The number of Americans without health insurance has increased by 7 million since President Donald Trump took office, new Gallup data released Wednesday shows.

The country’s uninsured rate has steadily ticked upward since 2016, rising from a low of 10.9 percent in late 2016 to 13.7 percent — a four-year high.

The uninsured rate is still well below where it was in 2013, before the Affordable Care Act’s expansion of health insurance coverage began. But under the Trump administration, a trend of Americans gaining coverage through the private marketplaces and the Medicaid expansion appears to be reversing.

Certain demographic groups are experiencing a greater loss of coverage than others. Gallup data shows, for example, that Americans who are younger and lower-income have seen a greater decline in insurance coverage than those who are older and wealthier. Women have had insurance rates decline more quickly than men.

This trend is especially surprising given that over the same time period, the unemployment rate has been declining. Usually, when more people have jobs, it means more people with access to employer-sponsored health insurance. But even during this period of job growth, America’s uninsured rate keeps climbing.

Trump wasn’t able to repeal Obamacare. So why are uninsured rates going up?

The Affordable Care Act is still standing law. Republicans weren’t able to repeal Obamacare when they controlled both houses of Congress. And the one big change they did accomplish — repealing the individual mandate — didn’t go into effect until this year. So why was the uninsured rate rising from 2016 through 2018?

There are probably a few factors at play that are worthing thinking about

Obamacare premiums have risen significantly since the law took effect. This is a challenge that started under the Obama administration and continued through the Trump administration. The Trump administration, however, took steps to make the problem more acute. It rolled back some key subsidies in a way that has made coverage more expensive for middle- and high-income Obamacare enrollees. Funding for Obamacare enrollment and outreach has also been cut significantly. This means fewer people might be aware of their health insurance options. As the Gallup report notes, sign-ups on Healthcare.gov “peaked in 2016 at 9.6 million consumers [and then] declined by approximately 12.5%, to 8.4 million in 2019, based on recently released figures.” The Trump administration has also allowed some states to require low-income residents to work in order to gain health coverage. Two states, Arkansas and Indiana, recently got the go-ahead from the Trump administration to add work requirements to their state Medicaid programs. There is early evidence that those new regulations are causing a loss of coverage. Arkansas’s state health department, for example, estimates that more than 16,000 people have lost coverage so far under its Medicaid work requirement. A decent number of Americans think that Obamacare was repealed. A YouGov poll at the end of 2017 found that 31 percent of Americans believed Republicans had successfully repealed the Affordable Care Act. More recent polling from the Kaiser Family Foundation finds that 17 percent of Americans believe the law has been repealed and 14 percent aren’t sure if it’s still standing. With that many Americans believing Obamacare doesn’t exist, it makes sense that you’re seeing lower sign-ups.

It’s not totally clear where this trend goes next. On the one hand, multiple states are beginning to expand Medicaid. Nebraska, Idaho, and Utah all passed ballot initiatives to expand the program for low-income residents in the 2018 midterms. Maine and Kansas are also likely to join the program this year. Those changes will increase the number of Americans with health insurance coverage.

But there are other things happening that will depress those figures. More states are going to roll out work requirements for Medicaid. The individual mandate penalty goes away this year, meaning there is no longer a tax for not carrying health insurance coverage. And the Trump administration isn’t likely to restore Obamacare’s outreach and enrollment budget anytime soon. All those trends are likely to decrease the number of Americans who have health insurance coverage for years to come.