Laura Rowley Money & Happiness

Last week, the government announced that the number of Americans who have no health insurance rose to 47 million, or nearly 16 percent of the population, from 44.8 million.

But even people who have coverage through their employers are struggling with health care costs.

Insurance, Not Assurance

According to a new study by Consumer Reports, 4 in 10 Americans can't depend on their health insurance.

"Of the people who had health insurance, some told us they postponed getting tests or treatment, going to doctor, or filling prescriptions because they couldn't afford it," says Consumer Reports senior editor Nancy Metcalf, the report's author. "They could not pay for their share of their health care over and above what insurance covered."

Respondents said they raided retirement accounts, borrowed from friends and family, or ran up credit cards to pay medical bills. Three percent of insured respondents said medical bills forced them to declare bankruptcy.

Coverage Uncovered

The Consumer Reports National Research Center surveyed 3,000 Americans between age 18 and 64. Its results mirrored the U.S. Census findings: 16 percent had no health plan at all.

Between 2001 and 2005, the number of middle-income families -- those earning $40,000 to $80,000 for a family of four -- who received health insurance through their employers declined by 4 percentage points.

Half of those were because the employer stopped offering coverage altogether, or offering dependent coverage; 15 percent gave it up because they could no longer afford the premiums.

Slow to Change

The United States spends $2 trillion a year on health care, more than any other country. But efforts to slow the growth in health care costs have failed for a number of reasons, Metcalf explains.

"People have been conditioned to believe that insurance companies are making tons of money by denying care," says Metcalf. "That was something they tried to do back in the '90s -- make people go through their primary care doctor, make sure the care they authorized was necessary.

"But our entire culture of health care rebelled against it," she adds. "Doctors hated being second-guessed, patients felt they were being jerked around; hospitals and specialists formed alliances and maneuvered themselves into much stronger bargaining positions."

A Wage-Care Gap

Meanwhile, employers heard loud and clear from workers, who demanded more choice. "What you see now is that a majority of employees are in PPOs [preferred provider organizations], which are much more permissive kinds of health plans where you have a large choice of doctors and you don't need permission to see a specialist," says Metcalf.

"The truth is that during that window when HMOs [health maintenance organizations] were really strictly managing care, health care costs slowed. Once the brakes came off, health care costs started running at two to three times inflation. It's not a sustainable thing when wages aren't going up."

The average family health care plan costs an employer about $12,000 annually, the report found. To maintain the same level of benefits, companies are either keeping wages stagnant or asking employees to pay more medical costs -- in higher premium shares or higher co-pays and deductibles.

For example, between 2000 and 2006, the percentage of workers with single PPO coverage who had a deductible of more than $500 rose to 38 percent from 14 percent. Last year, one in five employees enrolled in HMOs and PPOs had plans that set no upper limit on the amount of co-pays and deductibles they might have to pay in a year, according to a survey by the Kaiser Family Foundation.

Open Questions

With open enrollment scheduled for October at many companies, employees may be considering switching plans to save money. But do an analysis that goes beyond the cost of the monthly premium.

"Experts told us over and over to think of health care the way you think of homeowners insurance," says Metcalf. "Don't evaluate your coverage on the basis of how it works when you're healthy; evaluate what it will do when someone gets unexpectedly ill."

Most employers provide a summary plan description. Here are a few items to look for before you choose:

• Calculate the worst-case scenario for hospitalization.

This is the most expensive medical liability. What's the maximum out-of-pocket cost per family member on an annual basis if an event like an auto accident results in a long hospital stay?

• Is prescription drug coverage included in the maximum amount payable every year?

"It's the catastrophic illnesses -- cancer in particular -- that can blindside people," says Metcalf. "Prescription drugs to treat lymphoma can run $25,000 a year."

• What's the coverage for outpatient therapies?

This includes tests, physical therapy, home health care, and mental health treatment. Also be sure to check if the plan covers "durable medical equipment." This is a must when oxygen equipment is needed at home for a child who has asthma, say, or for other equipment such as a wheelchair.

• If you're choosing among several plans, check online to see if your state department of insurance has received complaints about them.

Some Final Tips

Add up your premiums and your plan's maximum out-of-pocket cap, says Metcalf. If that's way beyond your budget, a safer route may be to trade higher premiums for a lower out-of-pocket limit. If you have savings to offset a worst-case scenario, take advantage of the lower premiums. Consumer Reports offers a worksheet to help you decide which coverage is best.

Finally, Metcalf says, read and follow the plan rules. "One thing that trips people up is if they need to go to a hospital or emergency room, and the hospital is on their plan, but not necessarily every doctor," she says. "It's depressing to think you need to ask those questions ahead of time, but you really do. If someone is coming to treat you who is not on the plan, say, 'I'm sorry.'"

For more on health insurance coverage, including dental, see my blog.

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An Update on Banking Fees

Back in July, I wrote about some of the banking fees that can sap consumers ("Less Than Zero: How Overdraft Fees Can Trip You Up"). A number of readers subsequently emailed me with specific situations they encountered that they felt were fraudulent.

The Office of the Comptroller of the Currency (OCC), which regulates all national banks, recently launched a new web site that answers common questions about bank practices, based on decades of questions to the agency's call center. Consumers can use the site to file a complaint or call directly at (800) 613-6743.

Some 70,000 consumers contact the OCC annually with complaints, and over the last five years it's helped people get more than $30 million in restitution from banks. Don't hesitate to use the site for a minor complaint: More than half the cases involved less than $200.