The end of the month is always difficult for Beckie Clark, 58, and when she has to choose between medicine, a costly medical test or an appointment with a specialist, she does it.
"Dr Krist said, 'If you break a fever, you need to call.' He told me, he said, 'If you have a fever we will have to put you back at the hospital.'
Advertisement"And the first thing that went on in my mind was, 'Well, I am not saying anything because I can't afford to go to the hospital,'" Clark said.
For Clark and for many Americans, the economic crisis has implications for their health.
Between the 20,000 dollars of her pension fund that evaporated from the stock market and the rising cost of food and gas, Clark has a hard time keeping her head above water.
She has thought about selling her house, though it is not completely paid off, but with the housing market gone bad, it is no longer worth much.
Clark moves slowly, at the mercy of shooting back pains. She has herniated discs and has had six operations.
She still goes to see Dr Krist every week but has put off further visits to the surgeon and has stopped physical therapy sessions altogether.
And although she has health insurance, she is responsible for a portion of medical costs that far exceeds her budget.
Her doctor tries to help her, prescribing only generic drugs, for example.
Patients with financial problems on top of medical ones have become a growing part of his practice.
"There has always been an issue with lots of people not having access to good care, not being able to afford good care and things like that," he said.
"But now, most everyone is affected so it's more of a day to day issue, it's more something that has to be considered with every patient that we are seeing, with everyone that we are dealing with."
According to an October 2008 study by the Kaiser Family Foundation, one in three Americans had difficulty paying medical bills this year.
Almost half of those surveyed said they had a family member who did without their medicine or postponed or reduced their recommended medical care because of the cost.
Clark was not the only patient of Krist's who talked about financial pain to explain unpaid invoices or postponed visits. He saw three more on the same day.
One was Jennifer Clark, whose husband was just laid off. The family depended on his health insurance. Now, Clark is prioritizing her nine-year-old son. She postponed her last two dentist visits and her next appointment with Krist.
"I already thought about it and I think I will try to get my next prescription by phone," said Clark, a legal administration assistant.
"They are trying to do more things by phone, for example to talk about their blood pressure results instead of bringing them to check," said Edward Miller, an internist in Baltimore, Maryland.
But in the long run, delaying care can make you sicker, said Donald Fisher, president of the American Medical Group Association.
"The problem is that down the road you see the same people who are now forgoing healthcare services will probably find themselves much sicker and have a much greater economic impact on them because their cost will go up even more," Fisher said.
The situation is already critical, in his view.
During previous recessions, for a three to six month period, medical spending shot up as people fearful of losing their insurance crammed in doctors visits. Then came a major drop as the crisis spread.
But today, medical care is so expensive that the drop in medical spending is already well underway, he said.
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