If you can’t afford your employer provided coverage, you and your family are ineligible for subsidies from the ACA. This is known as the employer coverage “loophole.”  An employee who rejects “qualifying” coverage offered by his employer (presumably because they can’t afford the employee co-pay) cannot qualify for subsidies through the ACA marketplace for himself or any member of his family (even if the employer does not contribute to family coverage).

Some patients have insurance in another state that cannot be used in Massachusetts. There are those who have insurance, either through an employer, Medicaid or the ACA, but cannot use it in Massachusetts.  We have a substantial transient population in the Berkshires – farm workers, creative and performing artists, theater and concert support staff, students, nannies, housekeepers, etc. – who spend extended periods of time here but whose coverage does not reach beyond their home state.  Medicaid, for example, although largely federally financed, is a state run program and cannot be used across state lines.  ACA policies, too, are state-by-state and usually incur a substantial out-of-network co-pay.  And, of course, there are those whose immigration status makes them ineligible for ACA coverage.

The ACA policies with the lowest premiums carry very high deductibles and co-pays. Many of those who obtained insurance through the ACA marketplace, as well as many of those with employer sponsored insurance, are faced with very high deductibles and co-pays.  While the Affordable Care Act provides certain preventive screenings, such as mammograms, with no deductible or co-pay, patients who select a “bronze” plan (19% of all newly insured according to the Kaiser Family Foundation), which has the lowest premiums, will be faced with deductibles as high as $6,000 for an individual or $12,000 for a family, that make the coverage essentially unusable for most primary care services.  Even the second cheapest “silver” plan, the one most often selected, has deductibles of $2500 and $5000.  A recent article in the New York Times recounted the plight of such patients who have insurance but can’t afford to use it. These are the patients we refer to as “underinsured,” whose coverage is only useful for a catastrophic illness or injury.  Incidentally, this also includes many who have employer provided health insurance.