More than 1 million Americans have lost health coverage since 2016, a new report from the Congressional Budget Office finds.

The report — which came out within hours of the Mueller report on Thursday and so didn’t get much attention — follows other studies, all suggesting that America’s uninsured rate is rising under President Trump, whose administration has passed new rules that make it more difficult to enroll in coverage.

The CBO estimates that the number of Americans without insurance has risen from 27.5 million in 2016 to 28.9 million in 2018, an increase of 1.4 million Americans going uninsured.

Much of that increase is concentrated in the Medicaid program, where the Trump administration has approved new rules like work requirements that can make it more difficult for low-income Americans to enroll in the program.

It's not going to get much attention today, but the Congressional Budget Office estimates that there were 1.4 million more people uninsured in 2018 than in in 2016.https://t.co/PLn6DkA3Fp pic.twitter.com/cM5n5MRC3w — Larry Levitt (@larry_levitt) April 18, 2019

The other area where health coverage has declined is among Americans who purchase their own health insurance outside the Affordable Care Act’s marketplaces.

The CBO report does note that measuring the uninsured rate is a challenging task. It largely relies on survey data that Americans submit, rather than measuring enrollment in government programs, for example, where the agency can turn to administrative data sources.

Still, this report isn’t the first to sound alarm bells about a rising uninsured rate.

Gallup, for example, found in January that the country’s uninsured rate was at a four-year high — and that most of the increase had happened under the Trump administration.

It’s notable that these declines in coverage are happening even though Republicans were unable to repeal the Affordable Care Act — and all before the repeal of the requirement to carry health insurance took effect (that provision only kicked in at the start of 2019). The rising uninsured rate is happening at a moment when, on paper, Obamacare looks a lot like it did under President Obama.

There is some evidence that all the discussion of Obamacare repeal may be depressing insurance enrollment. A YouGov poll at the end of 2017 found that 31 percent of Americans believed Republicans had successfully repealed the Affordable Care Act.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-up rates in both the individual markets and Medicaid.

We also have more concrete evidence that new rules requiring Medicaid enrollees to work have led to lower enrollment in that public program, which is meant to serve low-income Americans. More than 18,000 people there have lost coverage since the Trump administration approved that new rule, which requires Medicaid recipients to work at least 80 hours per month (or participate in other qualifying activities) in order to receive their benefits.

Even without repealing Obamacare, it appears that the Trump administration is still having a tangible impact on insurance sign-ups — and fewer Americans are getting the coverage they used to.