Back in 2010, when the Affordable Care Act was signed into law, several provisions were debated about the legality of requiring people to purchase insurance or face a penalty.

In addition, concerns were raised that even with subsidies, the mandate required that an individual purchase insurance from a private company. This provision was upheld by the Supreme Court in June 2012.

The ACA has provided health insurance for millions of people who didn’t have it before, but each year the premiums spiral upward with no price controls in sight. Major companies such as Aetna, UnitedHealth Group and Humana exited the marketplace, stating it was not a sustainable business model and they were losing too much money to stay in the program.

For the individual, there was no guarantee that insurance premiums would remain affordable with the few companies still participating.

With a looming ACA repeal, and no guarantee of a replacement, there are striking similarities between the much maligned ACA and the very program now likely to be proposed for Medicare through a voucher system. In essence, it’s just Obamacare for the elderly, but this time the extra cost is shifted to one of the most vulnerable groups in society, seniors.

Although nothing has been finalized yet, some of the suggested entitlement revisions for Medicare are the very provisions that President Trump plans to repeal from the ACA.

The provision of a subsidy, the requirement that seniors find their own insurance plans to purchase from private companies and the lack of cost controls are the very same issues that are being repealed for the younger working classes, and yet are all part of the proposed voucher plan.

The ACA provided subsidies for those who financially qualified so that the cost of insurance was more manageable. The subsidies were meant to guarantee that insurance was kept affordable for everyone. As a result, more than 10 million Americans purchased insurance on the exchange, based on the latest data for 2017 alone.

The bottom line on the ACA is that in some cases the federal government is paying private companies to provide insurance for individuals.

Now consider the voucher system. The average cost of a Medicare Part B plan varies based on income. The cost for most seniors is $134 per month, but can be upwards of $428.60 a month based on yearly income.

The voucher proposal would give a certain dollar amount to eligible seniors to find and purchase their own plan. Again, federal dollars going into the hands of private citizens to purchase insurance from private companies. There has been no talk of any income-sensitive dollar amounts, but if it’s based on the current monthly costs, those who paid the most into the Medicare entitlement plan will end up with the least in a voucher system.

Insurance companies that sign up the healthiest of seniors would have the lowest costs. Those who sign up the sickest may not be able to cover their expenses. The same insurers that left the Obamacare marketplace could potentially leave the voucher marketplace, leaving fewer choices and no cost controls.

Premiums for Medicare plans are currently some of the lowest in the industry, with the federal government supporting any additional costs to the program with taxpayer dollars. If private companies are put in charge of selling Medicare plans to seniors with vouchers, they do not have the security of knowing that cost overruns will be covered. In order to balance their own bottom line, premiums for private plans can rise exponentially, very similar to the ACA exchange plans of the past.

This will not only affect the older patients, but eventually everyone as the premiums on the young also rise to help cover costs of the highest utilizers of the the health care system, seniors. Health care spending for seniors is five times higher than that for children and three times higher than for working adults.

But increasing the premiums to seniors who are living on a fixed income could make insurance unaffordable for those who need it the most. The only other way for insurance companies to save money is to restrict benefits or pay hospitals and doctors less.

Tom Price, the health and human services secretary appointed by Trump, has also proposed raising the age requirement to be eligible for Medicare benefits. As it stands now, everyone who is paying into the system has been told that at age 65, they are able to sign up for their health insurance benefits in the Medicare plan.

Many employers rely on this for their senior staff as it lowers the costs of having to enroll in the more costly private networks. But if the age is increased to 67, then workers will need to continue to stay employed longer in order to guarantee their health benefits.

This has downstream effects by reducing the available jobs for the younger workforce, but also increasing their health care premiums if the employer is given a plan that has to cover an older clientele. Although there may be a continuation of the inability to discriminate based on pre-existing conditions, there may also be an overall higher rate paid by everyone else to cover the costs of those closest to 67.

During his campaign, Trump promised to repeal the ACA, but he also promised not to touch Medicare for seniors. Only time will tell if he keeps his word. However, if Medicare becomes a voucher program, its not that hard to see the potential effects on seniors.

The very same issues that have plagued the federally and state run exchanges will now be passed on to seniors. This group risks potentially losing its long-awaited guaranteed health insurance program, just when they need it the most.