Sharon Kelly had always been healthy and never used her insurance plan much. That all changed in 2016, when a routine mammogram showed a lump in her left breast.

Kelly, a self-employed psychologist in West Chester, was swept up in a whirlwind of medical appointments, tests, and surgeries that got rid of the disease, but left her with $15,000 in medical bills.

“Medical debt is a very quiet and insidious kind of debt. It just starts coming from all different places. ... It doesn’t hit you until you’re at the height of it,” said Kelly, 55.

Two years later, Kelly’s cancer is in remission, but the lingering debt has had a profound effect on her approach to care. She paid the 2018 and 2019 premiums for her health plan, which she bought through the health insurance marketplace created by the Affordable Care Act, but didn’t go to the doctor for fear of adding to her debt. The premium alone was close to $7,000 a year.

“It kind of paralyzes you,” Kelly said. “I started thinking, ‘What if I just don’t have insurance?’”

That may seem dangerous for someone with a history of expensive medical needs — needs that would be even more costly without insurance to negotiate a lower rate and pay at least part of the bill. When people are uninsured, they are responsible for the full cost of their care, and when they can’t pay, their other assets, such as homes, businesses, and retirement savings, are at risk when debt collectors come calling.

But medical debt is forcing American families to take such risks. As out-of-pocket costs continue to rise — outpacing growth in wages — unpaid medical bills are piling up on kitchen counters across the country. And people stretched too thin are skipping preventive tests and scans, delaying needed care, and rationing medication or going without it entirely.

As the annual open enrollment for ACA plans begins Friday, medical debt can loom large over decisions about what kind of coverage to buy, or whether to buy any at all. In recent years, there has been a decline in marketplace enrollment among people who do not qualify for tax credits to help offset premium costs. They could be moving to employer-sponsored health plans through a new job or a spouse, choosing an off-market plan, or going without insurance.

Premiums for individual health plans, which are available through healthcare.gov for people who, like Kelly, do not have employer-sponsored health insurance, will go up an average of 4% in Pennsylvania in 2020. Though that’s a more modest increase compared to the marketplace’s earlier years, it’s little consolation, as the maximum amount insurers can require members to pay out of pocket in addition to their premium continues to rise, to $8,200 for an individual in 2020.

“People do make hard decisions when they can’t afford coverage; they absolutely do. Economists will tell you, ‘Sick people will find a way.’ But at some point, there’s only so much money,” said Karen Pollitz, a senior fellow at Kaiser Family Foundation.

High deductible, big debt

People faced with medical debt often are forced to take drastic measures to pay it down — tapping retirement funds or college savings accounts, taking out new loans, or opening new credit cards they may have little hope of paying off.

In Pennsylvania, people with insurance from a large employer paid for about 14% of their health costs out of pocket. But those with individual health plans paid about 22%, according to research by the Health Care Cost Institute in Washington.

The difference is the growth of high-deductible health plans that don’t pay benefits until patients have spent thousands.

“People are not over-utilizing health care, but the prices are going up, which drives spending. And, unfortunately, being in a high-deductible health plan puts patients more at risk of seeing those high prices translated into bills,” said John Hargraves, a senior researcher at the nonprofit, which studies health-care cost trends.

‘Sitting on a time bomb’

When Kelly got sick, her health plan had a $7,000 deductible, meaning she was on the hook for all her health costs until she cleared that figure. After reaching the deductible, patients continue paying a smaller share of their health costs until they meet their plan’s out-of-pocket maximum.

But Kelly got sick halfway through the calendar year. So, just as she was nearing that magic number, January came, and her deductible bounced back up to $7,000. Her treatment continued, as did the bills.

“It’s almost like you’re sitting on a time bomb,” said Sara Collins, vice president for health care coverage and access at the Commonwealth Fund. “You have this high-deductible plan you may not use much, but if you do get sick, you can end up with a lot of out-of-pocket costs.”

A whopping medical bill can be especially harsh for people who don’t have the luxury of paid sick days.

A lumpectomy removed the mass in Kelly’s breast, but doctors also wanted her to undergo chemotherapy, to be sure the cancer was gone. She declined, figuring it would make her feel too sick to work, putting her practice at risk.

“I just try to have peace with the situation. It’s not going to be my reality, being self-employed, to participate in treatment that makes me sick,” she said.

Kelly has since put off going to the doctor, instead doing her best to eat healthy and perform self-checks on her breasts. She has held onto her ACA marketplace plan, but doesn’t know if she will renew for 2020.

People shopping in the ACA marketplaces have a range of coverage and cost options, which is why patient advocates like Antoinette Kraus of Pennsylvania Health Access Network encourage people to shop around.

Bronze plans have the cheapest premiums and the highest deductibles, while gold and platinum plans offer the greatest coverage at the highest cost.

Silver plans fall in the middle, but can still be pricey. In the Philadelphia area, the benchmark silver plan will cost about $700 a month for someone Kelly’s age, with a $3,000 deductible.

“We need to address the affordability issue. Folks shouldn’t have to worry about going into medical debt at a time when they need care the most,” Kraus said.