Denise Prosser, 39, has battled cancer since she was a toddler.
Yet Prosser can't afford her next cancer treatment - a radioactive therapy that she's supposed to receive once a year - because she and her husband lost their jobs in December. Without insurance, she has postponed the radiation indefinitely and is taking only half of her asthma medications - sacrifices that often leave her gasping for air and could allow her cancer to come surging back.
"I can't walk more than 100 feet without sounding like I just ran a marathon," says Prosser, of Galloway, N.J.
Prosser is among millions of Americans who struggled last year to pay for health care or medications, the largest poll ever conducted by Gallup shows.
As the economy fell, the percentage who reported having trouble paying for needed health care or medicines during the previous 12 months rose from 18% in January 2008 to 21% in December, according to the poll of 355,334 Americans. Each percentage point change in the full survey represents about 2.2 million people, says Jim Harter, Gallup's chief scientist for well-being and workplace management.
Gallup, along with disease management company Healthways, surveyed a random sample of about 1,000 people nearly every day during 2008 about their physical, emotional and economic well-being.
The poll, the Gallup-Healthways Well-Being Index, shows that struggles to pay crossed all socioeconomic lines but hit some Americans harder than others: More than half of the uninsured had trouble paying for health care or medications during the year. So did more than 30% of blacks and Hispanics, compared with 17% of whites and 13% of Asians. Overall, women had more trouble than men. Those who were divorced, widowed or in domestic partner arrangements fared less well than those who were married.
Among other key findings:
• As the year progressed, fewer Americans reported getting health coverage through their jobs, dropping from 59% in the first quarter to 58% by the last.
• The number of African Americans reporting trouble paying for health care or medications rose six percentage points from the first quarter to the last, to 34%. People ages 25-34 also saw a big increase, up five points to 28%.
• Among the states, Hawaii had the smallest percentage of residents who had trouble paying for health care in the previous 12 months at 12%, and Mississippi the most at 29%.
"The biggest problem that the country has is actually the cost of health care," says Jim Clifton, Gallup's CEO. "It's a lot bigger problem than war and a bigger problem than the current meltdown because there are no fixes to it on the horizon right now. ... You can't just throw money at it. That's still not a fix."
The increasing trouble people have paying for medical care comes as Congress begins its most serious health care overhaul debate in 15 years - and as the economy continues to shed jobs.
Because most people still get health insurance through their jobs - rather than buying it themselves or being covered by a government program such as Medicare - the loss of a job can mean the loss of insurance.
Nearly 4.4 million people have lost jobs since the recession began in December 2007, the U.S. Department of Labor reports. Nearly one in 10 children and one in five adults under age 65 are uninsured, says a February report on the uninsured from the Institute of Medicine, part of the National Academy of Sciences, which advises the government on health care.
People without insurance are at much higher risk for a host of medical problems, the institute's report shows. They're less likely to get preventive care, more likely to be diagnosed with later-stage cancers and more likely to die if they suffer a heart attack, stroke, lung problem, hip fracture, seizure or trauma.
"The evidence clearly shows that lack of health insurance is hazardous to one's health," says report co-author Lawrence Lewin. "And the situation is getting worse."
Lower-income residents are more likely to have trouble paying medical bills and to lack insurance. Income also plays a role in how people feel about their own physical well-being.
The Gallup-Healthways poll found that 40% of those making $500 to $1,000 a month said they were dissatisfied with their health. By comparison, only 10% of wealthy people - those making at least $10,000 a month - are dissatisfied with their health.
Few safety nets
People often resort to desperate solutions to pay for health care for themselves and their families, says Christy Schmidt, senior policy director at the American Cancer Society's Cancer Action Network.
Some are tapping into their 401(k) plans and other retirement savings, she says. But even these funds may fall short, since many investments have lost half their value in the past year.
When money gets really tight, Schmidt says, many uninsured people cut corners on their health, such as by cutting pills in half or skipping doctor's appointments.
While Gallup's poll asked if the specific person being interviewed had cut back on "needed" health care, a February poll by Kaiser Family Foundation took a broader look at health care spending. In that poll, more than half of Americans said at least one person in their family had cut back on medical care within the previous 12 months because of cost.
Many people can't pay for coverage on their own, Schmidt says.
Among them are Denise Prosser, who worked part time in a day care before being laid off, and her husband, Warren, who was a television news director in Linwood, N.J.
