Twenty years ago, most U.S. residents with solid major medical coverage paid small co-payments when they sought ordinary in-network care. They might never have to worry about a deductible, and the deductible might be just $500, or less.

Today, the Patient Protection and Affordable Care Act (PPACA) and a general desire to make patients better health care shoppers are pushing insurers to give consumers more “skin in the game” — higher out-of-pocket costs.

Many people who had private health coverage through the new PPACA public exchange system get plans with deductibles of $6,350 for self-only coverage and $12,700 for family coverage.

See also: Underinsurance persisting in exchanges

PPACA cost-sharing reduction subsidies can reduce the out-of-pocket costs for consumers who earn less than 250 percent of the federal poverty level and buy the right coverage. Other consumers may have to pay thousands of dollars before their plans covers hospital care.

Some consumers have plans that cover nothing but the basic PPACA-required package of no-out-of-pocket-cost preventive services until the consumers spend enough to meet the deductible.

Meanwhile, 28 percent of U.S. residents told the Center for Financial Services Innovation that they have less than $1,000 in liquid savings, and 36 percent said they run out of money before the end of the month at least some of the time.

TransUnion found that many U.S. residents also have a hard time scraping up enough credit to pay unexpected bills.

See also: TransUnion To Offer Hospital Payment Card

At the end of 2014, typical consumers had just $1,350 in credit card borrowing power or other general-purpose revolving credit per $100 of costs in a health care services basket, down from $1,520 at the end of 2013.

Subprime consumers had just $360 in revolving credit capacity per $100 of health care services basket cost, down from $430 a year earlier.

Companies like Prosper Healthcare Lending that once focused on helping consumers pay for cosmetic surgery and dental care, and like and CarePayment, which has always been in the major medical health credit market, are now seeing more opportunities to help consumers pay ordinary medical bills. CarePayment announced in late 2014 that it had arranged $100 million in funding to back its patient finance program.

For a look at some of the new frontiers in patient finance, read on.

Tight rope

1. Patient finance companies could help consumers with “conventional” high-deductible plans. 

Just a few years ago, patient health care credit programs were controversial.

See also: Consumer Reports Pans Care Credit Practices

Today, as a result of the shift to high-skin-in-the-game coverage, and new bankruptcy rules that make disposing of debt through bankruptcy more difficult, basic medical credit programs are getting more attention.

Graham Anderson, director of health care marketing at Prosper Healthcare Lending, said in an interview that his company finds that its core business still relies mainly on relationships with dentists and providers of elective procedures, such as facelifts and bariatric surgery, not primary care providers, hospitals or surgeons who perform appendectomies.

One barrier to consumer use of the credit products for ordinary care has been a $2,000 minimum principal amount.

Another barrier has been physicians’ inclination to work out other types of arrangements for helping patients cope with financial limitations.

In the acute care medical field, “There still isn’t as big of a need there as we thought there was,” Anderson said.

But CarePayment has argued that demand for help with out-of-pocket acute care costs is bound to grow, given the trends in plan design.

Dripping faucet

2. Patient finance companies could help holders of health savings accounts (HSAs) cope when the flow of HSA assets runs dry.

Prosper, for example, has already formed an alliance with an HSA provider, and other patient finance companies already have relationships with HSA companies.

But “we don’t feel like there’s a lot of competition yet,” Anderson said.

Prosper feels as if it’s still a relatively early entrant in the HSA user finance market, Anderson said.

(Image: TS Photo/Kay Taenzer)

Four different happy piggy banks

3. Patient finance companies could reduce providers’ dependence on both patients’ ability to pay and insurers’ ability to pay.

Uncertainty about how the PPACA health insurance company risk-management programs will work has raised questions about whether all insurers will be able to stick to current claim payment timelines. Some providers may like the idea that they have a chance to get money from a patient finance company more quickly than they could get the money directly from the patients, or, in some cases, even from the health insurance companies. 

See also: Feds: “We’ll send some PPACA lifeboat money in December”