WASHINGTON, Feb. 22 (UPI) -- Nearly half of Americans -- including those with private insurance -- are worried about paying for healthcare, according to a new Zogby/UPI poll.
While three-quarters of those surveyed said they have private health insurance, 44 percent said they have hesitated to go to the doctor for fear of unaffordable out-of-pocket expenses.
One-quarter said they have been unable to pay a hospital or medical bill, and 40 percent report that their insurance has either refused to pay a bill or refused to cover a procedure, according to the survey of 10,258 adults, which had a margin of error of plus or minus 1 percentage point. The poll was conducted Feb. 9-12.
A big reason even insured people are worried about medical costs, experts say, is that employers are shifting costs to employees in the form of high co-payments and deductibles.
"In the early 1980s almost everyone had a plan with virtually no out-of-pocket costs," Robert Friedland, associate professor of health system administration at Georgetown University, told United Press International.
"Now that's virtually unheard of," he said. "It's completely reversed."
What started with co-payments for doctor visits and hospital trips has now expanded to almost every health service, and the crunch on consumers is not likely to end anytime soon, Friedland said. "I think there's another round of employer plan changes ahead."
Some consumers have been caught up in the latest healthcare trend, favored by the Bush administration, that places them in health plans with deductibles of $1,000, $2,000 or more. The plans are combined with tax-free health savings accounts to cover expenses below the deductible, but not all employers contribute to those accounts, and many employees are not able to scrape together significant savings.
But other consumers with more traditional plans still have trouble paying their ever-increasing out-of-pocket costs, said Georganne Chapin, chief executive officer of the Hudson Health Plan, a non-profit health plan licensed by New York state to provide low-cost care to low-income residents.
"I don't know why people think everyone can afford a co-payment," she told UPI. "I see people at my own grocery story counting pennies and putting food back on the shelf.
"The cost of living and cost of housing keep going up, and incomes haven't kept up with that. (Cost-sharing) shifts the blame for high healthcare costs onto individuals, and there's no evidence to back that up."
The problem can be compounded when low-income patients have the money, because many doctors' offices charge fees for billing that make patients' out-of-pocket costs even higher, she added, and "that just makes a poor person have to pay even more."
But fear of high out-of-pocket costs is not limited to the poorest Americans. Instead it is creeping ever higher on the income scale.
About half of those surveyed with incomes between $35,000 and $75,000 said they have hesitated to visit the doctor because of fear of out-of-pocket costs for doctor's visits, medicine and other services. Even among individuals with incomes above $100,000, one-third said they worry about what they will have to pay before they get medical care.
"It's really getting to the bleeding point where people are foregoing care," said Dave Knowlton, who serves on the board of directors of the Leapfrog Group, a coalition of large employers that works on healthcare cost and quality issues.
The purpose of co-payments used to be to limit consumers' use of unnecessary care, he said, but now they are about shifting costs.
That strategy can backfire, however, when workers forego primary care because of cost and then develop more expensive conditions later, Knowlton told UPI.
Some employers have already started to realize the downside of a cost-shifting strategy. Postal products giant Pitney Bowes, for example, recently found that by eliminating co-payments on all preventive services for its workers, the company actually reduced its healthcare costs.
"The leading edge of the employer community is starting to rethink this," Knowlton said. "The debate is about adherence and compliance instead of cost-shifting."
Employers who do not rethink the strategy could contribute to a vicious cycle of rising costs when workers with high out-of-pocket costs start showing up in emergency rooms and passing the expense on to other payers, he added. "If all you have is an (insurance) card that works 30 percent of the time, there's a 70 percent window of uninsurance.
"If we don't fix this soon, the likelihood of being able to sustain the employer-based healthcare system is zero."
Other employers are trying more nuanced strategies to contain costs than simply imposing higher out-of-pocket costs on all their employees.
One sound option is imposing different levels of cost-sharing on employees with different levels of income, said Ha Tu, senior health researcher at the Center for Studying Health System Change.
"Not all employees have the same financial resources, so the same benefit design for everyone will cause greater problems for some in terms of financial strain or access to care," she told UPI.
Few employers currently adopt such income-sensitive benefits packages, and current law even gets in the way, she said, as it is illegal for employers to offer different health savings accounts to different groups of employees.
It could also be a good idea to steer consumers toward efficient providers, instead of asking them to track the cost of every treatment, she added.
There is a growing market for plans that offer more customized benefits packages for different groups of employees, said Derek Peterman, president of Century Healthcare, which sells limited-benefit medical plans -- health plans that offer limited premiums and out-of-pocket costs in exchange for covering fewer conditions.
"It used to be that the CEO had the same plan as the janitor," he told UPI. "Now (businesses) are looking at the true insurance needs of different classes of employees."
Doctors should also help patients make tough choices about out-of-pocket costs, Arthur Garson, dean of the University of Virginia School of Medicine, told UPI.
"If someone needs something not covered by insurance, it is our obligation to say, 'This treatment is best and this second-best treatment is less expensive, but less effective,'" Garson said. "It's our responsibility to go over cost and efficacy with a patient and as best we can consult with them on both."
