Equally problematic, however, is the problem of increased cost-shifting to patients. High out-of-pocket expenses or exposure in the form of copayments, deductibles, or coinsurance has left an increasing number of Americans (almost one-quarter of insured, nonelderly adults) “underinsured” in 2014. These individuals, although insured, still struggle with medical bills and avoid needed care. Underinsurance, unfortunately, is “built into” the ACA. Plans purchased on the ACA exchanges, for instance, leave families responsible for as much as $13,200 a year in out-of-pocket payments after premiums are paid (depending on income).