A major goal of The Patient Protection and Affordable Care Act is to broaden health care access through the extension of insurance coverage. However, little attention has been given to growing disparities in access to health care among the insured, as trends to reduce benefits and increase cost sharing (deductibles, co-pays) reduce affordability and access. Through a political economic perspective that critiques moral hazard, this article draws from ethnographic research with the United Steelworkers (USW) at a steel mill and the Retail, Wholesale and Department Store Union (RWDSU) at a food-processing plant in urban Central Appalachia. In so doing, this article describes difficulties of health care affordability on the eve of reform for differentially insured working families with employer-sponsored health insurance. Additionally, this article argues that the proposed Cadillac tax on high-cost health plans will increase problems with appropriate health care access and medical financial burden for many families.