Scrimping Utahns are skipping preventive checkups and forgoing needed dentures and crowns. More are seeking treatment for depression and anxiety. They're lining up for nearly free health care or heading to emergency rooms.

Or they simply suffer until they can afford to care for their out-of-control diabetes or festering wounds.

"It takes a lot on one's body and soul even," said Shawna Zink, of Magna. "I'll be 45 this month and I feel like sometimes I'm 60."

Zink said she stands in line at food banks and takes advantage of low-cost health care through a charity. But her family still struggles to pay rent and utilities. Her daughter planned to start college this year, but couldn't get a student loan due to the credit crunch. Zink said her daughter has been dangerously depressed, in part due to financial pressure.

"She hasn't gone to counseling because she can't afford the $60 each session," Zink said.

Richard Hatch, chief clinical officer of Valley Mental Health Services, said the agency is "seeing a wide variety of things, but a lot of it is anxiety about how [the economy] will impact them . . . how it's all going to trickle down to people."

Kurt Micka, executive director of Utah Partners for Health, expects the worst is yet to come.

The nonprofit provides family practice, dental, eye and mental health care to uninsured residents of Magna, West Valley City and Kearns. Demand for treatment for anxiety and depression, he said, is up 32 percent this year.

The physical toll of stress: Irene of West Valley City, who asked to use only her middle name, said her depression is worse since she lost her job as a private school teacher. She said gas prices hurt enrollment at the elementary school.

"If I have something to get up and do, then I'm OK," she said. "Now, I take the kids to school and I come home and I look around and think, 'I have so much to do and I don't know where to start. OK, let's take a nap first.' "

Depression and anxiety "play a big role on a person's physical health," said John Houchins, a family medicine physician at the University of Utah's clinic in Sugar House. Depressed people are less likely to take their medications, exercise or eat right, he said.

And Heather Borski, director of the state's Bureau of Health Promotion, noted that chronic stress - from losing a job or worrying about paying bills or being able to retire - contributes to chronic diseases like diabetes, heart disease and perhaps cancer.

Hormones produced in response to stress, like adrenaline and cortisol, alter the immune system, change the way sugar is regulated in the blood and elevate blood pressure and heart rates.

"We seem to be in a much more stressful time right now. We'll be seeing the impacts of that in the days to come," she said.

Carl Rasmussen, a Lakeview Hospital doctor who specializes in psychiatry, said the top three issues that typically prompt people to seek help are relationship conflicts and stress related to finances and work.

Problems rooted in families' dwindling reserves of money, however, may take the top spot soon, he predicted. "That's probably going to be a greater stressor," he said.

People under stress are more likely to be irritable, have shorter attention spans and suffer panic attacks, he added. "They just don't cope as well. They just start to become overwhelmed."

No ounce of prevention: Some doctors also report seeing sicker patients who have forgone preventive care. Patients will show up with undiagnosed diabetes, their glucose levels four times higher than normal or "massive skin wounds" that started out small but grew without treatment, Micka said.

"Somebody called just five minutes ago about a tooth abscess that is causing tremendous swelling near his eye," Micka said. "That's a situation where they have not gone to the doctor [earlier] because they can't afford it."

Even low-income patients on public health insurance programs such as Medicaid or Medicare, whose basic care is covered, are skipping appointments because they can't afford transportation, said Gary Call, chief medical officer for Molina Healthcare of Utah.

"This is a population that has tremendous transportation barriers anyway," he said.

The result is a documented upswing in emergency room visits - and over time, an increase in health care costs for patients whose untreated chronic conditions worsen. "We may not see the impact of that for years," Call said.

About 8,300 more Utahns have turned to Medicaid for health insurance since August 2007, according to the Utah Department of Health.

The increased enrollment is happening while the state's revenues are down and Medicaid is trimming programs amid a budget shortfall. That means some Utahns no longer have the option of getting such care as physical therapy, chiropractic treatment or eyeglasses.

A growing number of people are seeking charitable care - and for larger amounts - said Jason Mathis, a spokesman for Intermountain Healthcare. It has seen requests for financial assistance increase about 9 percent over the same time last year.

