President Trump’s two biggest health care initiatives, aggressive efforts to roll back the 2010 Affordable Care Act and deep cuts to Medicaid, could strip insurance from as many as 3 million people aged 50-64. The biggest losers of all: Middle-aged people with disabilities.

ACA Cuts

Start with the ACA. Because the Republican Congress, at the urging of the White House, blocked Democratic efforts to extend certain provisions of the ACA late last year, many middle-aged people got priced out of their health insurance.

About 8 million ACA enrollees, or about one-third of those buying marketplace insurance, were age 50-64, many closing in on Medicare age. My colleagues at the Urban Institute estimate about 400,000 of those aged 55-64 will lose their marketplace insurance, about a 17% decline in coverage (note the Urban study looked at a narrower 55-64 age group, so the number of those 50-64 likely to lose coverage is even higher).

Keep in mind that older ACA enrollees already pay higher premiums than younger people. This age-rating is limited and varies among the states, but on average someone in their ‘60s pays premiums that are about three times higher than someone in their 20s.

The Cost Of Lost Subsidies

In addition, people making 400% of poverty or more lost all ACA subsidies this year. That affects single people with annual incomes of $63,840 or more and couples making $86,560 and up. For the benchmark silver plan, their 2026 premiums  were three times higher than they would have been with the subsidies.

The research organization KFF estimates the average annual premium for a 60-year-old would have been $5,525 under the now expired subsidies. But they now must pay $15,914, absent the tax credits. For somebody just above the subsidy threshold, that is roughly one-quarter of their total annual income.

In reality, many of these older workers already were buying bronze level plans, which had much lower premiums but far higher deductibles.

For a 60-year-old, annual premiums rose from $1,235 to $11,625, or from about 2% of their income to about 18%. About two-thirds of those age 50-64 already were enrolled in these lowest-cost ACA plans. Thus, they have no lower cost options in the ACA marketplace.

The average annual bronze plan deductible: $7,746. To put it another way, a 60-year-old who has a hospitalization or other serious medical episode could end up paying roughly $19,500, or about one-third of their annual income, on medical care, even with insurance.

However, the result for many of these older workers is not that they’ll be paying higher insurance premiums. Instead, because there is no lower cost marketplace plan to buy, they will have no insurance at all.

Some may seek commercial, unsubsidized coverage away from the ACA marketplace. But this insurance still will be very costly. They also could turn to low-cost insurance, but these policies often come with very high deductibles and lifetime coverage limits. Many exclude the very pre-existing conditions that middle-aged people are living with.

Medicaid Cuts

The Urban Institute estimates that roughly 2 million, and as many as 2.6 million, of those age 50-64 will lose their Medicaid benefits because of new work requirements Congress enacted last year and related changes.

Overall, about 11 million people aged 50-64 are enrolled in Medicaid and could be affected by the new work requirements. In this age group, about half have some chronic health conditions or are living with a disability. Nearly 90% have at least one chronic condition. About half work full- or part-time. Many others are family caregivers.

They are not the stereotypical 20-somethings sitting in their basements playing videogames that House Speaker Mike Johnson (R-LA) said were the target of the Medicaid cuts.

The big budget bill Congress passed last summer imposed new work requirements on adults under age 65 who live in the 42 states and the District of Columbia that expanded their Medicaid programs under provisions of the ACA. The federal Centers for Medicare and Medicaid Services recently proposed nearly 400 pages of rules to accompany the law.

To receive or maintain eligibility for Medicaid they’ll need to prove, at least twice a year, that they not only have a specific medical condition but also that their health prevents them from working or volunteering at least 80 hours a month. If a Medicaid recipient claims a work exemption as a family caregiver, they’ll also have to attest to the physical or cognitive limitations of the person they are caring for. However, the caregiver eligibility rules seem less stringent than the requirements for care recipients.

When the new CMS rules first take effect in 2027, they’ll allow a person to self-attest that they are medically frail and unable to work, without providing a lot of backup paperwork. But starting in 2028, they’ll need documentation, such as certification from a doctor, that their condition prevents them from working those 80 hours.

Some Medicaid experts argue the CMS requirements for medical frailty are far more restrictive than the law allows. But that will have to be tested in court.

Some will maintain eligibility by managing what likely will be complex paperwork. But others will lose their Medicaid benefits, either because they cannot work but can’t prove it is due to illness, because they are working but can’t produce the needed paperwork, or just because they get lost in the system.

The Biggest Losers

The new Medicaid restrictions will limit eligibility or benefits for a wide range of low-income people. But they may especially harm these older people of working age, who are more likely to have challenging medical conditions and already face high health care costs.

Slashing their access to both Medicaid and ACA marketplace insurance will not only jeopardize their health but impose a significant financial burden on them and their families. Without insurance, many will leave illness untreated until they are old enough to enroll in Medicare. That, in turn, will end up costing the government even more money.

A larger uninsured population also will be costly to hospitals, which are legally required to provide emergency care to all, even those with no coverage. And as much as they can, hospitals will pass on those costs to the rest of us through higher insurance premiums.

Low- and middle-income working age people in their 50s and 60s may not have been the population lawmakers had in mind when they slashed Medicaid benefits by $1 trillion and cut ACA subsidies. But they will be among the biggest losers.