 must complete at least 80 hours a month of work, community service, job training or education to maintain coverage, unless they qualify for an exemption. All states must comply with the new rule by Jan. 1, 2027.
This comes after Congress allowed enhanced subsidies for lower-income ACA enrollees to expire this past January. Already, coverage numbers are dropping:
- ACA plans hit an all-time high enrollment in 2025, of 24.3 million people.
- This year average monthly enrollments are projected to fall to about 17.5 million people.
These changes are certain to exacerbate the inequities already rife in America.
A report issued this month by the Campaign for Community Healthcare (CCH), a national partnership of healthcare advocacy groups, warned the combination of ACA cuts and new barriers to Medicaid enrollment “will likely cause historic coverage losses across the United States for years to come.” Nearly 16 million people will lose coverage by 2034, it projects.
An estimated 60 percent of those newly uninsured will come from communities of color.
The report projects that 4.3 million Latinos, 2.4 million Black Americans, nearly 1 million Asian Americans, Native Hawaiian and Pacific Islanders (AANHPI) and around 100,000 Indigenous people will lose Medicaid or ACA Marketplace coverage.
The share of uninsured is set to rise by 62 percent for Black people and 80 percent for AANHPI people.
“These coverage losses will deepen current problems, putting great strain on hospitals, clinics and other healthcare providers that, in many cases, struggle to meet community needs,” the authors warned.
In addition, a recent publication by my colleagues Jeff Crowley, Kirk Grisham and Vishakh Unnikrishnan, warns that people with serious health challenges like HIV and AIDS are particularly at risk from the new Medicaid requirements.
Led by Crowley, director of the O’Neill Institute’s Center on HIV and Infectious Disease Policy, the researchers found that while the law exempts people who are “medically frail” from Medicaid’s new work requirements, a June Interim Final Rule from the Centers for Medicare and Medicaid Services (CMS) narrowed that exemption. Under the rule, people living with HIV would not qualify unless their condition is considered “severe.”
Because roughly 40 percent of people living with HIV rely on Medicaid, the researchers warn the change could have devastating consequences.
This gutting of coverage is devastating and disheartening. The United States had been finally making headway on healthcare access: After reaching a high of 17 percent in 2009, the uninsured rate hit an all-time low of 7.7 percent in 2023—the first time the rate dropped below 8 percent since the federal government started tracking coverage in 2001.
The total number of uninsured fell from 31.6 million people to 25.3 million from 2020 to 2023 alone, driven largely by continuous enrollment in Medicaid and enhanced ACA subsidies.
But then the reversal started in 2023 with the “unwinding” of Medicaid’s COVID-19 protections. States were required to evaluate the eligibility of 90 million people; some 27 million lost coverage as a result, and a quarter of those are still uninsured.
Last year, the uninsured rate rose to 8.3 percent.
Both the O’Neill Center for HIV and Infectious Disease Policy and CCH reports suggest these actions to minimize the looming crisis:
- A number of states have filed lawsuits to stop CMS from enforcing the Interim Final Rule on work requirement exclusions. Organizations can submit amici briefs in support of these lawsuits, and work with state policymakers to mitigate harm.
- During the Medicaid unwinding, seven in 10 people lost coverage because of missing paperwork. The administration made the paperwork burdens far worse by making “medical frailty” impossible to verify based on medical records alone. Policymakers must work to radically lower red tape barriers to coverage.
- Patient navigators, case managers and community health workers must be educated on how to help people document work or receive exclusions. The HIV community must dedicate significant new resources to educating and equipping various clinical and community partners to assist people with enrollment.
With millions of Americans facing a loss of coverage, public health is sure to suffer, and inequality will rise for the most disadvantaged of Americans. Taking action to preserve Medicaid and ACA coverage is essential.
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