Chronic Problems

The older you get, the more likely you are to develop a chronic illness such as heart disease, high blood pressure or cancer. The more chronic illnesses you have, the more health care you need.

The inevitability of illness is why we buy health insurance in the first place; that way, when we get sick, we can afford medical care. At least that's why we bought insurance back in those good old days when insurance covered almost all of the cost of treatment. For many of us, however, that's no longer true.

About two of every five Americans — more than 100 million people — have at least one chronic illness, including heart disease, high blood pressure, stroke, cancer or lung problems such as asthma or emphysema. Most of those afflicted are working adults who are too young to qualify for Medicare.

A study published in July in the journal Health Affairs finds that working people with chronic illness are having a more difficult time getting medical care than they were a decade earlier. The study was conducted by researchers from the nonpartisan Kaiser Family Foundation, building on the results of a similar survey conducted in 1997. As you would expect, the problem is most acute among the growing numbers of people who have no health insurance.

National health spending soared by 87 percent between 1997 and 2006, to $2.1 trillion. Those cost increases have caused many doctors to cut back on the amount of free care they provide.

At the same time, many companies have stopped providing health insurance to their workers. That spells disaster for those with chronic illnesses. Because they're sick, insurance companies don't want them. As a result, many of them can't find insurance coverage on their own at any price. Some insurers even can cancel policies retroactively when doctors diagnose a chronic disease or one that's expensive to treat.

In the Kaiser study, about 34 percent of uninsured adults with chronic illness reported that they had no regular source of medical care.

That's up from 31 percent a decade earlier.

A little more than 35 percent said they had avoided seeing a doctor or seeking some other form of medical care during the previous year because they couldn't afford it; that's up from 32 percent in 1997.

People who had private insurance coverage were more likely to have a regular source of care in 2007 than they were in 1997. But in 2007, they were more likely to skip care recommended by their doctor. For example, the percentage of people who reported not filling prescriptions because of cost was nearly twice as high in 2007 as it was in 1997, which was before many insurance plans began imposing what are called "tiered" co-payments for drugs.

Under tiered plans, co-payments for drugs and even medical treatment are separated into categories according to cost. Patients who pay $20 to visit their regular doctor are charged, say, $40 to see a specialist. Co-payments for brand-name drugs are substantially higher than co-payments for less expensive generic drugs.

These kinds of plans have become widespread in recent years. They're designed to encourage people to stay well and prevent what researchers call "inappropriate use." An example of that is getting a hangnail trimmed in the emergency room instead of a doctors' office.

But as the Health Affairs study shows, tiered co-pays and higher deductibles are blunt instruments that also can discourage "appropriate" use. Yes, someone with a chronic illness may be more expensive to care for than someone without one. But in the long run, most experts agree that not treating the illness leads to higher expenses and worse outcomes.

Many, if not most, Americans will develop chronic illnesses. Without major reforms to the system that provides and pays for health care, they'll face an increasingly uphill fight to get the care they need.

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