Diane Burchett of Marble Hill, Mo., lost her job and her health insurance at the same time.

Burchett is one of 60 people put out of work when RapcoHorizon, an audio cable producer, closed its Advance, Mo., plant Jan. 2.

The company's employee health insurance helped pay the tab as she was treated for heart trouble, hypertension and diabetes. She takes five prescription medications and sees doctors regularly.

Charles Burchett, Diane's husband, is retired and has heath care through Veterans Affairs, but Diane does not.

"He pays the bills with his income," Diane Burchett said, "but we have no money for [doctors and prescriptions]."

Like the Burchetts, people who lose their jobs must often choose between physical and fiscal health. Federal law requires employers who provide health insurance to make the coverage available to former employees, but they must pay the full premium. Other options include buying an individual policy, being added to a spouse's policy, trying to qualify for Medicaid or doing without.

Many health-care providers report that more patients are showing up without insurance, electing to cover the bills themselves.

At Cape Urgent Care, a clinic that accepts patients without appointments, Dr. Byron Glenn said the number of patients without insurance is rising. Because they delay treatment, many are seriously ill by the time they seek help.

Glenn said self-pay patients account for about 5 percent of his practice. Before the recent economic downturn, that number was closer to 2 percent. "I'm seeing three to five self-pays a day," he said.

Unemployed patients treated at Cross Trails Medical Center's three locations can pay based on a sliding scale tied to their ability to pay. Chief operating officer Chrissy Warren estimates the number using the sliding fee schedule has increased 25 percent.

"What we have heard from patients is that this is due to them losing insurance," Warren said. "We also have heard from new patients that they have lost their jobs and have applied for Medicaid, which their current medical provider will not accept, so they come to us because we accept Medicaid."

Cross Trails' doctors are also seeing the trend toward patients delaying treatment. "Patients are definitely putting off visits, and when they do come in, they are being seen for multiple issues, rather than the follow-up appointment originally scheduled." said Dr. Edward Doyle, Cross Trails medical director.

COBRA coverage

The federal law requiring employers to continue health insurance, the Consolidated Omnibus Budget Reconciliation Act, known as COBRA, puts too much burden on unemployed people living off jobless benefits, according to a report released last week by Families USA, a national not-for-profit organization for health-care consumer issues.

According to the report, a single Missourian receiving an average of $1,083 monthly would spend about $373 for COBRA, or 35 percent of income. Keeping a family of four covered would consume 97 percent of the unemployment payments, the report said.

"COBRA health coverage is great in theory and lousy in reality," Ron Pollack, Families USA's executive director, said in a news release accompanying the report. "For the vast majority of workers who are laid off, they and their families are likely to join the ranks of the uninsured."

Pollack said unemployed workers need either subsidies to help them afford COBRA premiums or temporary health safety-net coverage through Medicaid.

There is some relief for workers who lose their job to foreign competition. Under the Trade Readjustment Act, workers at companies like RapcoHorizon will have 65 percent of their COBRA premiums paid while they are enrolled in retraining, said Drenna Overbey, human resources manager of RapcoHorizon.

Medicaid eligibility

Medicaid can be difficult to get as well. Most workers receiving jobless benefits are ineligible for Medicaid in Missouri because the income limit is $342 per month for a single person with three children. But while adults may have difficulty qualifying for Medicaid, the rules for children's coverage are more relaxed.

With an income limit of $5,300 a month for a family of four, the MO HealthNet for Kids program provides free or low premium-coverage for children whose parents don't qualify for Medicaid but can't afford private insurance.

Enrollment in the SCHIP program rose almost 9 percent between July and November, said Brian Hauswirth, spokesman for the Missouri Department of Social Services.

"It's safe to say the increase in the number of applications is roughly proportionate to the increase in the number of children receiving services," he said.

A new initiative for women's health was recently added to the Medicaid system, making it easier for lower income women to qualify.

Paying or doing without

Those who can afford individual health-care policies are signing up, according to Jack Seitz of Anthem Blue Cross Blue Shield in St. Louis.

"We're seeing a lot of people laid off turning to an individual plan," Seitz said.

Individual policy prices are based on age, pre-existing conditions, health and other risk factors. That means individual coverage is too expensive for many families.

Doing without, however, can leave families with staggering bills if a member is struck by a serious illness or injury.

Southeast Missouri Hospital has seen a 13 percent increase in self-pay admissions for the first 11 months of 2008, compared to the same period in 2007, said David Strong, the hospital's vice president.

Saint Francis Medical Center controller David Prather said that hospital saw about a 15 percent increase in self-pay patients last year.

Both hospitals said they are seeing an increasing number of uncollectable bills and emphasized that they will set up payment plans for patients.

For Diane and Charles Burchett, the strategy for dealing with a loss of medical coverage includes changes in their diet and exercise habits.

"I'm going to have to get healthy," Diane said.