The Trump Administration and Congress are moving quickly to pass legislation that could have significant implications for health coverage of older Americans. The House-passed reconciliation bill awaiting action by the full Senate, known as the One Big Beautiful Bill, includes several provisions that would affect health insurance coverage and well-being of older adults ages 50 and older, including those who are covered by Medicare.

The House-passed reconciliation bill includes an estimated $793 billion in federal Medicaid spending cuts over the next 10 years, including several provisions expected to increase costs or eliminate coverage for Medicaid beneficiaries, with similar provisions in the draft Senate bill. Collectively, these provisions could affect the 22 million people ages 50 and older with coverage under the Medicaid program by reducing the number of people with Medicaid and reducing access to health and long-term care services for people who remain enrolled in the program. The House bill and draft Senate language also include changes that are expected to reduce the number of people with ACA Marketplace coverage, including among 50-64 year olds.

According to KFF’s most recent poll, one third (34%) of adults ages 50 and older said they have a favorable view of the tax and budget bill moving rapidly through Congress, with stronger support among Republicans (61%) than Independents (23%) or Democrats (9%). After hearing that the bill would increase the number of uninsured by 10 million people, the share of adults ages 50 and older with favorable views drops from 34% to 24% and from 61% to 39% among Republicans. Among older adults who self-identify as MAGA, support for the bill drops from 70% to 45%. Support drops by a similar amount when people are told that the bill would decrease funding for local hospitals (see Figure 1 below).

Below are six health-related provisions to watch as the reconciliation bill works its way through the Congress. Some health care provisions of the Senate bill have been ruled out of order by the Senate parliamentarian and may need to be revised or eliminated for the legislation to pass with a simple majority.

1. New Medicaid Work Requirements. The largest source of federal Medicaid spending cuts would come from new work requirements that would be imposed on the Medicaid expansion population. The Congressional Budget Office (CBO) estimates that the work requirements in the House-passed bill would reduce Medicaid spending by $344 billion and cause nearly 5 million people to become uninsured. If passed, the bill would require adults ages 50-64 to meet new work and reporting requirements if they are enrolled through the ACA expansion. Most Medicaid enrollees ages 50-64 are working or could be exempt from the work requirements because of a disability or caregiving responsibility, but they would still need to comply with reporting requirements, putting them at risk of risk losing Medicaid coverage. According to a new KFF analysis, fewer than half of adults ages 50-64 would meet the work requirements through either employment or school, compared with 72% of adults ages 19-27 and 66% of adults ages 27-49. Those who do not qualify for an exemption could also face greater challenges reentering the workforce because of their age and physical limitations.

2. Changes to ACA Marketplaces. An estimated 5.5 million adults ages 55 to 64 get health insurance from ACA Marketplaces in 2025. The House-passed bill and Senate draft bill make changes to the ACA Marketplaces that would increase the number of people who are uninsured, including older people ages 50-64. The legislation in its current form, combined with the Trump administration Marketplace integrity rules, would shorten the open enrollment period, impose new documentation and pre-enrollment verification of eligibility requirements, and make other changes that would affect enrollment. Overall, the outcome would be loss of health insurance coverage for an estimated 4 million people by 2034, including older adults.

Further, because the bill in its current form does not extend enhanced ACA premium tax credits for Marketplace coverage that are set to expire at the end of this year, an additional 4.2 million people (including older adults) are estimated to lose coverage by 2034. Without enhanced premium tax credits, enrollees with incomes over four times poverty would lose subsidy eligibility and those with incomes between 100 and 400% of poverty will receive a smaller tax credit. Over half of individual market enrollees with incomes above four-times the poverty threshold are between the ages of 50 and 64.

Health insurance premiums are higher for people in their 50s and early 60s than for younger adults choosing the same plan in the same area. If the enhanced premium tax credits expire, enrollees currently receiving a subsidy could face higher costs to enroll, particularly if their incomes are about or above 400% of poverty. For example, according to the KFF calculator, a 59 year old single widow living in Jackson, Missouri earning $62,000 (just above 400% of the poverty level) would pay $5,270 for her silver Marketplace plan in 2025, but without enhanced premium tax credits, she would pay $14,213 in premiums, which amounts to 22.9% of her income for the same health insurance policy. It’s not hard to see why she and others like her might give up their Marketplace plans, given the cost relative to their income.

