Older pre-Medicare Americans will have to pay more for health insurance and health care should the Senate’s bill to repeal and replace the Affordable Care Act (ACA) — the Better Care Reconciliation Act (BCRA) — become the law of the land.

What’s more, older Americans may have to reduce the amount they save for retirement, or use retirement funds to pay for current health-care needs, or keep working to age 65 if only to keep their employer-sponsored health insurance plan.

Read: Older Americans may have to postpone retirement under Republican health bill

Number of people to lose coverage

The Senate bill would increase the number of people who are uninsured by 22 million in 2026 relative to the number under current law, slightly fewer than the increase in the number of uninsured estimated for the House-passed legislation, according to a Congressional Budget Office (CBO) report released on Monday. By 2026, an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law, the CBO says.

What’s more, the increase would be disproportionately larger among older people with lower income—particularly people between 50 and 64 years old with income of less than 200% of the federal poverty level, the CBO wrote.

Under the House bill, the American Health Care Act (AHCA), the CBO estimated that more than five million older adults ages 50-64 would lose health insurance.

These older Americans would likely have to return to work, or dip into retirement savings, or stop saving for retirement, or go without health care in the worst of cases, experts say.

Wider age bands and less generous subsidies

Older adults across the country, not yet eligible for Medicare but in need of health insurance, can also expect higher premiums under the Senate bill due to wider age bands and less generous subsidies than current law, according to Tricia Neuman, a senior vice president with the Henry J. Kaiser Family Foundation.

Read: Compare proposals to replace the Affordable Care Act, which compares the Senate and House plans.

The BCRA imposes, as did the House bill, what’s been called an “age tax” on older adults. “The ACA limits the premiums people 60 to 64 pay to three times what younger people pay, but the AHCA lets insurers charge older adults five times (or more if state law allows) what a younger person pays for the same health plan,” according to a Medicare Rights Center brief.

Read statement from Medicare Rights Center

Read statement from AARP

In some cases, the increase in premiums will be exorbitant. “People living in high-cost areas and have incomes 350% and 400% of federal poverty level (FPL) will see substantially higher premiums as a result of these changes,” says Neuman.

Read: How the Republicans and Democrats can both be right on Medicaid

Of note: The KFF published an interactive map that compares county-level estimates of premiums that consumers would pay under the ACA in 2020 with what they’d pay under the Senate’s BCRA.

That map shows, for instance, that a 60-year-old in Grant County, W.Va., with income of $40,000 (roughly the median household income in that county and 320% of FPL) would see their after-tax credit premiums rise 124%, from $4,080 for an ACA silver plan (10% of income), to $9,120 (23% of income) for a BCRA silver premium plan. The increase would be even greater for those on a bronze plan.

Here's the real reason why U.S. health care is so expensive

Consider also the case of Andy Landis, author of “Social Security: The Inside Story,” and his wife, both of whom are self-employed and both of whom have no employer-sponsored health plan.

Landis’s wife, who is three years shy of being eligible for Medicare, currently pays just under $700 a month, or $8,400 a year, for a silver (mid-level) plan with no subsidy under the ACA. “We’re not worried about losing our coverage,” says Landis. “We are worried about skyrocketing premiums under the GOP plans.”

Landis speculates that his wife’s premium will rise 67% to nearly $14,000 a year, not including the usual inflationary premium increases. “The bottom line: Both the House and Senate bills appear to vastly increase premiums for older self-employed workers like us,” Landis says. “We’re literally counting the months—and the premiums—until my wife turns 65 and becomes eligible for Medicare. That’s over $16,000 that the GOP bills will take from our preretirement savings.”

Landis also added: “We count our blessings that we can scrimp and cough up the money. Millions of people won’t have that luxury, and will simply lose their coverage. I resent the fact that all this damage is being done in order to give a massive tax cut to wealthier people, amounting to multiple millions for very wealthy individuals.”

