How did Medicaid enrollment change state-by-state after the Trump administration's policy shifts?

1. A nationwide drop tied to the “unwinding,” not a single Trump policy

The largest immediate cause of the state-by-state enrollment declines was the end of continuous coverage and the subsequent “unwinding” of pandemic-era rules that paused renewals — a process nearly all states completed by August 2024 — leading to large net disenrollments in FY2024–FY2025 rather than a discrete Trump-era administrative order (KFF’s trackers show most states took 12 months to complete renewals and that unwinding was the primary enrollment driver) ^{[4] [5]}.

2. Magnitude: how steep and how measured

KFF’s FY2025 Medicaid budget survey calculates a 7.6% fall in Medicaid enrollment in FY2025 and projects near‑flat enrollment for FY2026, a headline figure used by many analysts ^[1]. CMS monthly snapshots and MACLC trend reports capture point‑in‑time totals (e.g., ~77.6 million in July 2025 in the CMS snapshot), underscoring that national totals depend on how the count is made and reported by states ^{[3] [6]}.

3. Why states diverged: policy choices and expansions mattered

State variation reflects policy choices: some states implemented eligibility expansions, extended children’s continuous coverage, or improved ex parte (automated) renewals that mitigated losses and even added enrollment pressure, while others experienced larger procedural disenrollments (KFF notes two‑thirds of states told surveyors the unwinding drove declines, and about half cited expansions or postpartum changes that pushed enrollment up) ^{[5] [7]}.

4. The Trump administration’s role: rule changes, warnings, and downstream effects

Available reporting documents multiple Trump administration proposals and actions (work‑requirements discussion, funding shifts, rescinding some Biden-era policies, and new drug-pricing models) that could reshape Medicaid over time; but immediate FY2024–FY2025 enrollment declines align most directly with the unwinding and state renewal activity rather than a single new Trump rule (KFF’s “What to Watch” brief notes the Trump administration previously encouraged states to verify eligibility more often, and commentators flag several possible federal changes) ^{[8] [9]}. Several policy proposals and budget moves discussed in the reporting could cause larger state-level effects later, but their implementation and timing vary ^{[10] [11]}.

5. Which states lost the most — and why the raw numbers can mislead

State absolute losses are largest in populous expansion states because they enrolled more people during the pandemic; percentage declines differ by state depending on expansion status, renewal systems, and outreach. KFF’s state survey and tracker provide state-level monthly charts and cumulative percent changes from the month before each state resumed disenrollments, allowing granular comparison ^{[4] [5]}. CMS’s monthly snapshots give point-in-time rolls that complement KFF’s survey‑based estimates ^{[6] [3]}.

6. Fiscal context and politics: cuts, caps, and future risks

State Medicaid officials and policy analysts say FY2025 enrollment declines coincided with increased fiscal pressure: states expect spending increases even as enrollment dipped, and federal budget proposals or reconciliation laws discussed in 2025 (including large federal Medicaid cuts or financing changes) could shift state decisions and thus future enrollment trends — impacts would vary greatly by state, especially between expansion and non‑expansion states (KFF budget survey; Georgetown analyses on how cuts would hit expansion states harder) ^{[12] [13]}.

7. What reporting does not settle

Available sources do not provide a single, complete state-by-state list tying each enrollment change directly to specific Trump administration actions; instead, KFF, CMS, and academic trackers document the timing, magnitude, and drivers (unwinding, state policy choices, expansions) but leave longer‑term causal effects of new federal rules — such as work requirements, per‑capita caps, or drug‑pricing models — as projections or contested policy debates ^{[4] [5] [14]}.

Bottom line: most of the post‑pandemic, state‑level Medicaid declines reported through mid‑2025 reflect the scheduled unwinding of continuous coverage and state renewal processes, while federal policy proposals and early Trump administration actions created a web of possible future pressures that will play out unevenly across states ^{[4] [1] [8]}.