WEDNESDAY, Aug. 10 (HealthDay News) -- Millions of American families have trouble paying their medical bills or erasing their medical debt, even when they have health insurance, a new analysis reveals.

Almost two out of five adults -- an estimated 77 million people -- had medical bill and debt problems in 2003, analysts at The Commonwealth Fund reported Wednesday.

Uninsured individuals were twice as vulnerable, the study found. But having health insurance did not prevent financial hardship: The majority of adults who had bill problems and medical debt said they were insured at the time their difficulties began.

"What this study really shows is that people who are insured are also sharing medical burdens, and the type of insurance they have isn't adequately covering their out-of-pocket costs, and so their care is not being met," said study author Michelle M. Doty, a senior analyst at The Commonwealth Fund.

"Almost everybody but the really well-off are at risk here," added Carol Pryor, a senior policy analyst at The Access Project in Boston.

The new analysis helps to substantiate results of a widely publicized Harvard bankruptcy study that found many people were insured when they incurred the medical debt that contributed to their financial ruin.

It also raises a difficult question: Why are so many insured folks struggling with medical bills and debt? Doty and her colleagues implicated "gaps" in coverage, including high cost-sharing and a lack of key benefits, such as prescription drug coverage.

As an example, 49 percent of adults with deductibles of at least $500 a year had medical bill and debt woes, while 32 percent of those who had deductibles of less than $500 reported similar difficulties.

"The trend toward higher deductibles in employer plans may have gone too far," Karen Davis, president of The Commonwealth Fund, noted in a statement.

Not so, countered Dan Perrin, executive director of the HSA Coalition, a Washington, D.C.-based outfit that advocates the use of health savings accounts (HSAs) to keep health insurance affordable. By switching to a high-deductible health insurance plan, people can cut their monthly premiums and set aside some of the savings to cover their out-of-pocket costs, he added.

"The idea is to take money out of that check that's going to your insurance company, and put it in your account instead," he said.

Using data drawn from a 2003 health insurance survey, Doty and colleagues assessed the extent of Americans' medical bill-paying problems and current or accrued medical debt. In the survey, people were asked whether they had difficulty paying or were unable to pay their bills, whether they had been contacted by a collection agency about owing money for medical bills, and whether they had to change their way of life significantly to pay their medical bills.

"We weren't talking about luxury items you weren't able to purchase because of your medical bills," Doty noted.

Beyond creating financial hardships for families, medical bill and debt problems can cause people to forgo needed care. Even after adjusting for insurance, income, health status and other variables, people with medical bill and debt problems were much more likely to not fill a prescription, not see a doctor or skip recommended tests, treatments or follow-up visits, the study found.

"When people accumulate medical debt, they're embarrassed to go back (to the doctor)," Doty said.

As health plans respond to rising health-care costs by placing limits on coverage and raising patients' cost-sharing, policymakers must consider the plight of the nation's "underinsured," the authors concluded.

"We can no longer just add people (to insurance rolls) and think, 'Well, now they're insured,' without really looking at what they're getting when they are insured," Doty said.

More information

The Center for Studying Health System Change examines access to care and medical bill problems.