Midterm elections could decide if 6 million people in families can get affordable insurance Obamacare expanded insurance to 20 million people, but some are left behind.

This is a Kaiser Health News story.

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

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

Bradford-Trent, 54, knows she was lucky this time. But, because her family can’t afford health insurance, she worries about the next time something happens.

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

Although the Affordable Care Act is credited with expanding health insurance to about 20 million Americans, a small segment of the population — including Bradford-Trent — has been left behind.

The problem is called the “family glitch.” It’s deeply rooted in the health law’s weeds. And fixing it would cost taxpayers a bundle.

In the current Republican-controlled Congress — which has been more 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 on health care issues, pick up enough seats to control the legislative agenda.

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

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

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

His employer-based coverage alone would be a doable $172 a month. 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 — a total of $1,060. “That’s 25 percent of his take-home pay — 25 percent,” she said. “That’s astronomical.” And that doesn’t include out-of-pocket costs for any medications or procedures.

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

They’ve explored other health coverage options. She is looking for a full-time job with benefits. She and her husband have considered divorcing, or moving to another state, to see if she could qualify for health coverage. They’ve even turned to the ACA marketplace in search of an individual plan for her, but those generally have a price tag north of $400 a month.

This year, Obamacare open enrollment runs from Nov. 1 to Dec. 15. The Centers for Medicare & Medicaid Services announced Oct. 11 that the cost of premiums for plans available on the federal marketplace have, for the first time, trended downward. In 2018, by contrast, the national average rate of premium hikes ran well into the double digits. (Idaho’s average 2019 increase is 5 percent, far below last year’s 27 percent hike.)

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

“Last year there was essentially one issue, and that was all of the repeal-and-replace attempts,” said Matthew Buettgens, a senior research analyst at the Urban Institute’s Health Policy Center, who has studied the glitch. “Proposals to expand federal spending have not been active in the public debate.”

Any fix, for instance, would likely involve changing the eligibility calculation for marketplace subsidies — pegging the affordability standard to the coverage cost of the whole family rather than just an individual’s coverage. Doing so would increase federal spending by about $9 billion or $10 billion, according to estimates by the Rand Corp., a nonprofit think tank, since many more people would qualify for subsidies.

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

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

“If you talk about what might be realistically possible if the election produces strong shocks to the system, then maybe you think, ‘Well, the Democrats have the majority in the House. Maybe Democrats and Republicans could come together on some affordability reforms,” said Jonathan Oberlander, a professor of social medicine and health policy at the University of North Carolina at Chapel Hill. “This would be an enticing part of that agenda.”

The White House says it’s taking steps to address health care unaffordability — rolling out plans such as “association health plans” and “short-term limited-duration plans” — skimpier, less regulated coverage that also cost less. That could be an option for people priced out of both employer and marketplace plans, some experts say.

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

But other experts caution that those options leave patients vulnerable, since they can charge higher rates to people with preexisting conditions, cover fewer benefits and often have higher out-of-pocket costs. For Bradford-Trent, such plans cover too little to merit the price, she said.

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

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

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.