Striving to stay covered: Utahns also are struggling to get or keep commercial health insurance.

Jennifer Stark, an individual sales executive for Regence BlueCross BlueShield of Utah, said a growing number of new customers are applying for lower-cost plans, such as health savings accounts.

Existing customers are ringing up, too, some in tears, desperate to find a way to hold onto plans that are becoming increasingly difficult for them to afford.

"Money is tight," Stark said. "I can relate with a lot of these people calling in. People are working less hours. They're just trying to get gas, groceries."

Stark said she helps customers retool their plans, perhaps raising their deductibles and in turn lowering their monthly premiums, or making other changes. With her help, one family of six saw their monthly premiums drop by almost half.

More Utahns may find themselves in a similar situation in coming months as employers adjust their health insurance plans, Utah Partners for Health's Micka predicts. Many are expected to increase employee contributions or eliminate insurance benefits altogether.

University Hospital attributes such decisions to the jump in uninsured patients it has seen over the past three years. They used to make up 2 percent of patients; now it's 5 percent. Spokesman Christopher Nelson expects the figure to rise over the next fiscal quarter - along with visits to the ER.

"We expect people will start showing up in the emergency department with more catastrophic problems because they haven't been getting preventive care," he said.

Postponed procedures: Treatments Utahns consider elective or lower priority are also starting to dip.

Klemont Adams, business manager of a dental practice in Helper and another in Grantsville, said its cleanings and fillings remain on target because they're covered by insurance. But patients aren't showing up for more expensive treatments like dentures, crowns and braces. Clinics that emphasize cosmetic procedures, like teeth whitening, are suffering more, he said.

Demand for dentures, which cost at least $800 for a full set, is down 40 percent from two months ago, Adams said.

"People who need their teeth out and need dentures, and there's a huge population of those in Utah, they just get teeth out one at a time when they hurt until they come up with the money for the whole thing," he said.

Heather Alcorn, administrator of the Foothill Family Clinic in Salt Lake City, is "anxiously awaiting" the fallout. "Everyone is fearing that payments could stop coming in. People are losing insurance [from losing their jobs] and therefore they won't come in when they need to be seen."

Intermountain Healthcare's Mathis said some procedures, such as colonoscopies, are being postponed. A claims report by Regence BlueCross BlueShield of Utah also shows slight dips in the number of hysterectomies, vasectomies, and cataract and hip replacement surgeries being performed.

Mitch Tibbitts, chief financial officer for Mountainstar, said he's seeing lower volume in some types of outpatient care, though it may be too early to pin it on the economy.

As demand for health care waxes and wanes, "we attempt to adjust our cost structure accordingly, but in the short term we don't plan to do anything different," he said.

"We still provide the same level of care," Tibbitts said, "it just provides another challenge."

hmay@sltrib.com

Ways to save money on health care

* Don't assume your employer's coverage is a good deal: Buying individual coverage for a spouse or children may be cheaper. Comparison shop; check out one of the Web's insurance portals like ehealth.com.

* Compare hidden costs: After spending reaches a specified deductible, some policies cover only 50 percent of bills, others cover 80 percent or more. Some plans set annual limits for prescriptions.

* Use flexible spending accounts, which let you use pre-tax dollars to cover deductibles, co-payments, eyeglasses, kids' braces and more.

* Ask questions: Ask your doctor and pharmacists in-depth questions and get involved in your healthcare.

* Consider lifestyle changes: Are you eating healthy foods? Taking a multi-vitamin? Getting enough sleep? Exercising? Do you smoke? Discuss with your doctor how your habits may be impacting your health and the amount of prescription medications you need to take. Check with your health plan for programs to help you take the first steps to a healthier life.

* Investigate online resources: Be sure to visit your insurance company's Web site and browse through the tools it offers.

* Generics: Ask your doctor or pharmacist if there's a generic alternative for any prescription drug you are taking. Generics are as safe and effective as brand name drugs, but cost less.

* Formulary: Check to be sure the prescription drugs you are taking are part of your health plan's preferred medication list (also called its formulary). There are often many medications available that treat the same condition, and the formulary is made up of the safest and most cost-effective medications.

Source: Regence BlueCross BlueShield of Utah