SACRAMENTO, Calif. - Swan Lockett had high hopes that President Barack Obama's health overhaul would lead her family to an affordable insurance plan, but that hasn't happened.
Instead, because lawmakers in her state refused to expand Medicaid, the 46-year-old mother of four from Texas uses home remedies or pays $75 to see a doctor when she has an asthma attack.
"If I don't have the money, I just let it go on its own," Lockett said.
Swan Lockett stands for a photo in the courtyard of her apartment complex, Monday, in Houston. Lockett said she was unable to get an affordable health care plan on the federal marketplace.
The federal health care overhaul has provided coverage for millions of Americans, but it has only chipped away at one of its core goals: to sharply reduce the number of people without insurance.
President Barack Obama announced last week that 8 million people have signed up for coverage through new insurance exchanges, but barriers persist blocking tens of millions of people around the nation from accessing health care. Questions of eligibility, immigrant coverage and the response from employers and state legislatures mean considerable work lies ahead for health care advocates and officials - but cost remains a particularly high hurdle for low income people who are most likely to be uninsured.
"We think that most people will get insurance once it's affordable to them," said Cheryl Fish-Parcham, of Families USA, a health advocacy group.
There are myriad ways people fall into coverage gaps. Some are eligible for discounted policies but say they still can't afford their share of exchange plans. Others earn too much for subsidies. Immigrants living in the country illegally can't obtain care under the law. Dozens of states haven't expanded Medicaid. And some employers have reduced staff hours to avoid being mandated to provide care.
"I'm a nurse, but my employer doesn't offer health insurance," said Gwen Eliezer, 32, who lives north of Asheville, N.C.
Eliezer works an average of 29 hours a week at a nursing home, so her employer isn't required to cover her. She qualifies for a subsidy but says the plan she found with a $200 monthly premium and $6,500 deductible is too expensive. So while her 6-year-old son qualified for Medicaid during open enrollment, she goes without. She pays cash to see a doctor for gastrointestinal pain but says she can't afford to get the problem diagnosed.
"If I went through an emergency room, I can claim acute pain," she said. "But then I'd end up with a lot of debt to a hospital."
Before the launch of the Affordable Care Act, about 48 million people, or 15 percent of the population, went without health insurance, according to the U.S. Census Bureau. The number of people recently enrolled includes those who switched from previous plans, and it's not clear how many previously uninsured people are now covered.
The share of adults without insurance shrank from 17.1 percent at the end of last year to 15.6 percent for the first three months of 2014, according to a Gallup-Healthways Well-Being Index released this month. The decline would translate to about 3.5 million people gaining coverage, according to the study. Another study by RAND Corp. shows a larger number of adults gaining coverage.
U.S. Department of Health and Human Services spokeswoman Erin Shields Britt said Monday that the law has brought greater security for millions of Americans but more work remains. In addition to 8 million people who signed up for private insurance through exchanges, Medicaid enrollment has increased by at least 3 million.
"As we look to next year's open enrollment, we will continue to target outreach efforts to encourage the uninsured to explore their coverage options and enroll in a plan that meets their needs and fits their budget," Britt said.
For hair salon owner Lola Smith of Palo Alto, in eastern Pennsylvania coal country, budget is her chief concern. She said she couldn't afford a policy from the federal exchange. Instead, she bought a cut-rate plan for $148 a month that helps pay for hospitalizations and doctor visits. "It doesn't cover very much. It's just basic," she said.
The plan doesn't qualify as health insurance under Affordable Care Act regulations, and Smith expects to be hit with a fine until she qualifies for Medicare next year.
Immigrants living in the U.S. illegally are ineligible for coverage. The Migration Policy Institute estimates that more than 7.5 million people fall into this category and rely on emergency rooms and safety net clinics. About 1 million members of this population are from California.
"When I see there are American citizens who don't have access to health care because they can't pay for it, I figure that I'll have even less of a chance to have access to health services," said Jose Diaz, a 67-year-old day laborer in Pomona, Calif., who came to the U.S. illegally from Mexico City nearly a decade ago. "It's very sad."
Nearly 5 million low-income, childless adults are without health care, according to a December survey by Kaiser Family Foundation.
A Medicaid expansion could help close that gap, and the federal government has offered to pay states nearly all of the costs for covering individuals who earn up to $16,000 a year, 138 percent of the federal poverty wage.
However, 24 states have opted against it, saying they don't trust the federal government to deliver on its promises and don't want to be stuck with a program they can't afford.
Health advocates say getting those states to expand would reduce hospitalization and emergency costs across the system.
"That affects all our pocketbooks, because we all pay for uncompensated care when people don't have timely access to preventative care," Fish-Parcham said.
Texas is among the states to reject the expansion, and Lockett says she's been shut out.
The Houston woman earns too much for Medicaid or a subsidy but can't afford a full plan. She earns $1,225 a month and takes her children - a 5-year-old daughter, 18-year-old twin boys and a 19-year-old son - to the emergency room or a clinic when they need care.
"I was disappointed," Lockett said, "because I was kind of excited about getting on the Affordable Care Act on the marketplace."