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Policy Series

What's at Stake

Over time, policy ideas gain and lose popularity, including several that threaten the effectiveness of major health care programs like Medicare, Medicaid, and the Affordable Care Act (ACA). In this series—What’s at Stake—we explore some of these reform ideas and how they could affect coverage, care, and outcomes for older adults and people with disabilities.


Understanding these issues is important, as it may influence how a person votes, donates to causes, or interacts with elected officials. Importantly, while some of the ideas may appear partisan, many enjoy broad support, and all are sensitive to shifting political dynamics.


This work was supported in part by the AARP Public Policy Institute. Medicare Rights Center maintains full editorial control over all of its policy analysis and communications activities.

Medicare Reforms in the Inflation Reduction Act

The Inflation Reduction Act (IRA) of 2022 made key changes in Medicare law and coverage to improve prescription drug affordability for older adults and people with disabilities. Since its passage, some stakeholders and lawmakers have targeted IRA policies for revision or repeal, especially the law’s Medicare Drug Price Negotiation Program. Depending on the provisions targeted, this would increase beneficiary costs and increase Medicare spending.

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Medicare Private Contracting

Some policies would give Medicare providers the right to charge beneficiaries more for care than is currently allowed through balance billing or private contracting arrangements. Under Medicare private contracting, providers could charge their Medicare patients more than they currently pay or require them to negotiate a contract for the cost of their care.

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Medicare Means Testing

A core component of Medicare is its universality. Some policy ideas would undermine that promise by limiting certain benefits to people with lower incomes or requiring those with higher incomes to pay more for care. Means testing any portion of Medicare would add administrative complexity and access barriers.

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Raising the Medicare Eligibility Age

A commonly discussed reform would raise the Medicare eligibility age from 65 to 67 or even 70. This would reduce access to care and disproportionately harm some who can least afford it, including people who work in physically demanding jobs and older adults of color. 

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Medicare Premium Support

Proposals to turn Medicare into a premium support system, also called a defined contribution system or a voucher program, are evergreen. Such programs would give people with Medicare a voucher or coupon worth a certain amount toward the purchase of health coverage. If the voucher did not cover the full cost, the person would presumably have to pay the rest or go without coverage.  

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Affordable Care Act Coverage Expansions and Consumer Protections

The Affordable Care Act (ACA) strengthened Medicare and Medicaid and created important coverage avenues and consumer protections for people of all ages. Despite these successes, the health law continues to face opposition from some policy corners in Congress, the states, and the courts. If repealed, people would lose protections, including free preventive services in Medicare. 

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Medicaid Financing

Proposals to restructure Medicaid’s financing often recommend transforming the program from a guaranteed benefit to a fixed payment system, coupled with new limitations on costs or care. Such changes can put access to care at risk, especially for older adults and people with disabilities. 

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Medicaid Waivers

Many states have expanded coverage and care through Medicaid 1115 waivers, but some have attempted to use them to limit eligibility or restrict coverage, which could prevent people from accessing needed care. 

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Medicaid Work Requirements

State and federal support for conditioning Medicaid eligibility on compliance with monthly employment and reporting requirements persists, with strategies like 1115 waivers and statutory changes among the most prominently discussed. Such requirements create unnecessary barriers to care while increasing the administrative burden for enrollees and states. 

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