What’s at Stake in 2026: The Affordable Care Act

In a year already marked by rising health care costs and Medicaid service reductions resulting from federal spending cuts, health care will undoubtedly be a focal point in the coming months. A KFF poll indicates that the cost of health care is the top economic worry among the American public in 2026, with 44% of voters saying the issue will have a major impact on their voting decisions in November.

Today, the Medicare Rights Center launched What’s at Stake for Older Adults and People With Disabilities, a public education series that distills how ongoing and proposed changes to Medicare, Medicaid, and the Affordable Care Act (ACA) could affect health coverage and costs for older adults and people with disabilities. This educational series is designed to help the public, advocates, and policymakers better understand these proposals as national conversations on health care policy continue.

A well-informed and engaged public is key to protecting affordable and accessible care. “These policy proposals have real consequences for older adults and people with disabilities, whether or not they’re in the headlines on any given day,” says Fred Riccardi, President of the Medicare Rights Center. “As current and future beneficiaries of the Medicare program, it is important that people understand the value of these programs and how changes may impact their ability to access and afford care in the future.”

What’s at Stake for Older Adults and People With Disabilities includes 10 fact sheets—each centered on a policy idea, regulatory area, or piece of legislation—supplemented by a summary infographic and two explainer videos. Each month, we will highlight one policy topic on the blog, beginning with the ACA’s protections for older adults and the current threats those provisions face.

The Affordable Care Act

The ACA strengthened Medicare, expanded Medicaid, and broadened health care coverage for people of all ages. Most plans in the Health Insurance Marketplace are required to provide comprehensive coverage of essential health benefits and offer preventive services without requiring patient cost sharing.

The law also limited many of the methods by which insurers had previously discriminated against older customers and tried to price them out of care. The ACA eliminated annual and lifetime limits on care, and it disallows most insurers from denying coverage based on pre-existing conditions.

Current and Future Threats to the ACA

Ongoing

The current administration has made several legislative actions to limit the accessibility and reach of ACA provisions. The 2025 budget bill, HR 1, established federal work reporting requirements that will go into effect at the end of 2026 for people enrolled in expansion Medicaid. Most people with Medicaid already work or qualify for an exemption to this rule. But the requirement to prove their work status will cause many people to lose coverage due to a quagmire of red tape and hard-to-meet deadlines. ACA Marketplace customers face similar obstacles to coverage, pending litigation on a final rule issued last summer. This rule would set up new bureaucratic and cost barriers, allow coverage denials for people who owe premiums, and limit essential health benefits for those seeking gender-confirming care.

The expiration of the ACA enhanced premium tax credits at the end of 2025 contributed to the dramatic increase in premium costs this year. Marketplace plans became prohibitively expensive for many, hitting older adults especially hard and forcing many to forgo care in order to afford other necessities. Analysts warn that without congressional action to restore the tax credits and mitigate the effects of HR 1, Marketplace enrollment may be cut in half.

Proposed

There are several other concerning policies that have been proposed by the administration to roll back previous protections and weaken the ACA. A new ACA proposed rule threatens even more Marketplace disruption. Short-term limited duration insurance (STLDI) and association health plans (AHPs) are two non-ACA-compliant forms of insurance for which the administration has signaled support. These non-compliant plans do not offer the same breadth of benefits as ACA-compliant plans and are allowed to charge customers differently based on factors like age, gender, and employment. Because of their more meager coverage, STLDIs and AHPs typically have lower premiums than ACA plans, making them able to lure customers to opt for plans that do not fully meet their health needs.

At the state level, Medicaid waivers may allow state programs to add further restrictions on the Medicaid expansion population beyond federal work requirements. Waivers typically respond to state and national pressures, and the current administration’s position on waiver funding and priorities—combined with the federal implementation of work requirements—may open the door for more states to pursue more restrictive practices.

View the fact sheet: What the Affordable Care Act Means for Older Adults.

View the series: What’s at Stake for Older Adults and People With Disabilities.