Insured people are also feeling the strain of medical expenses

NEW YORK - The economic slowdown has swelled the ranks of people without health insurance. But now it is also threatening millions of people who have insurance but find that the coverage is too limited or that they cannot afford their share of medical costs.

Even many of the 158 million people covered by employer health insurance are struggling to meet medical expenses that are much higher than they used to be - often because of some combination of higher premiums, less extensive coverage, and bigger out-of-pocket deductibles and copayments.

With medical costs soaring, the coverage many people have may not adequately protect them from the financial shock of an emergency room visit or a major surgery.

For some, even routine doctor visits might now take a back seat to basic expenses like food and gasoline.

The problem is most acute for people with no insurance, a group expected to soon exceed 48 million, but those with insurance say they, too, are feeling the pain.

"It just keeps eating into people's income," said James Corbin, a former union official who works for the local utility in Tucson.

Corbin said that under their employer's health plan, he and his co-workers are obliged to pay up to $4,000 of their families' annual medical bills, on top of about $1,600 a year in premiums. Five years ago, they paid no premiums and were responsible for about $2,000 of their families' medical bills.

"That's a big jump," Corbin said. "You've just lost a month's pay."

Many doctors say the soft economy is making some insured people hesitant to get care they need, reluctant to spend a $50 copayment for an office visit. Parents "are waiting longer to bring in their children," said Richard Lander, a pediatrician in Livingston, N.J. "They say, 'The kid isn't that sick; her temperature is only 102.' "

Since 2001, the employee's average cost of an annual healthcare premium for family coverage has nearly doubled - to $3,300, up from $1,800 - while incomes have come nowhere close to keeping up.

Factor in other out-of-pocket medical costs, and the portion of the average American household's income that goes toward healthcare has risen about 12 percent, according to the consulting and accounting firm Deloitte, and is now approaching one-fifth of the average household's spending.

In a recent survey by Deloitte's health research center, 7 percent of people said they felt financially prepared for their future healthcare needs.

Specialists say that too often for the underinsured, coverage can seem like health insurance in name only - adequate only as long as they have no medical problems.

"There's a real shift in the burden of healthcare to people who happen to be sick," said Paul B. Ginsburg, the president of the Center for Studying Health System Change, a research group in Washington.

Companies and policymakers have yet to focus on what the faltering economy means for employees' medical care, said Helen Darling, president of the National Business Group on Health, a Washington association of about 200 large employers.

"It's a bad-news situation when an individual or household has to pay out-of-pocket three, four, or five times as much for their health plan as they would have at the time of the last recession," she said. "Americans have been giving their pay raise to the healthcare system."

Sage Holben, a 62-year-old library technician with diabetes who is active in her local union in St. Paul, said that in 2003 union members agreed to a two-year freeze on wages to protect their healthcare coverage.

But for the union, which will begin talks on the next contract this fall, it may be difficult to continue that trade-off, Holben said.

"It's at the point where we're losing, anyway," she said.

"I live paycheck to paycheck," said Holben, who makes close to $40,000 a year at Metropolitan State University.

When she took the job in 1999, she said, the health benefits required no copayments for doctor visits.

Now, Holben's out-of-pocket cost per visit is $25, and she pays $38 a month for her diabetes medicine.

She has not been to the eye doctor in two years, even though eye exams are crucial for people with diabetes and she knows she needs new glasses.

Nor does she monitor her blood sugar as regularly as she should because of the cost of the supplies.

"It's not an extravagant expense," she said. "It just adds up." And it comes atop the increasing cost of utilities, gasoline, and food - and the few hundred dollars of repairs her 1994 Chevrolet Cavalier needs.

Many employers recognize that their workers are struggling financially, even as they are asking them to pick up more of their healthcare bills.

"It makes the work we have to do even more challenging," said Anne Silverman, the vice president in charge of benefits in North America for the publishing company Reed Elsevier.

"Employees are being stretched in terms of their disposable income."