A shift in coverage has even the insured skipping medical care

On a Friday evening, the end of an exhausting week of juggling work and a sick child, Lezlie Walla posted on Facebook pictures of the red spots spreading across her 3-year-old's body.

"Need some input," she wrote. "Son had strep last Friday. Still on amoxicillin. Developed a rash today. He says it's not itching. Thoughts?"

In truth, the 34-year-old single mother of two knew her son, Caleb, should go to the doctor. She also knew she couldn't afford it.

This is crazy, she wanted to scream. She has insurance, but it comes with a $6,000 family deductible - $2,000 for each of them - that she must pay before her policy typically pays a dime. Last year, she was uninsured. This year feels exactly the same.

Walla is one of the millions caught in the reshuffling of the who-pays-what calculation within the U.S. insurance industry, especially in employer-sponsored group plans used by the vast majority of Americans.

Twenty years ago, high-deductible plans were rare. Now they have taken root, shifting more and more out-of-pocket costs onto consumers.

This year, for the first time, a majority threshold was crossed as 51 percent of American workers have a deductible of at least $1,000. That compares with just 10 percent a decade ago, according to the Kaiser Family Foundation's 2016 annual health benefits survey released in September.

Not only has the number of plans with deductibles grown, so, too, has the amount patients must come up with before coverage kicks in. Today, the average deductible in individual plans that have one is $1,478. In 2006, according to Kaiser, it was $584.

In the past five years alone, deductibles have risen 10 times faster than inflation and nearly six times faster than paychecks.

As a result, even the insured are putting off medical care or skipping it altogether.

"I feel like crap," Walla posted that Friday night as she tried to decide. An after-hours nurse had called and said she could go to the emergency room, go to an urgent care clinic the next morning or tough it out through the weekend. As the hours passed, she couldn't quiet the numbers in her head:

Eighty-five, for the dollars she'd already spent on the first doctor's appointment; $32, the price of two bottles of bubble-gum-flavored antibiotic, the second bought after she accidentally spilled the first; $1,500 for an emergency room visit; $200 for urgent care on a Saturday; $100 for the amount in her checking account; seven for the days until she got paid again.

The next morning, when the rash turned to welts, she loaded Caleb in the car.

"Don't do anything fancy," she pleaded when told he needed a different antibiotic. The final cost was $150 for the appointment and $40 for the new medicine. She asked the office to bill her. She would face it another day.

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Economists call it "skin in the game," a theory that if consumers treat health care like other shopping they will be more prudent.

Within the past decade, the insurance industry and employers began emphasizing high-deductible plans, in some cases steering employees toward them. For 2016, such plans are defined as having a deductible of at least $1,300 for an individual or $2,600 for a family.

They are touted as a hedge against rising premium prices, but the philosophical justification is that workers have been too insulated from skyrocketing medical and pharmaceutical prices.

"If a consumer doesn't have some kind of cost share, they might not think twice about what provider they see or how frequently," said Michael Williams, a Houston-based partner at Mercer, a global human resources consulting firm.

As the number of high-deductible plans skyrocketed, premiums did, in fact, stabilize. This year and last, the average premium price of employer-sponsored plans rose just 3 and 4 percent, respectively, the Kaiser study showed.

In 2005, about 1 million people in this country had high-deductible plans coupled with a pretax health-savings account. By early 2015, that number had shot up to 19 million, according to figures from American's Health Insurance Plans, the insurance industry national trade association.

One of the most striking things about this sea change is how little notice it captured.

"While much of the country has been focused on the super-heated political debate over the Affordable Care Act, under the radar screen, there have been far more fundamental changes in insurance that affect many more people," said Drew Altman, president of the Kaiser Family Foundation, one of the nation's leading health-policy research think tanks.

This year, about 155 million people got health coverage from an employer; about 11 million got it through the ACA exchanges.

The trajectory of the cost-sharing load was charted in another Kaiser analysis this year. Between 2004 and 2014, the amount of patients' contribution to their health care rose 77 percent, while the average payment by insurers rose 58 percent.

High-deductible plans are part of an array of choices people now have, said Clare Krusing, press secretary for the insurance industry trade association. Consumers, she said, can better "prioritize monthly health care expenses."

