One of the conditions of ACAeligibility is that the consumer doesn't have access to“affordable” coverage through work — that is, the employee's shareof the insurance would cost no more than 9.86 percent of householdincome.

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Last Christmas Eve, Justine Bradford-Trent slipped on ice, slamming to the ground. Herelbow swelled. Was it broken? She couldn't tell.

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Because Bradford-Trent was uninsured, she weighed her options. She couldgo to the emergency room, the immediate but more costly option. Theurgent care center cost less, but it was closedfor the holiday. The Idaho resident decided to wait and, once theswelling subsided, she concluded it was just a bad bruise.

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Related: High deductibles blur line between insured anduninsured

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Bradford-Trent, 54, knows she was lucky this time. But, becauseher family can't afford health insurance, she worries about thenext time something happens.

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“What if … I end up with cancer or [something] like that,” shesaid. “I don't want to be faced with a decision of having to make achoice: to live or die? Or do we go into debt so deeply that it'sthousands and thousands of dollars just to save me, and we're stuckin debt for the rest of our lives?”

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Although the Affordable Care Act is credited with expandinghealth insurance to about 20 million Americans, a small segment ofthe population — including Bradford-Trent — has been leftbehind.

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The problem is called the “family glitch.” It's deeply rooted inthe health law's weeds. And fixing it would cost taxpayers abundle.

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In the current Republican-controlled Congress — which has beenmore interested in dismantling the health law than building on it— such a fix is unlikely. Unlikely, that is, unless the Democrats,who have been campaigning hard for the congressional elections onhealth care issues, pick up enough seats to control the legislativeagenda.

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Under the ACA, people who meet a particular income threshold canget a federal subsidy to help buy insurance on the marketplace. Oneof the conditions of eligibility is that the consumer doesn't haveaccess to “affordable” coverage through work — that is, theemployee's share of the insurance would cost no more than 9.86percent of the employee's household income.

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The sticky part: calculating affordability considers only thecost of insuring one family member, even if the person's spouse andchildren also would be covered through that health plan. So whilethe cost of individual coverage might sound feasible, adding therest of the family would quickly cause financial strain.

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For Bradford-Trent, it's a real problem. Her husband, who worksin commercial construction, makes $66,000 per year and is thefamily's primary breadwinner. She's a part-time notary public,earning “a few hundred dollars a month — not enough to pay forinsurance,” she said.

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His employer-based coverage alone would be a doable $172 amonth. That's well within the 9.86 percent “affordability”threshold. But to add their daughter to the plan is another $270.To add Bradford-Trent as well would add $718 more, she says — atotal of $1,060. “That's 25 percent of his take-home pay — 25percent,” she said. “That's astronomical.” And that doesn't includeout-of-pocket costs for any medications or procedures.

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For now, they've chosen to buy insurance for her husband anddaughter. She goes without and hopes to stay healthy.

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They've explored other health coverage options. She is lookingfor a full-time job with benefits. She and her husband haveconsidered divorcing, or moving to another state, to see if shecould qualify for health coverage. They've even turned to the ACAmarketplace in search of an individual plan for her, but thosegenerally have a price tag north of $400 a month.

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This year, Obamacare openenrollment runs from Nov. 1 to Dec. 15. The Centers forMedicare & Medicaid Services announced Oct. 11 that the cost ofpremiums for plans available on the federal marketplace have, forthe first time, trended downward. In 2018, by contrast, the national average rate ofpremium hikes ran well into the double digits. (Idaho's average2019 increase is 5 percent, far belowlast year's 27 percent hike.)

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Policy analysts say there is no obvious solution to the familyglitch. It's a widely recognized problem that has gotten lost inthe shuffle, as it affects a relatively small number of Americans —up to about 1.8 percent of the population, or 6 million people.

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“Last year there was essentially one issue, and that was all ofthe repeal-and-replace attempts,” said Matthew Buettgens, a seniorresearch analyst at the Urban Institute's Health Policy Center, whohas studied the glitch. “Proposals to expand federal spending havenot been active in the public debate.”

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Any fix, for instance, would likely involve changing theeligibility calculation for marketplace subsidies — pegging theaffordability standard to the coverage cost of the whole familyrather than just an individual's coverage. Doing so would increasefederal spending by about $9billion or $10 billion, according to estimates by the Rand Corp., anonprofit think tank, since many more people would qualify forsubsidies.

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Such a change was proposed by Hillary Clinton during herpresidential campaign and is now part of bills put forth bySen. Elizabeth Warren (D-Mass.) and Rep. Frank Pallone (D-N.J.), though both bills have stalled onCapitol Hill.

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But the idea could gain traction if Democrats — who are alreadycampaigning on health care and slogans like “Medicare-for-all” —take one or both chambers of Congress.

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“If you talk about what might be realistically possible if theelection produces strong shocks to the system, then maybe youthink, 'Well, the Democrats have the majority in the House. MaybeDemocrats and Republicans could come together on some affordabilityreforms,” said Jonathan Oberlander, a professor of social medicineand health policy at the University of North Carolina at ChapelHill. “This would be an enticing part of that agenda.”

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The White House says it's taking steps to address health careunaffordability — rolling out plans such as “association healthplans” and “short-term limited-duration plans” — skimpier, lessregulated coverage that also cost less. That could be an option forpeople priced out of both employer and marketplace plans, someexperts say.

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“If your alternative is less affordable coverage — or none atall — they look more attractive,” said Thomas Miller, a residentfellow at the conservative American Enterprise Institute, aWashington think tank.

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But other experts caution that those options leave patientsvulnerable, since they can charge higher rates to people withpreexisting conditions, cover fewer benefits and often have higherout-of-pocket costs. For Bradford-Trent, such plans cover toolittle to merit the price, she said.

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For now, she feels forgotten. And hopes she won't get sick.

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“There are choices you don't want to have to make for yourselfin life because affordable health care is not available,”Bradford-Trent said.

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Kaiser Health News isa nonprofit news service covering health issues. It is aneditorially independent program of the Kaiser Family Foundation,which is not affiliated with Kaiser Permanente.

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