President Donald Trump’s administration has succeeded in gutting the the Affordable Care Act and attacking access to healthcare coverage for low-income families—causing the number of uninsured children in the U.S. to climb to more than four million, a study released Tuesday finds.

The Georgetown University Center study found 400,000 children lost their health coverage between 2016 and 2018, making this year the second in a row to see the number of uninsured children rise.

There are now more uninsured children in the U.S. since the Affordable Care Act (ACA) was enacted in 2014. The Georgetown researchers described the increase as part of “a very troubling trend.”

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“The decline in health coverage occurred at a time when children should have been gaining coverage in the private market and is a red flag for policymakers as even more children would likely lose coverage in an economic downturn,” said Joan Alker, executive director of the Center.

Alker blamed the decline on “the Trump administration’s actions or inactions that have made health coverage harder to access,” including the shortening of the ACA enrollment period; fewer resources given to ACA outreach efforts; a delay in implementing CHIP, which covers families that don’t have employer-based insurance and don’t qualify for Medicaid; and Trump’s “public charge” rule, which experts say has deterred immigrant families for applying for government programs.

The uninsured rate among children dropped sharply after the ACA, also known as Obamacare, went into effect. In 2015, four million children had no health coverage, compared with nearly five million in 2014. Georgetown’s study reveals that many of the gains made under the Obama administration have been erased by Trump.

Low- to middle-income families have been hit hardest by the decline in health coverage, and the majority of uninsured children are eligible for Medicaid or CHIP but are not enrolled.