3. Blocking Implementation of the Medicare Savings Program and Medicaid Eligibility and Enrollment Rules. Older adults are also at risk of losing coverage due to provisions in the House-passed bill and the Senate Finance Committee language that would block implementation of two Biden-era rules that were intended to streamline the enrollment process for Medicaid, especially for older adults and people with disabilities. The second largest source of federal reductions in Medicaid spending stems from these two provisions, which are collectively estimated to reduce federal Medicaid spending by $167 billion.

Both rules aim to reduce barriers to enrolling in and maintaining Medicaid coverage. They are expected to disproportionately affect enrollment among older adults and people with disabilities because there are specific requirements related to streamlining enrollment among Medicare beneficiaries, and to facilitating smoother enrollment for people who are eligible for Medicaid because they have a disability, are ages 65 and older, or use long-term care.

CBO estimates that the reconciliation language would result in 1.3 million low-income Medicare beneficiaries losing Medicaid coverage. A separate KFF analysis shows that the loss of these benefits would result in a someone with an income of $967 per month paying $185 per month in Medicare premiums, or about 20% of income, without accounting for other non-trivial out-of-pocket costs, including Medicare cost-sharing requirements and the loss of Medicaid benefits.

4. Reducing Spending for Long-Term Care Services. If signed into law, the House-passed bill and the draft Senate legislation would reduce federal funds for nursing facilities and would likely lead to reductions in spending for other long-term care services. The bill would reduce federal Medicaid spending by $23 billion over 10 years by prohibiting implementation of a Biden Administration rule on nursing facility staffing. The rule aims to help address long-standing concerns about inadequate staffing and the quality of care, locking into place a federal judge’s ruling to overturn key elements of the rule.

The reconciliation bill could also reduce Medicaid funds available to nursing facilities through a moratorium on provider taxes (in place for nursing facilities in 46 states) and new limits on some payments to nursing facilities (known as state-directed payments). In the House bill, those provisions jointly account for $161 billion in reduced federal Medicaid spending over 10 years, although they would also affect hospitals and other providers. The Senate Finance language would also reduce existing state-directed payments to 100% of Medicare rates in states that have adopted the ACA expansion and 110% of Medicare rates in states that have not.

If past predicts future, substantial cuts to federal Medicaid spending could lead to reduced spending for home care, which includes long-term care provided in people’s homes and the community (and is sometimes referred to as home- and community-based services or HCBS). During the last major reduction in federal spending, all states reduced spending on home care by serving fewer people (40 states) or by benefits or cutting payment rates (for long-term care providers) (47 states). As a significant source of Medicaid spending comprised of optional services for which there are already waiting lists, home care may be especially vulnerable.

5. Prohibiting Medicare Coverage for People with Lawful Immigrant Status. Under current law, undocumented immigrants are not eligible for Medicare. Medicare coverage is restricted to people who are citizens or permanent legal residents. Both the House-passed reconciliation bill and draft Senate legislation include a provision that would prevent defined groups of individuals who are lawfully present in the U.S. from becoming eligible for Medicare benefits. The legislation would also terminate Medicare coverage for currently eligible beneficiaries who are not U.S. citizens, green card holders, certain immigrants from Cuba, and people residing under the Compacts of Free Association within a year of enactment of the legislation. Individuals affected by this provision and their employers would continue to be required to pay Medicare payroll taxes. This would be the first time that Congress has taken away coverage from potentially eligible legally residing individuals.

The Senate parliamentarian has ruled that this provision, as currently drafted, would require 60 votes to pass.

6. Adding Work Requirements and Cutting Spending for Supplemental Nutritional Assistance Program (SNAP). The House-passed reconciliation bill and draft Senate bill includes nearly $300 billion in cuts to SNAP benefits. Reductions of this magnitude, coupled with work requirements, are likely to affect the health of older adults, particularly given the strong ties between health and nutrition. As noted above, work requirements, even with exemptions, pose administrative hurdles for older adults that put them at risk for losing SNAP benefits. An estimated 9.2 million Medicare beneficiaries received SNAP benefits to help cover the costs of food and groceries in 2022, according to KFF analysis. The SNAP work requirements may particularly exacerbate financial challenges for older Medicaid enrollees ages 50 and older who are two and a half times more likely to experience food insecurity than other older adults not enrolled in Medicaid (28% compared to 10%).