Before the ACA, my uncle (lower-middle class, with two kids and a wife in a two bedroom apartment in Indiana), had to choose between between paying the gas bill and paying for his near-daily dialysis, which is not a service provided by emergency rooms. He had picked up Hep C as a young teenager and could not afford insurance in adulthood due to this pre-existing condition. The only "health care" he would have had access to was the ER when he inevitably suffered renal failure.