From funding cuts to policy reforms, the Republican-passed reconciliation bill (HR 1) directly harms older adults, including by making health care and coverage less available and more expensive. As the fate of expiring Affordable Care Act (ACA) tax credits remains uncertain, we look to a recent KFF analysis for more on how HR 1’s interactions with the ACA will impact adults ages 50 and over.
HR 1’s Impact on ACA Marketplaces
HR 1 makes changes to the ACA Marketplaces that will increase the number of uninsured and premium costs.
Enrollment Changes
Combined with the Trump administration Marketplace integrity rules, the new law will make it harder to sign up for a Marketplace plan, in part by shortening enrollment timelines and creating burdensome administrative requirements. As many as three million people, including older adults, are expected to lose health coverage as a result.
Premium Tax Credits
The law also fails to renew the premium tax credits that are set to expire this year. Since 2012, ACA tax credits have helped people with low and middle incomes pay their Marketplace premiums. In 2021, the American Rescue Plan Act (ARPA) increased the amount and availability of the credits and the Inflation Reduction Act (IRA) in 2022 delayed their expiration, but only until the end of 2025.
This assistance has allowed millions of adults ages 50 to 64 buy coverage—spurring a 50% reduction in the uninsured rate among this cohort.
Today, the enhanced credits ease ACA Marketplace plan affordability for more than 22 million people, including many older adults who are not yet Medicare-eligible. The credits reduce enrollee premium payments by $705 a year, on average. This assistance has allowed millions of adults ages 50 to 64 buy coverage—spurring a 50% reduction in the uninsured rate among this cohort—while helping overall Marketplace enrollment grow from 12 million in 2021 to a record 24.2 million in 2025.
Older Adults at Significant Risk
If the enhanced tax credits lapse, Marketplace enrollees with incomes over 400% of poverty ($84,600 for a family of two in 2025) will lose all assistance, and people with incomes between 100% ($21,000 for a family of two) and 400% of poverty will receive less support.
Older adults would be hit especially hard. Over half of all enrollees who would be cut off from subsidies are between the ages of 50 and 64. They would they be on the hook for the full costs of their premiums, which are expected to increase by at least 18% in 2026, though some could see much higher jumps. And these enrollees are already at a cost disadvantage: under the ACA, insurers can charge people in their 50s and 60s higher premiums than they charge younger adults who purchase the same plan in the same area.
Under the ACA, insurers can charge people in their 50s and 60s higher premiums than they charge younger adults who purchase the same plan in the same area.
As a KFF example illustrates, the impacts would be severe: A 59-year-old single widow earning $63,000 (just above 400% of the poverty level, $62,600 for an individual) would pay $5,355 for her silver Marketplace plan in 2026 if Congress extends the enhanced premium tax credits before the end of this year. But if the credits expire, she could pay more than twice that—$14,213 in premiums, almost 23% of her income—for the exact same health insurance policy.
What’s at Stake
If the enhancements expire, nearly all (92%) of the 5.2 million adults ages 50 to 64 with Marketplace coverage would experience higher costs next year. Analysis suggests enrollees could see premiums rise by 75% on average, while people in rural areas could see a 90% increase.
While some may be able to find other insurance, millions will not. The resulting coverage losses would mean reduced access to care and worse individual health outcomes as well as higher Medicare costs, because more people would enter the program in poorer health and needing more expensive interventions than they would have otherwise.
The coverage losses would mean higher Medicare costs, because more people would enter the program in poorer health and needing more expensive interventions.
Across all age groups, at least 4.2 million people are expected to become uninsured unless Congress acts.
Congress Must Act Quickly
At Medicare Rights, we will continue to work to protect the ACA’s coverage gains. People must have access to high-quality, affordable health care and coverage. To that end, we urge lawmakers to extend the enhanced credits without delay. Otherwise, people may have no choice but to drop their Marketplace plans, setting in motion harmful coverage losses that could undermine individual health and economic security as well as Medicare sustainability.
Read the KFF report, What Could the Health-Related Provisions in the Reconciliation Law Mean for Older Adults?