Others are fearful that older Americans will not only lose savings to pay for current health care expenses but lose even more. “Medical costs are already a leading cause of bankruptcy,” says Katy Votva, president of Goodcare.com. “Approval of this legislation will cause intolerable financial strain a considerable number of households. Additionally, all others with health insurance will pay higher premiums and taxes due to the inevitable cost shifting requited to pay for uncompensated care.”

Medicare savings provisions

Neuman also noted that the Senate bill includes all Medicare savings provisions included in the ACA, such as reductions in payments to health-care providers and Medicare Advantage plans. “It even retained the controversial Independent Payment Advisory Board (IPAB), a provision that could compel savings beginning in 2019,” she noted. And, Neuman says the “Senate bill retains the ACA Medicare benefit improvements, such as closing the Medicare Part D doughnut hole and reducing cost-sharing for preventive services.”

For his part, Jae Oh, author of “Maximize Your Medicare: Understanding Medicare, Protecting Your Health, and Minimizing Costs”, says Medicare beneficiaries who have delayed Medicare Part B enrollment and who are covered by an employer-sponsored group plan, will definitely want to reconsider.

“It has always been the case that the premium may or may not be superior to Medicare along with either a Medigap/Part-D or Medicare Advantage plan,” he says. “The BRCA adds a further set of factors to consider. The BRCA could potentially change the definition of essential health benefits, and if that is the case, then the quality and services provided by the employer-sponsored plan may not be appropriate for the employee.”

In theory, he says, an employer with employees in multiple locations will be able to choose a state, in which an employee resides, as the template for the entire group plan, and then change the benefits of the entire plan, which can include lifetime benefit limitations or limitations against certain conditions. This is also affects spouses, particularly because many employers charge substantially more for the spouses of active employees, Oh says.

Medicare trust fund might become insolvent sooner

Older adults on Medicare would be mainly affected by two changes in the Senate bill, Neuman says.

“The Senate bill repeals the payroll tax surcharge on people with high earnings which helped strengthen the Medicare trust fund,” she says. “Repealing this surcharge accelerates the insolvency of the Medicare Trust Fund which means policymakers will need to take action sooner to be sure Medicare can continue to meet its obligations beginning less than a decade from now.”

Others have a similar observation. “The ACA extended the lifespan of Medicare,” says Votava. “These tax cuts will result in Medicare becoming insolvent sooner.”

The Hospital Insurance (HI) trust fund (which funds Medicare inpatient services, or Part A) is expected to go negative in 2028, at which point the program would only be able to pay 87% of benefits, \according to a 2016 Medicare Boards of Trustees report.

Changes to Medicaid

Though not a direct change to Medicare, Neuman says changes to Medicaid in the Senate bill are likely to affect people on Medicare. “The Senate bill caps the growth in Medicaid spending, and over time, this cap is expected to rise more slowly than the actual cost of care,” she says. “This is an issue because 11 million people on Medicare rely on Medicaid to help cover their health and long-term care costs.”

And just as the proposed per capita caps ratchet down to CPI-U, Neuman says boomers will be turning 80, which is about the age when seniors begin to need long-term services and support. “Only a fraction of the Medicare population have sufficient savings to cover their own long-term care costs, which is why Medicaid plays such an important role, and why changes to Medicaid could impact a surprisingly large number of older adults over time,” she says.

Read AARP blog: The Senate Health Reform Bill Slashes Medicaid Severely

Kip Piper, president Health Results Group, also says the federal funding caps on nursing homes and home care options will affect older Americans. “The bill caps annual increases in federal Medicaid per capita funding first by CPI-U medical and later by only regular CPI-U,” he says. And that, he says, “is not sufficient to keep up with increases in nursing home operating costs and wages, much less the cost of increasing intensity of services needed by an aging population, living longer but needing more intense assistance and supports and greater range of physical and cognitive disabilities.”

Medicaid is the primary payer source for most certified nursing facility residents, with more than six in 10 (63%) of residents having Medicaid as their primary payer in 2014, according to the Kaiser Family Foundation.

The bill also makes additional funding cuts to Medicaid payments to nursing homes, Piper says. “This is by reducing provider assessments — a common way Medicaid programs use to help pay nursing homes and hospitals,” he says. “States don’t have the money to make up for these cuts in provider assessments, which will mean the risk of deep payment cuts to nursing homes.”

