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According to a new Gallup survey out Wednesday, the rate of Americans without insurance has climbed to a four-year high, to 13.7 percent of the U.S. population.

Women and young people were among the groups with even lower rates of insurance: Gallup found people under 35 had an insurance rate of 21 percent, up 4.8 percent from 2016. Women without insurance, meanwhile, were “among the fastest rising, increasing from 8.9% in late 2016 to 12.8% at the end of 2018.”

Gallup attributes those increases to a number of factors, including premiums going up—which we saw in the stories submitted by readers on what they paid on the exchanges this year—and the “a significant reduction in public marketing and shortened enrollment periods” put in place by the Trump administration.

The rate of insurance for people making less than $24,000 increased by slightly less than that of people making between $24,000 and $48,000, at 3 percent and 2.8 percent, respectively. People making less than $24,000 will mostly qualify for Medicaid, depending on the state—some states don’t offer Medicaid for non-disabled adults without dependent children regardless of income—and some states have managed to expand Medicaid even under Trump, though others have put into place extremely punitive work requirements that have reduced enrollment rates. But it shows how tenuous the promise of help in the Affordable Care Act is for middle-to-low income Americans. If the subsidies start to disappear or insurance companies raise premiums significantly, they’ll feel the hit.

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Vox noted today that the increases are “especially surprising given that over the same time period, the unemployment rate has been declining.” It’s almost as if Trump’s boasting about the “great economic story” of this country is bullshit—the unemployment rate, let alone the stock market or profits, doesn’t tell you the whole story of what’s happening in most Americans’ financial lives. When insurance costs more, sometimes hundreds of dollars more a month, but wages remain the same, people get fucked.

This is what happens when healthcare coverage is subject to the whims of a marketplace. This is what happens when healthcare coverage is dependent on an individual’s finances, or job situation, or ability to navigate the complicated process of signing up for Medicaid in states with work requirements. This is what happens when healthcare is not treated as a right for all citizens.