Here are two facts and a question.

First the facts. After its implementation in 2014, the Affordable Care Act (ACA), or Obamacare, which is still the law of the land, led to the sharpest decline in the number and share of Americans without health insurance coverage since the passage of Medicaid and Medicare in 1965. Also: Most working-age people get health coverage through their jobs, and job gains have been strong and unemployment low in recent years.

Now, the question: Do you think health coverage went up or down in the years leading up to the current pandemic?

Based on those facts, you would probably say “up.” You would be wrong. According to Census Bureau data, coverage has declined to the point where nearly 1 in 10 people in the United States — 9.2 percent, or more than 29 million people — lacked health insurance last year (see Figure 1). More Americans were uninsured in 2019 than in 2018, the third year in a row both the number and share who are uninsured have increased. That’s a sharp reversal from 2016’s historic low uninsured rate of 8.6 percent, according to analysis by our colleagues Aviva Aron-Dine and Matt Broaddus at the Center on Budget and Policy Priorities.

How could those two facts — the ACA remains in place and the job market tightened significantly over the past few years — square with the reality of declining coverage? It’s neither a mystery nor an accident: Despite the ACA’s historic expansion of health coverage to millions of Americans, the Trump administration has taken steps limiting access to comprehensive health coverage.

The pandemic has underscored the recklessness of this sabotage. Because of the administration’s attacks on health coverage, the United States entered the pandemic with 2.3 million more uninsured people than in 2016, including 700,000 more uninsured children.

The administration’s attack has been relentless and multifaceted. It has encouraged states to restrict Medicaid coverage, including taking coverage away from people who don’t meet harsh work requirements or pay premiums or who miss paperwork deadlines. The administration has also sown fear among families with immigrants that enrolling in Medicaid or Marketplace health coverage could prevent them or their family members from remaining legally in the United States.

That’s apart from the Trump administration’s attempts to repeal the ACA as a whole. The latest attempt — a lawsuit in which the administration and 18 Republican attorneys general are asking the Supreme Court to strike down the entire law — may still succeed, particularly given the death of Supreme Court Justice Ruth Bader Ginsburg. If the ACA is struck down, some 20 million people would lose their health coverage, and millions more with preexisting conditions could be charged more or denied coverage altogether.

What’s especially perverse is that even as the administration continues attacking Medicaid, more and more research documents that program’s positive impacts. The ACA’s expansion of Medicaid to low-income adults saved the lives of more than 19,000 adults between the ages of 55 and 64 between 2014 and 2017, research has shown — while the states that rejected expansion have seen more than 15,000 older adults die prematurely. Medicaid coverage also improves families’ financial security, reduces the likelihood that people will skip needed medical care or medications due to cost and increases the share of people reporting excellent health.

Medicaid’s role has only grown due to the pandemic and economic crisis. States are leaning on Medicaid as the backbone of their public health infrastructure, expanding home- and community-based benefits and improving access to testing and treatment. As unemployment remains elevated, people who have lost job-based coverage are relying on Medicaid for access to care.

Americans recognize Medicaid’s importance. Across party lines, voters have a far more favorable view of Medicaid than they do of their representatives in Congress. This summer, voters in the traditionally red states of Oklahoma and Missouri approved ballot initiatives to expand Medicaid to hundreds of thousands of low-income adults.

States and the federal government must act quickly to reverse the destructive trend of climbing uninsurance rates. States should continue to strengthen and expand coverage through Medicaid, rejecting the Trump administration’s path of greater restrictions. Congress should support states’ covid-19 response by further increasing the federal share of Medicaid funding (the program is jointly financed by states and the federal government). This would provide not only essential coverage but also economic stimulus to states, which could then spend freed-up health-care dollars on other needs.

The ACA isn’t perfect, but it triggered a decline in uninsured rates that is one of the most important policy successes in decades. It delivered a level of security to millions of families who formerly lived in fear of being bankrupted by an unforeseen illness. It also made them healthier by enabling them to get preventive care and family health services.

By intentionally working to reverse that trend, the Trump administration has added to the financial insecurity and ill-health of millions of Americans — just in time for the worst pandemic in a century.