Doctors see patients make difficult decisions after loss of jobs, insurance benefits.

It took Dr. Obinna Oriaku several months last spring to get Byron Sanders' high blood pressure under control with four medicines.

Then Sanders, who owns a commercial cleaning service, lost his major client and couldn't continue paying for health insurance. He didn't see Oriaku for seven months. He knew it was risky, but he stretched his medicines to make them last longer.

“Sometimes I would skip a day,” said Sanders, 52, of Charlotte. “Sometimes I would skip two days.”

By the time he saw the doctor again in December, his blood pressure was dangerously high – 160 over 110, instead of 135 over 83.

Today, his blood pressure is manageable again, and Oriaku has switched him to more affordable drugs.

As the economy continues to decline, Sanders is one of many people who find themselves making difficult choices about whether to spend limited resources on health care or on other essentials such as food and housing. Like him, many consumers are skipping doctor's appointments, postponing surgery or forgoing pricey prescriptions.

And experts say this is just the beginning of the problem in health care. It will only get worse as the effects of the recession ripple through families across the country.

In Charlotte, some health care providers report a decline in nonemergency hospital admissions and in doctors' office visits.

Doctors say more patients are asking to substitute generic medicines for brand names and questioning how much surgeries will cost and how much they'll have to pay out-of-pocket.

Dentists, too, say patients are postponing care.

When that happens, “small problems end up becoming big problems,” said Dr. Mustafa Shah-Khan, who owns a dental practice in Charlotte. “An out-of-pocket (bill) that would have been $200 ends up being a $3,000 problem.”

Instead of paying for crowns and root canals, two or three of Shah-Khan's patients have chosen to have teeth pulled. Many patients without dental insurance are putting off routine cleanings and X-rays, he said. Even some people who have dental insurance are skipping routine care.

“People just by nature will start not doing things,” Shah-Khan said. “A decent number of people just don't have any disposable income right now.”

Signs of the times

Here are some indicators of the problem:

More than one-third of respondents to a Kaiser Family Foundation poll last fall said they or a family member postponed needed health care, a 7 percentage point rise since April.

Also, one in seven Americans under 65 went without prescribed medicines in 2007 as drug costs spiraled upward in the United States, according to recent findings by the Center for Studying Health System Change in Washington. That's up substantially since 2003, when one in 10 people under 65 went without a prescription drug because they couldn't afford it.

Prescription drug sales were slowing at the end of last year, according to published reports. And in January, Laboratory Corporation of America in Burlington lowered estimates for 2009 revenue growth based in part on the potential impact of the economy on demand for lab tests.

“What we're seeing now is just the beginning of the economic impact on health care,” said Dr. Kevin Schulman, professor of health policy at the Fuqua School of Business at Duke University.

“We'll continue to see people losing their jobs and (insurance) coverage. We'll continue to see small employers dropping their coverage.”

On top of that, Schulman predicts large employers will be more aggressive in negotiating 2010 insurance contracts to keep costs down. They could continue asking employees to pay higher deductibles and co-pays or drop coverage altogether, Schulman said.

In the short term, if people skip doctors' visits and medication, “they end up coming to the emergency room, which is a more expensive place to take care of patients,” he said.

“In the long run, they get diagnosed with later stages of cancer that might be much more costly to treat. And basically they live shorter lives.”

High deductibles, co-pays

Some people are deferring health care because they've lost their jobs and their access to health insurance.

With unemployment rising, the number of North Carolinians without health insurance has risen to an estimated 1.6 million, the highest in 10 years, according to the N.C. Justice Center, which advocates for the poor.

But even people who haven't lost their jobs or their health insurance are finding it harder to afford care because of higher deductibles and co-payments. The percentage of workers who pay annual deductibles of at least $1,000 has gone from 12 percent to 18 percent in just the past year, according to the Kaiser Family Foundation.

“Co-payments and deductibles are pretty expensive these days,” Schulman said. “People's ability to pay their share of costs with the economic downturn is much more in question.”

In the past, consumers might have borrowed through their home equity loans, he said. But with bank failures, the flow of credit has dried up.

Walidah Id-Deen, 37, of Gastonia, doesn't own a home, but she does have medical and dental insurance through her employer, a Charlotte nonprofit organization, and Veterans Affairs benefits because she's an Air Force veteran.

Despite that, she's putting up with pain from a cracked tooth because she can't afford her share of the cost for dental work. Id-Deen also has a broken crown and fears she'll need a second treatment to clean the space between two teeth where a cyst has developed, causing intermittent pain.

In January, she paid $100 for a deep cleaning to treat gingivitis, but she said two new crowns and treating the cyst would cost $1,000 more out-of-pocket. “I just don't eat on that side,” she said. “I eat on the other side.”

Id-Deen loves her job, but with three children, 8 months to 10-years-old, she finds it difficult to save money on a salary of less than $30,000 a year. “If it starts hurting really bad,” she said, “I just gotta cough it up. I'll have to go to the dentist by force.”

Surgeries now, not later

Officials at Carolinas HealthCare System, which owns or manages more than 20 hospitals, say they're seeing about 5 percent fewer nonemergency admissions. Patient visits to doctors' offices owned by the system also are down by about 10 percent.

“I can't say if it's a direct result of the economy,” said Russ Guerin, a CHS senior vice president, “but it's the biggest decrease we've seen since we've been managing (physician) practices… Normally, we would project an increase of about 2 percent due to population growth.”

At OrthoCarolina, Charlotte's largest orthopedic practice, scheduled surgeries are up over this time last year, said Dr. Thomas McCoy, a knee and hip-replacement specialist.

“That's not to say that I think health care delivery is immune from the economic downturn.” But McCoy said his subspecialty is “somewhat buffered” because the majority of patients who need knee and hip replacement are over 65 and covered by Medicare.

Also, he said, some people have lost jobs and extended their insurance temporarily through COBRA protections – the right to continue employer-based insurance by paying the entire premium out of their own pocket. These patients may decide to have surgery sooner than planned, while they're still insured.

Many doctors think Charlotte is not yet seeing the worst of the economic downturn for health care, said Dr. Bill Poston, president of the Mecklenburg County Medical Society. “They think we're ahead of the curve by about six months. That being said, (doctors say) their patients are extremely anxious about keeping their jobs … and their health care.”

Mental health professionals are seeing the apprehension in their patients.

“Almost everybody I see is having more anxiety than before,” said Poston's wife, Pam Poston, a Charlotte therapist. “Their situations are becoming worse because of the stress. Marriages are really suffering. If they were bad before, it seems they are much worse now.”

At the same time, many people who may need therapy can't afford it, she said.

“One man called the other day and said, ‘If I can't get this insurance approved, I can't come to see you. I can't afford the $50 co-pay.”

Karen Garloch: 704-358-5078.