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The Affordable Care Act was intended to provide healthcare coverage to the poorest and most vulnerable Americans. But in states that decided not to expand their Medicaid programs under the law, many are being left behind. The name of the game is the workaround - inventive ways that people can still qualify for a subsidy on the exchange, even if they think they earn too little. Jenny Gold sent this report.

JENNY GOLD, BYLINE: In the mountains of western North Carolina, navigator Julia Buckner spends hours driving on the winding roads of what she calls God's Country, reaching out to the rural residents of some of the poorest counties in the state.

JULIA BUCKNER: So, we're in far western North Carolina, the seven furthest counties. We are, as we like to say, about two hours from anywhere.

GOLD: Buckner grew up here then moved to Atlanta to study theology. She came back to Appalachia to try to help her community and landed a job signing people up for health insurance.

BUCKNER: It's helpful that I'm from here and I speak like I'm from here. I can, you know, talk with a mountain accent. And so folks sort of tend to trust that.

GOLD: But she says the hardest thing is that for about nine out of 10 people she talks with, there's nothing she can do for them. That's because North Carolina is not expanding Medicaid.

BUCKNER: I take someone who's working poor, I ask them to come see me, and then I find out not only are they poor, but they're too poor for me to help. It's almost as if I wished I hadn't have even seen them.

GOLD: But she keeps trying. Recently, she visited Carolina Kitchen, one of the three restaurants in Graham County, where she speaks with the hostess.

BUCKNER: Hey there. I'm Julia.

KITTY WILLIAMS: I'm Kitty Williams.

BUCKNER: Nice to meet you. So, I'm the health care navigator for Graham and Swain Counties, and these are some of my flyers. And I was just going to see if I could leave them here in case folks had questions when they come in to eat. And also I wanted to see if you had health insurance yourself.

WILLIAMS: No, I do not. I need it.

BUCKNER: You need it? So, you need to come talk to me.

WILLIAMS: OK.

GOLD: She asks Williams how much she expects to earn this year. If she makes more than $11,500, she might qualify for a tax subsidy to help her purchase private coverage on the exchange. If she earns less, she'll fall into what's called the coverage gap - people who don't earn enough to get a subsidy under the health law and can't get Medicaid in North Carolina.

BUCKNER: Do you think you would make around...

WILLIAMS: Yeah, probably. Probably around that. Maybe not quite that much.

GOLD: Buckner says that's a pretty common response. But she isn't one to give up easily. Instead, she's getting creative and looking for workarounds that may sound counterintuitive. But if Buckner can help Williams and others think of different ways to boost their income, they may be able to earn enough to get a subsidy.

BUCKNER: Folks are trying to use every source of income, whether it's selling tomatoes from their garden, or perhaps they've never actually sold the hay off of their field. They've just always let their nephew cut it for free.

GOLD: Or they might be able to get coverage under another part of the law. About 40 minutes away, Buckner has an office in Swain County - well, sort of. The local courthouse lets her set up shop in their small claims court when it's not in session. Wandering around town, she spots a young man with a thick red beard and a flannel shirt, playing banjo in front of the bank.

(SOUNDBITE OF MUSIC)

BUCKNER: Do you have health insurance?

JOHN MARTIN: I do not.

BUCKNER: All right. Who do you work for?

MARTIN: Right now - I used to work for the railroad. Currently, they laid me off for the down season.

BUCKNER: All right.

GOLD: Martin used to have coverage through his mom's plan, but he lost it when he turned 21. And like Kitty Williams, he earns less than the federal poverty level. But it turns out, he's only 24 - bingo. The law allows people under 26 to stay on their parent's plan.

BUCKNER: Your mom and you and the banjo should come in and see me.

GOLD: Martin was able to get coverage through his mom. And even for those a little older, there might still be an option.

(SOUNDBITE OF BELLS RINGING)

GOLD: At a church in nearby Franklin, Chuck Cantley stopped by a presentation about the health law.

CHUCK CANTLEY: Well, I got something from Blue Cross-Blue Shield saying that my new plan would cost $1,100 a month. That's a equivalent to my plan I pay $240 a month for now. Well, I can't do that. So, I've got to find another option. Either that or...

GOLD: Sixty-two-year-old Cantley is retired but was waiting to collect Social Security until he was 66, but he needs coverage now. So, he applied for Social Security early to help push him and his wife up to the poverty level. It worked - he qualified and signed up for coverage. Julia Buckner says using these sorts of strategies, she's been able to help nearly a hundred people get coverage. And that gives her hope.

BUCKNER: The folks that have been able to sign up, they are ecstatic. And as long as we keep hearing success stories, then that energy and excitement is just going to grow.

GOLD: For NPR News, I'm Jenny Gold.

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