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Which Americans Are Shut Out of the Affordable Care Act?

Teresa Mears

As the deadline for enrolling in an Affordable Care Act marketplace insurance plan approaches on Dec. 15, some people are finding themselves left out.

Since the ACA went into effect in 2013, more than 20 million additional Americans have been able to buy health insurance, cutting the rate of uninsured from 18.2 percent in 2010 to 10 percent in 2016, according to the Kaiser Family Foundation. Of the 27 million Americans under 65 still without health insurance, the KFF estimates that 5.3 million could get assistance paying for marketplace plans and another 7.5 million could buy plans at full price. And another 6.4 million could be eligible for Medicaid, according to the organization.

But as Congress and President-elect Donald Trump consider whether to repeal, replace or modify the insurance marketplace, there are still people who cannot find affordable insurance and remain shut out of the marketplace, which enrolled about 12.7 million Americans last year.

"Affordability remains a primary barrier," says Karen Pollitz, a senior fellow at the Kaiser Family Foundation.

[Read: How Affordable Care Act Marketplace Insurance Plans Will Change in 2017.]

While some people like undocumented immigrants aren't eligible to use the marketplace even without subsidies, others who are eligible find themselves unable to purchase plans because of cost.

While the ACA cannot reject someone because of pre-existing conditions, its plans can charge more for people who are older or those who smoke. Anyone who makes more than $47,520 a year ($64,080 for a couple and $97,200 for a family of four) is not eligible for a subsidy, which means they pay full price.

The ACA marketplace offers four tiers of plans: Bronze, which is estimated to cover 60 percent of medical costs; Silver, which is estimated to cover 70 percent; Gold, 80 percent; and Platinum, 90 percent. Most people choose Bronze or Silver plans, and those tiers have the most plan options.

In Fort Lauderdale, Florida, for example, the cheapest Bronze plan available for a 60-year-old woman who doesn't smoke is an HMO for $582 a month, with a $7,150 deductible, which comes out to $6,984 in premiums and $7,150 in medical costs before any services are covered. That's nearly 30 percent of before-tax income for someone who makes $48,000 a year. The premiums alone are 15 percent of income.

For a couple, both 60, making $65,000 a year, premiums would be $1,164 for that plan, with a $14,300 family deductible. The $13,968 premiums would eat up more than 20 percent of their income, and a serious illness would cost the couple 43 percent of their income before insurance kicked in.

A 25-year-old would pay $215 a month for the same plan. A family of four, comprised of two 40-year-old adults and two children, would pay $820 a month with a $14,300 family deductible.

The new Simple Choice plans, available for slightly more, would allow for primary doctor visits for a $45 copay and generic drugs for a $35 copay before the deductible is reached. But the plans charge a hefty coinsurance amount until the out-of-pocket limit of $7,150 for an individual or $14,300 for a family is reached.

The people hardest hit by these costs are those who earn too much to qualify for a subsidy but too little to pay the premiums, or people who can't afford the premiums even with a subsidy.

Another sizable group who are left out are the spouses and some children of Americans who are offered health insurance through their workplace but can't afford it. Whether the coverage is considered affordable is based only on the cost of the employee's plan, and many companies charge family members more for coverage, sometimes full price.

[Read: 10 Things to Do When Choosing an Obamacare Health Plan.]

Many spouses who fall into what is called the ACA's "family glitch" have incomes low enough to quality for subsidized marketplace plans, but they aren't eligible because they have access to other insurance -- even though they can't afford it. Their children often qualify for the Children's Health Insurance Program or Medicaid.

"It is something we are concerned about and would urge lawmakers to take action," says Lydia Mitts, senior policy analyst for Families USA, which trains navigators who provide guidance to health care consumers. "It needs to be fixed so these people have access to affordable coverage."

But she notes that people shouldn't assume they don't quality for plans or premium tax credits without talking to someone who can help them evaluate their situation. You can find local help on the healthcare.gov site.

Those who aren't eligible for the ACA marketplace can buy insurance directly from insurance companies, though that is sometimes more expensive. Other options are health care sharing ministries and short-term policies. But the reality is that people left out of the ACA have few good options, which is why most remain uninsured. The best way to check on options is to consider tapping a knowledgeable local insurance broker.

These are the major groups who are left out of the ACA:

People who are eligible but can't afford the premiums. Among this group are the self-employed workers, retirees younger than 65 and those whose employers don't offer insurance. The KFF estimates that 3 million Americans fall into this group.

People who can't afford the insurance offered by their employers. While most large employers subsidize the cost of health insurance for employees and often for dependents, some small employers offer insurance at full cost or charge dependents more. If the insurance is offered, those employees and their families can't get financial help with marketplace plans. About 4.5 million uninsured Americans fall into this group, according to the KFF analysis.

People who don't get Medicaid but don't make enough to qualify for the ACA. In the 19 states that opted against expanding Medicaid, an individual must earn at least $11,880 a year to be eligible for marketplace coverage with subsidies. Someone who can't work at all, perhaps because of an illness or unemployment, would not qualify. The KFF estimates that about 2.6 million people fall into this group in those 19 states.

[See: A Consumer's Guide to Obamacare.]

Undocumented immigrants. Those who are not citizens, legal permanent residents or otherwise lawfully present are not eligible to buy marketplace plans, even at full price. That accounts for about 5.4 million uninsured people.

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