• Elective surgeries like hip and knee replacements, diagnostic tests and outpatient procedures fell roughly 1 to 2 percent in recent months at many hospitals, said Dick Clarke, president of the Healthcare Financial Management Association. While the decline seems small, the numbers typically climb 2 to 4 percent a year as the population ages.

• U.S. hospitals are reporting an uptick in emergency room patients, according to the American Hospital Association. Clarke said that includes a rise in uninsured patients with conditions that could have been treated elsewhere, and he expects that to increase.

The U.S. unemployment rate has climbed from 4.7 percent to 6.1 percent over the past year, costing many newly jobless people their health insurance. But the uninsured are not the only patients feeling the economy's sting.

Shelley, the Ohio office manager, said that because of the worsening economy and rising co-payments under her health plan, she is putting her husband's medical needs first. He is a substitute teacher who has had kidney and pancreas transplants, is on a dozen medications and needs bloodwork every month.

"It's tough even when times are good," she said. "The out-of-pocket is still thousands a year."

Dr. Ted Epperly, a family physician at a Boise, Idaho, clinic for the poor, said office visits were down 20 percent in August, mostly in prenatal visits by pregnant women and checkups for chronic conditions such as high blood pressure, asthma and diabetes.

"The longer it goes and the more skipped visits, the greater the opportunity there will be for bad outcomes," Epperly said. "It's not a matter of if. It's a matter of when."

Walgreen Co. pharmacies have been calling customers, making emotional arguments for why they should be getting prescriptions refilled. "For example, do they want to be around when their kids grow up, or their grandkids?" Jeff Rein, Walgreen's chief executive, told analysts last month.

In Sacramento, Calif., an area with lots of home foreclosures, primary care physician Dr. Ron Sokolov said he saw a 5 percent drop last month in patient visits compared with the year before.

He said the decline is mostly in cash-paying patients. It means those with rashes, sore ankles and other non-emergency symptoms put off treatment, he said. He has also noticed more patients are overdue for screening tests such as Pap smears and mammograms.

"A lot of people have to first put food on their table and keep their shelter," Sokolov said.

In the Palm Beach, Fla., area, another spot rife with foreclosures, Dr. Richard Hays said patients ask him to phone in prescriptions because they cannot afford an office visit or a missed day's work. Patients are demanding more generics and more drug samples, too, and stretching annual visits to 18 months.

"Everything gets a little stretched out," he said. "People have become acutely aware of the cost."

At Ohio State Medical Center in Columbus, Dr. Andrew Thomas said one of his patients put off having an MRI done for severe back pain "because literally she didn't have the gas money to drive across town."

Patients are often too embarrassed to admit they are struggling financially, he said. He offered them this advice: "If you're on a bunch of different medications, ask your doctor, 'Which one of these could I get by on for six months without taking?"'

"Your doctor might say, 'Some of these are imperative, but if you really need to save money, these are the ones I could cut out or change the dosage."'