Sixty percent of kids who have lost medicaid coverage came from nine states where Republicans pushed against medicaid expansion, new data from the Biden administration shows.

Health and Human Services (HHS) secretary Xavier Becerra sent letters to nine states — Arkansas, Florida, Georgia, Idaho, Montana, New Hampshire, Ohio, South Dakota and Texas — that have refused Medicaid expansions urging lawmakers to take advantage of dozens of federal strategies and policies HHS has put forward. That includes 400 state flexibilities the agency has approved to make re-enrollment easier, such as expanding Medicaid.

A total of 10 states have refused Medicaid expansion and disenrolled more kids than all expansion states combined — something that Becerra called alarming in his letters.

“Because all children deserve to have access to comprehensive health coverage, I urge you to ensure that no child in your state who still meets eligibility criteria for Medicaid or CHIP loses their health coverage due to ‘red tape’ or other avoidable reasons,” Becerra wrote. “This is especially important for communities of color and underserved communities across the country – we know more than half of all children in Medicaid and CHIP are Hispanic, Black, Asian/Pacific Islander or American Indian and Alaska Native.”

At least 2.2 million kids have been removed from Medicaid and the Children’s Health Insurance Program (CHIP) during a period of so-called “unwinding” of pandemic-era coverage protections, though some experts estimate the number is higher.

States were temporarily required to keep people covered by Medicaid enrolled over the course of the COVID-19 public health emergency in exchange for greater federal funding. This effort helped  reduce the number and rate of uninsured children to its second-lowest in U.S. history and reversed the steady increase of uninsured children in the country.

Enrollees face technical problems, clerical errors, administrative delays and thousands of low-income children lost medical coverage during the unwinding.

Many Republican-led states have opted out of further Medicaid expansion since the unwinding began. The Biden administration’s report names this as a driving factor in falling child enrollment numbers.

South Dakota and Idaho saw the sharpest enrollment decreases, with a 27 percent  decrease in child enrollment between March and September of this year. Texas and Florida account for more than 1 million of the children who have lost coverage. In each state, Republicans have refused to expand Medicaid to low income families, despite voters’ overwhelming approval of expanding the program.

Many Republican lawmakers have even led the charge in campaigns to gut Medicaid, including Texas Gov. Greg Abbott, Idaho Rep. Britt Raybould, and Montana Rep. Art Wittich.

In states like these children age 19-23 make up the highest rates of disenrollment, according to Monday’s report.

Becerra called on states to make transferring children from Medicaid to CHIP easier, reduce call center wait times and adopt special rules that permit states to make the process of keeping children enrolled in Medicaid smoother in a press conference Monday.