by Abeer Malik
In an ideal world, everyone has a “safety net” — a reliable layer of support that catches us when life’s challenges become overwhelming. For many Americans, the Affordable Care Act (ACA) has been a crucial piece of that safety net, providing access to affordable health care, expanded coverage options, and support for innovative medical care delivery methods that lower health care costs. During Donald Trump’s previous tenure as president, his repeated attempts to repeal and replace the ACA signaled a clear intent to overhaul federal health care insurance programs, even though the efforts ultimately fell short.
With Trump’s 2024 re-election, while broad health care debates are reignited, it is crucial to zero in on what this means specifically for aging Americans.
Older Americans between 50 and 64 who are not yet eligible for Medicare rely heavily on the ACA for essential health services and protections that shield them from exorbitant premiums, discriminatory practices, and high out-of-pocket costs. Those eligible for Medicare — individuals aged 65 and older — also benefit from ACA provisions that close the prescription drug “donut hole” and provide preventive services without cost-sharing. However, Medicare does not cover all health care needs, notably long-term care services. Medicaid can step in to provide coverage for such critical needs that Medicare does not address, but many people must deplete their assets to qualify for Medicaid. Trump’s renewed focus on repealing parts of the ACA and revisiting Medicaid block grants and cap proposals threatens to unravel these protections, potentially pricing seniors out of coverage.
Medicaid Expansion at Risk
A recent explainer highlights the 2024 election’s potential impact on Medicaid’s future direction. Medicaid, jointly funded by federal and state governments, is the primary public payer for comprehensive health care and long-term care services in the United States. The ACA expanded Medicaid eligibility, allowing millions of low-income adults to access essential health care services, including millions of seniors. However, Trump’s proposed health care reforms, particularly Medicaid block grants and capped funding, would cut federal funding and remove critical protections, leading to reduced coverage, limited benefits, or tightened eligibility requirements. This would disproportionately affect seniors who rely on Medicaid for services that Medicare does not cover, such as nursing home care and home health services, leading to increased out-of-pocket costs and poorer quality of care for this vulnerable population.
Trump’s approach to health care reform reflects an agenda of state-level decision-making over federal support. If implemented, Medicaid rollback would inevitably place the burden on states to allocate reduced funds, creating a patchwork of Medicaid programs across the country that lead to inconsistent care based on state budgets rather than patient needs. Consequently, seniors in states with more generous Medicaid programs or political commitment to health care access may have better access to coverage, while those in states with stricter policies or budgetary constraints could struggle to find affordable care, raising equal protection concerns under the law.
Protections for Pre-Existing Conditions in Jeopardy
The ACA also introduced several measures to combat age and health discrimination by insurers, preventing them from denying coverage or charging higher premiums based on pre-existing conditions — a category that naturally expands with age. Trump’s push to “reverse the regulatory protections in Obamacare” and his support for policies allowing insurers to consider pre-existing conditions, would effectively turn back the clock, not only disproportionately impacting older adults but also potentially violating federal anti-discrimination laws, such as the Age Discrimination Act and the Americans with Disabilities Act. While age is not a “suspect class” under the Equal Protection Clause, if states revert to discriminatory pricing practices due to the ACA’s partial or complete repeal, the weakened protection could amount to unlawful discrimination against seniors based on age and disability status.
Short-Term Health Plans: A Step Backward for Seniors’ Coverage
During Trump’s first term, his administration promoted short-term health plans as a low-cost alternative to ACA-compliant plans. Marketed as an affordable choice, these plans are not subject to the ACA protections, and are not required to guarantee coverage for pre-existing conditions, long-term care, or other essential health services, leaving enrollees exposed to significant financial risk.
While the Biden-Harris administration reinstated limits on these plans in 2024 — reversing Trump-era policies that expanded them — a second Trump presidency could potentially see a revival of these plans. Although aimed at increasing consumer choice, such plans could destabilize insurance market regulations and have historically been known to prioritize younger, healthier individuals while raising premiums for sicker and older adults.
A Call to Action: Safeguarding Health Care for Seniors
As we look to the future, it is essential to explore policy solutions that protect seniors’ health care coverage. While implementing these solutions might seem challenging under a renewed Trump administration, unexpected shifts in policy are not unprecedented, and proactive advocacy and innovative approaches could still create opportunities for meaningful reform.
- One critical measure could be to establish federal minimum standards for Medicaid services that benefit seniors, such as nursing home care, prescription drugs, and preventive services. Codifying essential services into federal law could ensure all states provide a baseline level of care, reducing disparities caused by state budget differences and affirming the federal commitment to vulnerable populations.
- Introducing a public health insurance option specifically for adults aged 50-64, who are not yet eligible for Medicare, could also provide affordable, comprehensive coverage for seniors who might otherwise fall into a coverage gap due to potential ACA rollbacks. Drawing on models like Washington State’s Cascade Care Program, a federal public option could stabilize the individual market and offer reliable health care access for aging Americans.
- Drawing inspiration from Japan and Germany’s long-term care insurance programs, the U.S. could establish a federal Elder Care Trust Fund to provide dedicated resources for senior health care services. Funded through progressive taxation or other equitable means, such a trust fund could offer financial stability to eldercare programs, ensuring consistent support regardless of political shifts.
- Stricter federal regulations on short-term health plans could protect seniors from inadequate coverage and financial risk. Ensuring these plans meet specific standards, including protections for pre-existing conditions, and capping out-of-pocket expenses would maintain the integrity of the insurance market and safeguard seniors’ health care needs.
In a renewed Trump era, seniors’ access to health care insurance hangs in the balance, with potential shifts in Medicaid and ACA protections threatening to fragment the safety net that so many rely on. As we wait for Trump’s health care agenda to take shape, lawmakers, advocates, and the courts must grapple with the administration’s anticipated rollbacks, and ensure that every senior, regardless of state or income, can count on a secure, affordable path to essential health care insurance.
Abeer Malik’s (LL.M. 2025) research interests include medical law, law and technology, and corporate law. Her research project will examine the legal and ethical implications of AI’s integration into precision medicine (PM), focusing on the distinct challenges AI introduces compared to general healthcare.
