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Millions of Americans are projected to lose health insurance over the next decade due to recent federal legislation, primarily the 2025 Budget Reconciliation Act known as HR1 or the "One Big Beautiful Bill Act", which enacts significant cuts to Medicaid and allows enhanced Affordable Care Act (ACA) subsidies to expire, potentially leaving 10-16 million people uninsured by 2034.

“Medicare is the primary healthcare insurance program for 70 million older adults over age 65 and many younger people under 65 with disabilities,” said Amber Christ, Managing Director for Health Advocacy, Justice in Aging at the weekly American Community Media national briefing. “These vulnerable populations will be the hardest hit. “

“These losses stem from Medicaid funding reductions, new eligibility hurdles (like paperwork and work requirements), and higher ACA marketplace premiums after subsidies end, impacting low-income individuals, families, people with disabilities and seniors, said Christ.

 “The American community is looking at health cost increases and access decreases,” said Tomas Bednar, Senior Vice President & Counsel, Healthsperien LLC. 

“Those with the lowest incomes are going to see their household resources decrease the most because of HR1. They're going to see a decrease of about 3% or $1,200 a year from their households.”

HR1 cuts the very programs that older adults living in poverty rely on

The median income for older adults is around $30,000. 70% of older adults earn less than $50,000! The average household income of those 65 and over is about $57,000. It’s the lowest of any age group. Nationally, fifteen percent of older adults are living in poverty.

“This year, according to the census data, older adults were the only ones to experience an increase in poverty rates! That increase has been happening every single year since 2020,” said Christ. 

Cuts to Medicaid significantly affect older adults 

Medicare is the primary healthcare insurance program for 70 million older adults over the age of 65 and many younger people under 65 with disabilities. It is the federal program. The seniors became eligible based on the Medicare taxes they paid for a certain period of time.

Cuts to Medicaid significantly affect older adults because many Medicare enrollees rely on Medicaid for supplemental coverage and essential long-term care services. 

“Many people believe that if you have Medicare, everything's covered. But Medicare has huge gaps in coverage as Medicare is really expensive and it's Medicaid that fills in those gaps for 12.5 million older adults and people with disabilities who have low income and resources, who are duly enrolled in both Medicare and Medicaid, said Christ. 

The biggest gap in Medicare coverage is long-term care. Medicaid, not Medicare, is the primary payer of long-term care in the United States. It covers more than 60% of all nursing facility care and is the main payer for at-home services through Medicaid Home and Community-Based Services (HCBS). Medicaid also fills other gaps left by traditional Medicare, including coverage for dental, vision, and hearing services.

Medicaid plays a crucial role in making Medicare affordable. Medicare premiums are substantial, and beneficiaries are responsible for 20% coinsurance for most physician or specialist services. Medicaid helps cover these costs for low-income older adults, preventing significant financial hardship.

“Without Medicaid's financial assistance older adults and people with disabilities could not afford Medicare. Medicare would become an unusable benefit,”said Christ. 

Nearly 30% of Medicaid expenditures go toward Medicare beneficiaries, underscoring the program’s central role in supporting older adults. Medicaid is also vital for adults ages 50–64, individuals with disabilities, people managing chronic illnesses, and caregivers who obtain coverage through Medicaid expansion. 

Under the Affordable Care Act, Medicaid expansion made coverage available. It helps seniors

Low-income adults, and more than 5 million adults ages 50–64 rely on this expanded eligibility to keep health coverage. Additionally over 4 million family caregivers are enrolled in Medicaid expansion for their own health care. 

The Affordable Care Act (ACA) and the marketplace coverage also plays a real role for older adults, people who retire early, or take part-time work because they're providing caregiving, for example, or they're getting ready to retire, or they have a chronic illness and can't work as much enroll through the marketplace, said Christ. Through the ACA they receive enhanced premium tax credits. In fact, 51% of people receiving enhanced premium tax credits are individuals ages 50 to 64.

The cuts to Medicare, Medicaid, and the Affordable Care Act have significant ramifications for older adults.

HR1 is ending eligibility for Medicare for millions of lawfully present immigrants

Many of the lawfully present immigrants who will be denied health coverage are seniors. This includes individuals who have paid Medicare taxes for years, yet will no longer have access to the coverage they paid into. For some, coverage will be terminated even if they are already enrolled in Medicare. 

“This is unprecedented: to our knowledge, there is no prior instance in which individuals who were eligible for Medicare lost that eligibility,” said Christ. 

As a result, many immigrants will become uninsured due to the unaffordability of marketplace coverage. This population is excluded from enhanced premium tax credits and is also ineligible for Medicaid, effectively eliminating all affordable coverage options. Consequently, millions of individuals are left without health insurance.

Over 1 trillion cuts to Medicaid impact seniors

Either through direct cuts to states and federal funding or from eligibility changes fewer people will be enrolled in Medicaid. “The impact on seniors just got glossed over by lawmakers saying, that's not going to happen,” said Christ. 

States stand to lose billions of dollars in federal funding that support their Medicaid programs, and they will be forced to fill that budget gap. There are only a few ways to close a hole of that magnitude: cutting provider payment rates, restricting eligibility, reducing benefits—or, most likely, all three.

Home and community-based services account for 51% of optional spending in Medicaid. It is likely to be one of the first things on the chopping block. 

“They will cut provider rates, they will cut hours, or they will cut eligibility. We're already seeing that. Just most recently, Colorado's governor proposed cutting HCBS provider rates., and hours of personal care to older adults and disabled people,” said Christ. 

How adding work requirements to Medicaid impacts seniors

The most fundamental change in H.R. 1 is the addition of work requirements, referred to as “community engagement requirements”, for Medicaid. These requirements target the Medicaid expansion population, particularly adults ages 50 to 64, including people with disabilities or chronic conditions, as well as caregivers. Under this policy, individuals would be required to prove that they are working or qualify for an exemption in order to maintain their health coverage.

The Congressional Budget Office estimates that 5 million people nationwide would lose Medicaid coverage as a result of these requirements. Importantly, this loss would not be because people are unwilling to work or fail to meet an exemption, but because of administrative barriers and red tape associated with documenting compliance.

“We're at the highest rate of uninsured right now, and we're in a position right now where we're going to see that completely rebound, and millions of people losing coverage.”

There are already bills in Congress to rescind the healthcare provisions, or to repeal the healthcare provisions in H.R. 1.