A 60-year-old individual with anincome of $50,000 will pay at least one-fifth of what thoseearnings on premiums for the least-expensive ACA plans across abroad swath of the Midwest. (Image: KFF)

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Those who seek health coverage under the Affordable Care Act don't expect to have tofork over a sixth—or even a fifth—of their annual incomes for apolicy on the exchanges. After all, the name of the law is theAffordable Care Act.

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But that's exactly what older middle-class Americans arestruggling with, according to a Washington Post report. And theproblem is worse in rural areas, says a Kaiser Family Foundation analysis that findsthat the rural middle class is being hit particularly hard.According to its analysis, those with incomes above 400percent of the Federal Poverty Line ($48,560 for an individual and$100,400 for a family of four in 2019) are not eligible forsubsidies and are struggling to afford their ACAplans.

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Related: Health insurance premiums crushing for those payingfull price

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For example, a 60-year-old individual with an incomeof $50,000 will pay at least one-fifth ofwhat those earnings on premiums for theleast-expensive ACA plans across a broad swath of theMidwest. Elsewhere in the country, those premiums eat upat least a sixth of 60-year-olds' incomes.

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That could make a lot of people just skip buying coverage, nowthat there's no longer a financial penalty for doing so.

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Such a strategy makes sense, if you consider thatpeople making $45,000 are at 371 percent of the poverty level andthus are eligible for subsidies, but those making $50,000 are at412 percent and not eligible. There's no phaseout, so people wouldabruptly go from subsidy eligibility to no subsidy at all based ona fairly small proportion of additional income.

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Add in the fact that insurers can charge older people threetimes what they do younger people, and you have a recipe fordisaster. That demographic group is particularly vulnerable, saysthe report, thanks to two things: that “cliff” that ends premiumsubsidies at 400 percent of the poverty line and the ACA's abilityto multiply older Americans' premiums by three. Most 40-year-oldsjust under the cliff, it adds, only have to fork over 5 percent oftheir income to get coverage, while for people who are over thecliff, only 10 counties in the country have premiums that areequally affordable.

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But it gets worse. In nearly all of Nebraska, 60-year-oldresidents with a $50,000 income don't get off just paying 20percent of their income for premiums; instead, it will cost thembetween 30–50 percent of what they make annually. Try living onthat.

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And of course the Trump administration is pushing short-term,limited-duration plans as an alternative to ACA coverage, but suchplans can exclude people with preexisting conditions and don't haveto provide anywhere near the level of coverage (all those requiredservices the ACA must offer) that ACA plans do. So even if they canafford them, such plans may do the at-risk crowd little to no goodat all.

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Actions already taken or under discussion include reinsurance,an increase in subsidies, a change in the “cliff” and even aMedicare buy-in for people 50 and over. But so far nothing hasemerged as a single viable solution.

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Marlene Satter

Marlene Y. Satter has worked in and written about the financial industry for decades.