The 600 stitches on her back testify to her long struggle with cancer. She was first diagnosed at 18 months old. A new tumor, in her thyroid, developed when she was 27. Her lung capacity has declined by 50% since then as her health has deteriorated, leaving her unable to work full time.
The Prossers say they can't afford coverage through COBRA, a program that allows workers to keep their health insurance for 18 months after they leave their jobs, just as long as they pay 100% of the health premiums themselves.
A COBRA plan would cost the Prossers $900 a month, Denise says. With help from the recently passed economic stimulus package, which provides a federal subsidy worth 65% of COBRA premiums, the Prossers still would have to pay $300 a month - an especially high price tag for people who no longer have regular salaries.
After she lost her job, Prosser applied for official status as disabled through the Social Security Administration but was turned down: "They said I wasn't disabled enough."
Even patients who qualify as disabled may struggle with medical bills, Schmidt says. Most people have to wait two years after being declared disabled before they qualify for Medicare coverage. If patients opt for 18 months of COBRA, that still leaves a six-month gap.
That puts Prosser - whose doctor recently found a lump on her thyroid - in a sort of no man's land.
Prosser fears the lump could be a relapse of the thyroid cancer she developed in 1997. Although her thyroid specialist gave her some free medication samples, the doctor would not treat Prosser without insurance.
Prosser hopes to see a doctor through a charity clinic in Atlantic City but worries her husband's income from his unemployment check - $622 a week before taxes - may disqualify them.
A domino effect
Even charity care and emergency rooms can't guarantee that uninsured people - especially those such as Prosser, who have a long history of complex problems - get the treatment they need, says John Ayanian, a Harvard Medical School professor and co-author of the Institute of Medicine report. Free clinics often struggle just to find generalists, he says, let alone specialists.
The problem extends beyond individual struggles.
Eroding insurance coverage can undermine the health of entire communities, Ayanian says. Hospitals and doctors may have trouble paying their own bills in communities with large numbers of uninsured. That can drive away specialists and make it harder for even well-insured people to find care, the report says.
Often, people without insurance must struggle on their own.
Calls to the cancer society's insurance hotline have increased by 6% since last year, Schmidt says. Although the society sometimes can help patients find coverage, three out of five callers find those options - such as individual health policies or state-sponsored high-risk pools - too expensive, Schmidt says.
Nor is there any guarantee those options will be available. Individual policies sometimes won't cover pre-existing medical conditions, such as cancer, depression or pregnancy, or will not pay for care needed for those conditions during an initial period of six months or more.
Jim Hann, 51, who's losing his job as a chemical operator at the Americas Styrenics plant in Marietta, Ohio, next month, won't be able to afford COBRA, even with the federal subsidy. The plant is laying off 65 of 100 employees. That didn't deter him, however, from donating a kidney to his wife, Hannah.
In the past decade, Hannah has weathered more surgeries than they can count: seven or eight operations to cut away dying sections of bowel, a small intestine transplant and, in February, the kidney transplant at Washington's Georgetown University Hospital.
"He tells me he'd give me both of his if that's what it took," says Hannah, 49, a few days after the February transplant.
Their surgeon moved up her transplant surgery by a month, before Jim's coverage lapsed. Although Hannah's disability makes her eligible for Medicare, she has used Jim's generous company-funded insurance until now. Medicare will cover her health care after Jim loses his coverage in November.
Jim plans to get by without any insurance. That's a gamble, given that kidney donors have an increased risk of high blood pressure and kidney problems.
After taking care of Hannah for so many years, Jim says he's well-prepared for his next career.
He has decided to enroll in a nursing program that will make him a registered nurse within two years. Until then, he says, the couple will "tough it out" by living off their savings, Hannah's disability check and the proceeds they make selling their home to move into a smaller, cheaper house. If needed, Jim says he's prepared to return to driving a truck or waiting tables while going to school.
But he doubts he'll ever find another job like the one he lost. Factories are laying off at least 1,000 workers in the region around Marietta and Ravenswood, W.Va., about 50 miles away, where Century Aluminum is shutting down a plant and letting go about 600 employees.
The Gallup-Healthways survey found nearly 25% of people in the congressional district that includes Marietta didn't have enough money to pay for health care in the past year.
"There aren't even any bad jobs," Jim says. "It's the same all over."
Contributing: Susan Page