The number of Americans without health insurance plunged after Obamacare started. Now, early evidence suggests, it’s beginning to climb again.

New polling from Gallup shows that the percentage of uninsured Americans inched up throughout last year. That trend matches other data suggesting that health coverage has been eroding under the policies of the Trump administration.

Gallup estimated that the uninsured rate for adults increased by 1.3 percentage points. That would mean an increase of more than three million people without insurance between the first quarter of 2018 and the end of the year. Gallup said this was a four-year high, although a major methodology change a year ago may make such longer-term comparisons less precise.

“There’s no question that some of the reductions in the uninsured rate that we have measured over the course of Obamacare has now been given back,” said Dan Witters, the research director for the survey.

That may not be a surprise given the White House’s approach to health policy. It has consistently criticized the Affordable Care Act. And it has sought to weaken it legally, pulling back on funding to publicize coverage opportunities, and approving policies that make it harder for eligible people to enroll and stay enrolled in state Medicaid programs.

The administration has signaled that the use of certain public health insurance programs, like Medicaid, might count against immigrants applying for green cards. Other, more complex policy changes increased the cost of individual health insurance last year, although prices were on track to fall slightly, on average, this year.

Still, the increase in uninsured Americans could be a new pattern, even for the Trump administration. Although earlier surveys from Gallup and the Commonwealth Fund, a health research group, measured a rising uninsured rate, big government surveys from the census and the Centers for Disease Control and Prevention found coverage rates that were holding steady.

The employment picture has continued to improve during the Trump presidency, and more Americans have found full-time jobs. That trend is usually associated with improvements, not declines, in health coverage.

Data about initial sign-ups for last year’s Obamacare marketplace plans showed a decline of about 1.2 million people. There is less information about the number of Americans who buy their insurance directly from health insurers. But a report from the Department of Health and Human Services suggested that about one million fewer people bought coverage in 2017 than 2016, largely because of price, and declines may have continued last year.

The federal government has allowed states to impose new barriers to Medicaid, and enrollment declines appear to be occurring there, too. States have asked people to provide more documentation to enroll, or to verify their eligibility more often, policies that have been shown to depress enrollment.

Two states have imposed work requirements for some users of their programs, with five more about to start. Overall numbers from federal reports on Medicaid enrollment show 1.5 million fewer people insured through the program from December 2017 to October 2018, the most recent month with available data. The biggest declines came in Tennessee and Texas, which have begun to reconsider eligibility more often. In both states, Medicaid numbers fell by 11 percent.

Eliot Fishman, the policy director at the consumer health advocacy group Families USA and a former Medicaid official, has been tracking the Medicaid numbers. He said the big drops in several states were largely the result of state policy changes that might have attracted more federal pushback under the Obama administration.

“There’s a number of states where you’re looking at a high proportion of Medicaid enrollment and a high proportion of the state’s population losing health insurance flying under the radar,” he said. “That has public health effects.”

Several states will expand their Medicaid programs this year, after voters approved ballot initiatives, so further declines from work requirements and other policies in some states may be balanced out by gains in coverage elsewhere.

Measuring the precise shape of any coverage declines may take some time. It will be several months before results from the federal surveys on 2018 are final. Benjamin Sommers, an associate professor at the Harvard School of Public Health, who has worked extensively with Gallup data, said he was waiting for more research before drawing firm conclusions about how many Americans had lost coverage, given the recent changes in the Gallup survey. (After years of conducting its surveys by telephone, Gallup in 2018 changed to mail and internet responses.)

“It’s suggestive, and definitely merits us digging deeper into this,” he said.

Margot Sanger-Katz is a domestic correspondent and writes about health care for The Upshot. She was previously a reporter at National Journal and The Concord Monitor and an editor at Legal Affairs and the Yale Alumni Magazine. @sangerkatz • Facebook

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