It does work for some. Others, particularly those with low to moderate incomes, don't see it that way.

"If you told the average person that America was experiencing historically slow growth in health-insurance prices, they would look at you like you are out of your mind," Altman said.

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Lezlie Walla understands insurance better than most. Her job is to negotiate with carriers to secure coverage for patients at an inpatient substance-abuse treatment center. She has been uninsured herself, on the ACA exchange, on Medicaid and covered by employer-sponsored plans. She earns a middle-class salary and rents a house in a tidy northwest Houston subdivision. She also lives paycheck to paycheck.

So when faced with the choice of a high-deductible plan costing $330 each month or one with a lower deductible that was about $200 more, there was no contest.

Weeks later, at the pharmacy to refill a prescription for her 7-year-old daughter's attention deficit hyperactivity disorder, she was surprised it was not covered until the deductible was met. The price was $300 a month. Walla walked out empty-handed. She sat in her car and wept.

Her daughter's therapy sessions, $150 per week, also were subject to the deductible. She stopped them even though her daughter, Bailey, was making progress. Walla eventually worked out a hardship arrangement with Pfizer, the pharmaceutical company, to get her daughter's medication for free.

When Bailey's doctor suggested a medication change, Walla said no, because she did not want to lose her arrangement with Pfizer.

"We have given up a lot of medication that the doctor wants her to try," she said.

That kind of talk troubles Mitch Rothschild, executive chairman and founder of Vitals, a New Jersey-based online consumer health care support site. It gives voice to a survey his company commissioned in July asking 500 Texans about their health care habits.

Nearly 1 in 3 with insurance said they had delayed or skipped a medical treatment or doctor visit in the past two years. Of those with high-deductible plans, the number neared 1 in 2.

"My reaction was, wow, we're in a lot of trouble in this country," he said.

His study also found that more than a third of people, both with and without insurance, admitted significant financial problems because of medical bills. That rose to 42 percent among those with high-deductible plans.

"This is a very blunt tool for controlling costs," said Sara Collins, an economist and vice president for health care coverage and access at the Commonwealth Fund, a health public-policy research foundation.

Other research has found people now avoid preventive care even though much of it is excluded from deductibles under the Affordable Care Act.

The amount of money middle-income Americans spend on health care has risen from 5.7 percent in 1984 to 8.6 percent in 2015, as household expenses for things such as food and clothing have gone down, according to data from the Hamilton Project, an economic policy initiative at the Brookings Institution. That suggests people are squeezing money out of other budget categories to pay for health care.

"There is this constant shuffling across budgets for basic needs," said economist Diane Whitmore Schanzenbach, a senior fellow at the Brookings Institution and director of the Hamilton Project.

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Juli Thomas Mathew sees it every day. An attorney for major credit-card companies handling debt collection lawsuits, Mathew's dining table at her home in Sugar Land is stacked with legal files. The pain of America's debt shows up in the letters from those who have fallen behind.

My mother has Alzheimer's …

My wife has been hospitalized multiple times …

Very sorry my mother ran up this credit card debt …

Most delinquencies can be traced, directly or indirectly, to medical bills, and the majority of people involved have insurance. Mathew remembers a lawyer who spent nearly every penny he had to save his wife. He ran up six-figure balances on credit cards before she died of breast cancer. That case was eventually settled.

"I don't think people have any idea that it could be you tomorrow," she said.

Or her.

Mathew's own insurance, through her job, has a $4,000 deductible. About to deliver her third child, she recently suffered whiplash in a car accident but hesitated going to the doctor because she feared the out-of-pocket cost. She still owes money from the delivery of her last baby, 15 months ago.

Krusing, of the insurance trade association, said the industry doesn't gain when customers use their policies less, noting that deferred care can cost more if a condition worsens.

"There is no incentive for any health plan in having people delay necessary medical care," she said.

Still, Collins would like to see insurers and the public sector rethink the issue.

"Benefits need to be redesigned to encourage people to go to the doctor when they need to," she said.

Back at Walla's house, the medical bills pile up. She figures she owes about $1,500 so far this year since she switched to the high-deductible plan. She cuts costs as she can but refuses to let her children see her stress.

"They deserve to be kids," she said. "They don't need to worry about grown-up things."