According to Piper, Every state Medicaid program covers both nursing home services and an array of home and community-based services, with many states also covering assisted living, Piper says.

“Federal law mandates that states cover nursing home services and cannot have waiting lists for nursing home care,” he says. “Home and community-based services, personal care, homemaker assistance, self-directed personal assistance, and assisted living are optional. States don’t have to cover these services and they may eliminate them, cap enrollment, have waiting lists, or tighten criteria of who gets services and how much. Faced with less federal funding and the need to manage costs within regular consumer inflation, some states may need to cut back.”

Piper says the bill also redistributes some federal funding from states that spend more on specific populations, like the elderly and persons with disabilities, to lower cost states. “State per capita costs for these populations vary widely, much less so for children and non-disabled adults under 65, so this will intensify the impact on states that, for various reasons, spend more per person,” he says.

Planned Parenthood

The BCRA also prohibit federal Medicaid funding for Planned Parenthood for one year. “The prohibition of Medicaid reimbursement for Planned Parenthood discriminates against poorer women of all ages, including many over 50,” says Votava. “This organization provides a full spectrum of women’s health care, including over 600,000 women’s cancer screenings in 2016. The Senate plan does not include a viable alternative for those women to get necessary care.”

Changes in essential benefits

The ACA requirement to cover 10 essential health benefit categories is not changed. However, “the 1332 waiver authority is amended to make it easier for states to eliminate or change the essential health benefits standard for health insurance coverage offered in the individual or small group market,” according to a Kaiser Family Foundation brief.

“The potential lack of essential benefits can be disastrous for all” says Votava. “Everyone under 65, whether they have ACA plans or employer plans, may lose coverages. The lack of prescription benefits, mental health care, and maternity benefits will leave a substantial number of folks in the lurch.”

Oh says those who will not be 65 by 2020 — the year Medicaid expansion, which includes cost-sharing reductions, are scheduled to begin — will face difficult choices.

“There is reportedly a large increase in enrollments of ‘ancillary’ products, such as critical illness and hospital indemnity, among many, which offer cash payments to those that receive new diagnoses that will require medical care,” Oh says. “There products have a cash benefit which is paid to the policyholder under these situations. This set of policies is highly fragmented, and the differ wildly, and caution should be in selecting a particular plan.”

Those who do not qualify for Medicaid, and who face much higher premiums, may want to consider these ancillary products now, because those products usually do have “pre-existing conditions” clauses, Oh says. “So ultimately, the combination for older Americans may become either cheapest possible health insurance plus an ancillary product to cover a one-time large deductible bill, if a very serious health situation arises.”

The annual enrollment period will also narrow. “And that means that the best combination of ‘cheapest health insurance plan’ with ‘ancillary product’ or either one of these independently, will need advance work, because while ‘ancillary products’ do not have enrollment calendar deadlines, health insurance will,” Oh says.

High-risk pools

According to the Kaiser Family Foundation, the BCRA create a $62 billon fund that states can use to fund high-risk pools, among other things. Experts say this high-risk pool fund is a non-starter. “High-risk pools were economic and practical failures in the past,” says Votava. “There is no reason to believe they will be successful with this proposal. For one, the earmarked funding is woefully insufficient.”

Health Savings Accounts upped

The BCRA increases the annual tax-free contribution limit to equal the limit on out-of-pocket cost sharing under qualified high deductible health plans ($6,550 for self only coverage, $13,100 for family coverage in 2017, indexed for inflation). Plus, additional catch up contribution of up to $1,000 may be made by persons over age 55. Both spouses can make catch up contributions to the same HSA.

Read: Tax provisions in the Senate health care bill

As is the case already, amounts withdrawn for qualified medical expenses are not subject to income tax. However, the tax penalty for HSA withdrawals used for nonqualified expenses is reduced from 20% to 10%, effective Jan. 1, 2017.

“While increasing HSA limits is a positive move, most people will still find the bottom line cost is out of reach for their family budget,” says Votava.