Editor's note: This is the last in a three-part series on the future of the Affordable Care Act in light of Republicans' pledge to dismantle President Barack Obama's signature health care law when they take control of  Congress and the White House next year.

Tiffany Blackstone opened her mail this year to something all too familiar.

The $500-deductible Capital Blue Cross plan the Manchester Township woman chose to cover herself for $398 a month in 2016 would no longer be offered. A similar plan for 2017 would cost $582 each month and come with a $1,000 deductible.

For the fourth time since she started purchasing private insurance that complies with the Affordable Care Act, her individual plan was scrapped and her premiums would rise if she didn’t take action.

In the past, Blackstone said, she’s looked on the federal health-insurance marketplace set up under the ACA to purchase plans, but her income doesn’t qualify her for cost-reducing subsidies. Days before the deadline, the 30-year-old mother and wife said she’s still investigating her options when it comes to 2017 coverage.

“It’s just excessive to maintain insurance of that nature,” Blackstone said.

As insurers pull out of the federal health-insurance marketplace, citing low profits and sicker-than-expected enrollees, monthly premiums on the exchange  go up. They are expected to rise about 25 percent nationwide for 2017, 32 percent across Pennsylvania and more than 40 percent in York County.

Subsidies: The increases should be offset for most consumers by higher tax subsidies, according to the federal government.

The state Department of Health and Human Services says 85 percent of shoppers on the federal marketplace qualify for cost-reducing tax subsidies, given to those who make less than 400 percent of the federal poverty rate. The 15 percent of shoppers who don’t qualify for subsidies must still purchase insurance under the Affordable Care Act.

Unfortunately for Blackstone, she falls in the 15 percent. After exploring group plans, she and the employees of the small financial-services firm she works at decided private insurance was the way to go.

“It’s hard to find someone who is not having significant parts paid for them that is happy about it,” Blackstone said.

Future: President-elect Donald Trump and the Republicans who will control the House and Senate starting in January are planning to repeal or replace the ACA, a move that would certainly affect the 20 million people — including 1.1 million Pennsylvanians — who state and federal health departments say purchase their coverage through the marketplace or benefit from expanded Medicaid.

Though Blackstone said she favors some provisions of the law, the mandate that everyone carry health insurance or face a tax penalty is troubling.

“I think a lot of the complaints of the situation are going to go away,” she said about the future of the law. “That’s how the people have spoken.”

But there's more to the ACA than the health care exchanges; in fact, other parts of the law affect many more people and remain quite popular.

Provisions eliminating out-of-pocket costs for many preventative services, providing financial help to Americans who don’t get insurance through their jobs to help them purchase coverage, giving states the option of expanding their existing Medicaid programs and allowing young adults to stay on their parent’s insurance plans until age 26 had as much as 86 percent support, according to a November survey by the nonprofit Kaiser Family Foundation.

Getting coverage: For Americans such as Blackstone, the ACA has been a financial strain and unexpected burden. For others, such as York City resident Shannon High, getting coverage has meant everything.

High, an office manager for the York Art Association, is the only paid employee of the nonprofit. The 30-hour-a-week position lets her do something she loves and pays the bills, but it comes with no health insurance.

Through expanded Medicaid, she was able to sign up for a Medicaid-managed care plan through Gateway Health.

“The Affordable Care Act established by President Obama makes sense; it’s necessary, and the rhetoric of small businesses is absolutely divisive and evidence that they’re not aware of the struggle that people are dealing with,” High said. Under the law, business owners with 50 or more full-time employees are required to offer health coverage or face a tax penalty.

High, who has a 21-year-old daughter who is deaf and a 24-year-old daughter who uses behavioral health services, said she relies on expanded Medicaid and provisions of the ACA to take care of her family. 

The younger daughter is able to be on her father’s plan until she turns 26, a provision Blackstone said she wished she had when she was younger and one that Republicans generally favor. The older daughter has coverage despite a pre-existing condition.

"You have a different insight when you’ve been a single mom with a child with a disability and when you’re a divorced individual," High said. "You end up having to make choices just for the chance of having health insurance."

Prohibiting insurance companies from denying coverage because of a person’s medical history was favored by 69 percent of those surveyed by Kaiser.

Even Blackstone acknowledged there are some parts of the ACA she likes.

“There’s some great things it did, but it needs to be altered," she said.

Open enrollment on the federal marketplace ends Jan. 31. The deadline to enroll for coverage starting Jan. 1 is Dec. 15.

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