TL/DR –
The Republican-passed reconciliation bill (HR 1) has made changes to the Affordable Care Act (ACA) Marketplaces, leading to potential increases in the number of uninsured and premium costs. Enhanced premium tax credits, which have aided millions of people in paying their premiums, are set to expire this year, and as many as three million people may lose health coverage as a result, particularly older adults. If the enhanced tax credits lapse, older adults, who are already disadvantaged by being charged higher premiums under ACA, would face even steeper costs, and the overall number of uninsured could increase by 4.2 million people unless Congress intervenes.
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The Republican-approved reconciliation bill, HR 1, stands accused of undermining the health care needs of older adults. The bill is said to limit access to healthcare and increase costs for senior citizens. Concerns exist about the future of the expiring Affordable Care Act (ACA) tax credits. Further insights into this issue are provided in a recent KFF analysis, which explores HR 1’s impact on the ACA and its effect on adults aged 50 and above.
ACA Marketplaces and the Implications of HR 1
Modifications brought about by HR 1 to the ACA Marketplaces are expected to raise the number of uninsured individuals and escalate premium costs.
Changes in Enrollment
The new law, coupled with the Trump administration Marketplace integrity rules, is projected to complicate the process of enrolling for a Marketplace plan. It achieves this by curtailing enrollment timelines and introducing complex administrative requirements. Consequently, about three million people, including older adults, are predicted to lose their health coverage.
Premium Tax Credits
HR 1 does not renew the premium tax credits poised to expire this year. Since 2012, ACA tax credits have provided financial relief to individuals with low and middle incomes, helping them afford their Marketplace premiums. In 2021, the American Rescue Plan Act (ARPA) raised the credit amount and availability. In 2022, the Inflation Reduction Act (IRA) postponed their expiration but only until 2025.
This assistance has allowed millions of adults aged 50 to 64 to purchase insurance, leading to a 50% decrease in the number of uninsured individuals in this age group.
Today, these enhanced credits improve the affordability of ACA Marketplace plans for over 22 million people, including older adults who are not yet eligible for Medicare. The credits reduce enrollee premium payments by an average of $705 per year. This assistance has allowed millions of adults aged 50 to 64 to purchase insurance, leading to a 50% decrease in the number of uninsured individuals in this age group. Meanwhile, the overall Marketplace enrollment has grown from 12 million in 2021 to a record 24.2 million in 2025.
Risks for Older Adults
If the tax credits expire, Marketplace enrollees with incomes above 400% of poverty ($84,600 for a family of two in 2025) will lose all financial aid. Those with incomes between 100% ($21,000 for a family of two) and 400% of poverty will receive less assistance.
Older adults stand to suffer the most. Over half of all enrollees who would lose subsidies belong to the age group of 50 to 64. They would need to pay their full premium amounts, which are expected to rise by at least 18% in 2026 although some could experience even larger increases. These enrollees already face a cost disadvantage: Under the ACA, insurers can demand higher premiums from people in their 50s and 60s compared to younger counterparts purchasing the same plan in the same area.
Under the ACA, insurers can demand higher premiums from people in their 50s and 60s compared to younger counterparts purchasing the same plan in the same area.
A KFF example highlights the severe impacts: A 59-year-old widow earning $63,000 (a little above 400% of the poverty level, $62,600 for an individual) would need to pay $5,355 for her silver Marketplace plan in 2026 if Congress extends the premium tax credits before this year ends. However, if the credits lapse, she may have to pay over double that amount—$14,213 in premiums, nearly 23% of her income—for the same health insurance policy.
The Stakes
If the enhancements expire, almost all (92%) of the 5.2 million adults aged 50 to 64 with Marketplace coverage are expected to face increased costs in the coming year. Studies suggest that enrollees could witness an average premium rise of 75%, with people in rural areas potentially experiencing a 90% increase.
While some individuals might be able to secure other types of insurance, millions will not. The resulting loss in coverage would not only limit access to care and deteriorate individual health outcomes but also inflate Medicare costs, as more people would join the program in poorer health, necessitating pricier interventions.
The resulting loss in coverage would not only limit access to care and deteriorate individual health outcomes but also inflate Medicare costs, as more people would join the program in poorer health, necessitating pricier interventions.
Across all age groups, a minimum of 4.2 million people are expected to become uninsured unless Congress intervenes.
Urgent Action Required from Congress
At Medicare Rights, our efforts are focused on preserving the coverage gains achieved through the ACA. We strongly believe in the necessity of providing high-quality, affordable health care and insurance coverage. We implore lawmakers to extend the enhanced credits without further delay to prevent people from having to abandon their Marketplace plans. This would prevent damaging coverage losses, which have the potential to destabilize individual health and economic security, as well as the sustainability of the Medicare program.
For more information, read the KFF report, What Could the Health-Related Provisions in the Reconciliation Law Mean for Older Adults?
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