There are an estimated 31 million Americans with private health insurance who can barely afford to use it. A recent report from the Commonwealth Fund dubs these people as "underinsured," because their deductibles and out-of-pocket costs are so high relative to their incomes.
Twenty-eight-year-old Diana Ionescu of Los Angeles is a typical underinsured. She has two part-time jobs, but she doesn't get health insurance through either one. Thanks to the Affordable Care Act, though, she was able to buy a cheap, subsidized plan through Health Net last year.
Ionescu would like to use her insurance, but she generally doesn't. Her plan has a $1,000 deductible, meaning she will have to pay $1,000 in medical bills before her coverage kicks in. So she skips doctor's visits.
"I do have some back pain that is probably from biking and backpacking and a previous moped accident that I haven't really gotten checked out, and I've been putting it off," Ionescu says, over lunch at L.A.'s Grand Central Market.
Ionescu's deductible is roughly five percent of her total income - and that puts her squarely among the roughly one in four Americans the Commonwealth Fund considers underinsured.
For Ionescu and others in this boat, insurance is purely a safety net.
"In case something really bad happens, and I go to the emergency room and it costs $10,000 or whatever, having insurance will really offset that cost," she says. "But I definitely haven't used it for anything else, for any sort of more minor care."
A 'disincentive' to get care
Growing deductibles have become a barrier for a lot of people. The Commonwealth Fund study found that over the past decade, the size of people's deductibles has shot up.
In 2003, just 1 percent of Americans with private insurance had a deductible of $3,000 or more; in 2014, it was 11 percent. Meanwhile, the percentage of people with no deductible dropped from 40 percent in 2003 to 25 percent in 2014.
The Commonwealth Fund says it's too early to know whether the Affordable Care Act is contributing to this trend.
Insurers say they're moving to more high-deductible plans to cut costs, and to make consumers more cost-conscious. But study co-author Sara Collins, vice president for health care coverage and access at the Commonwealth Fund, believes high deductibles are having another effect.
"It's pretty evident that among people with lower incomes, moderate incomes, that those high deductibles are a disincentive to get health care that people really should be getting," Collins argues.
A recent report from Families USA backs up Collins' theory: It found that among people who bought their own insurance in 2014, one-in-four went without tests, treatments or prescription drugs because they couldn't afford their deductible and other out-of-pocket costs.
We 'juggle' the costs
Monique Dow made that sort of calculation last summer, when she was considering surgery to have fibroids and a polyp removed from her uterus.
But she hesitated: The procedure would cost several thousand dollars, and she and her husband would have to dig into their wallets to pay the bill. The family had a $6,000 deductible; its out-of-pocket costs were capped at about $13,000.
"My husband just happened to say, 'well, you know, we've planned on doing it,'" recalls Dow, 44, who lives near Watsonville. "He flippantly said, 'wouldn't you want to know if there's something growing in there that shouldn't be?'"
She finally got the surgery in early November. Their fears were confirmed: Doctors found a rare type of cancer in the polyp.
"I waited all that time, not knowing that I had this growing in me," Dow says. "If we had the lower deductible, I probably would have figured that out a lot sooner, and not be waiting on what I thought were all benign things going on."
In early December, she went in for another surgery to have her uterus removed.
Today, Dow is still recovering - and still paying off bills. There are the bills from last year's surgeries, and since their deductible reset in January, there are yet more bills from follow-up care she's received this year.
"We've paid thousands of dollars, and we've still got, even this month, I think I have another thousand that I had to pay," Dow says.
She says the situation is very stressful, noting,"we kind of juggle it on the [credit] cards and do what we need to do."
Dow says her ordeal convinced the family to switch to a plan with a higher premium and a lower deductible of $3,000. But that doesn’t mean health care is any more affordable to them. She says they’re still avoiding doctors' visits for minor things like sports injuries and stomach bugs.