More and more Americans are keeping their fingers crossed that they don't fall sick, with a combination of spiralling health insurance costs and slower wage growth forcing even relatively affluent workers to cut back on prescriptions and visits to the doctor.
A study by wages consultancy WageWorks has found that, while Americans accept in principle that in an ageing society health care costs will have to rise, in reality they are struggling to afford the bills.
The survey found that more and more insured Americans are behaving just like the uninsured and simply ignoring their health needs as a way of coping with rising health care costs.
More than half of those surveyed who had employer-sponsored health insurance said they had delayed a medical or dental visit in the past year.
Furthermore, more than a firth reported having cut back on prescription medicine.
The implications of this for workplace productivity and the wider economy could be significant Ė as it is self-evident that workers who do not feel 100 per cent for whatever reason will not work as effectively as those who are fully fit.
"With so much industry and legislative focus on reducing the number of uninsured, we wanted to understand what is happening to those who already have insurance. It turns out they're adopting the tactics long used by those with less access to care," said Jon Kessler, chairman of WageWorks.
"The health care challenge is spreading to the middle class. Higher costs and slower wage growth, also in part due to health care, mean even fairly affluent families have to make tough choices," he said.
Nearly three quarters of the insured Americans surveyed said they were concerned about out-of-pocket health care costs such as medication, insurance plan deductibles and laboratory fees.
A majority blamed rising costs directly to health insurance companies while a significant number also cited employers scaling back on health benefits and general rising costs.
Ominously, 60 per cent of those who got insurance at work expected to get less of it in the future, the survey also found.
Over the next three to five years, nearly a third said they expected their employer's contribution to health insurance to be cut in half.
A quarter expected their employer to replace conventional insurance with cheaper high-deductible plans.
And when asked about who should be most responsible for keeping health care spending as low as possible, more than two out of five believed it should be their own responsibility.