HACKENSACK, N.J. — Frances Giordano found out she had lung cancer in June. After that, the bad news just kept coming.

First, she discovered that even with a good job and health insurance, her medical expenses were more than she could afford on disability.

Then she started slipping into debt, like millions of other Americans who don't have the cash to cover their medical bills. Hospitals expect to be paid promptly and offer little leeway to insured patients. Unpaid bills go to collection agencies, damaging a person's credit history for years.

Finally, she learned that fighting for her life was not her only battle or maybe even her toughest. When she finished her chemotherapy in December, she was fired. "Due to changes in business operations," wrote her employer of more than six years, "We can no longer hold your position open."

It arrived nine days before Christmas.

"I'm a good person," the 58-year-old Giordano said in an interview, crying. "I worked hard. Isn't having cancer enough"

The crisis in American health care is not limited to hospital emergency rooms where uninsured people wait for care. It also is found in a neat, three-bedroom house in Dumont, N.J., occupied by a widow who worked full time, raised two kids and likes to get her nails done occasionally.

In less than a year, Giordano lost her health and her job. Now, she's afraid she'll lose her good credit and her health coverage.

In the lonely hours of the night, she said she thinks about giving up.

Giordano had health insurance throughout her illness. She didn't have to beg for treatment and was not denied it. She loves the surgeon and oncologist and nurses whose care, she hopes, will give her many more good days with her first grandchild, born in July.

But she may be ruined financially. In this country, people can go broke if they get sick.

A cancer diagnosis "is a catastrophic double whammy" for many patients, said Blair Horner, an American Cancer Society vice president, "bad news on their health and potentially catastrophic news for their finances."

Despite the passage of national health care reform in 2010, many of the changes intended to protect people from situations like Giordano's haven't been implemented yet.

Without a salary, she can't afford to extend her coverage. She doesn't know how she'll pay off her hospital debt. She is desperate to keep her bills from going to a collection agency because a mark on her credit history could make it hard to buy a smaller place to live when she's ready.

And then there's the unsettling "activity" near her esophagus, spotted on a recent PET scan. Her doctors say it should be biopsied; Giordano says she can't afford the co-pay and doesn't want to hear more bad news.

"How does my body recover from chemotherapy with all this anxiety and stress?" she said.

"Bottom line? People can't get sick. They can't get cancer."

Each week, more than 31,000 people are diagnosed with cancer nationally, according to the American Cancer Society.

Cancer "is one of the most expensive illnesses to have," said Barbara Hoffman, founding chairwoman of the National Coalition for Cancer Survivorship and a law professor at Rutgers-Newark. "It results in a lot of personal financial stress and can lead to personal bankruptcy."

Even when patients have coverage, they "may not be protected from high out-of-pocket costs when they are diagnosed with cancer," according to a 2009 report by the Kaiser Family Foundation and the American Cancer Society. Along with high insurance premiums, those costs may force patients to pile up debt to pay for the care they need — or postpone or skip lifesaving treatment.

"Having insurance increases people's ability to access care," said Mark Rukavina, an expert on medical debt and the executive director of The Access Project, a Boston-based health care advocacy group. "The good news is that they get the care, but the bad news is it's unaffordable."

As medical costs rise, employers have shifted more of the burden to employees through premiums, co-payments and coinsurance.

"The days of Cadillac health plans are pretty much over," said Peter Cunningham of the Center for Studying Health System Change in Washington.

Each year, an increasing share of Americans spend more than 10 percent of their income on premiums and out-of-pocket costs for health care, the standard used to define a "high medical cost burden," he said. Surprisingly, that trend has "been increasing the most for people with employer-sponsored insurance," he said.

It's especially marked among small businesses, like the one for whom Giordano worked.

Giordano's share of her medical expenses included: $125 for each same-day procedure, such as a biopsy or the implantation of her chemotherapy port; $100 for each MRI, CT or PET scan; $40 for each visit to the specialist; and $250 a day, to a maximum of $1,250, each time she was hospitalized. Her policy, from Oxford Health Plans, placed no limit on out-of-pocket expenses.

And she is one of the lucky ones. A growing number of New Jersey residents — more than one in eight — do not have health insurance at all.

"We've seen a pretty substantial erosion over the past 10 years in people who work for small employers who even have coverage from their employer," Cunningham said.

Ellen Stovall, a three-time cancer survivor and senior adviser at the National Coalition for Cancer Survivorship, said survivors already face daunting choices as they make treatment decisions.

"The last thing they need is to worry about losing their health coverage or paying high cost-sharing or premiums," she said. "Yet the fact is that ... many Americans are underinsured — something they often don't realize until they have a devastating diagnosis."

More than one in five American families experience problems paying medical bills, the Center for Studying Health System Change reported in November. Some 44 million Americans are paying off medical debt, the Commonwealth Fund said, up from 37 million in 2005. Congress reported in 2010 that 30 million Americans of working age were contacted by a collection agency for unpaid medical bills.

One survey periodically asks people how they have been affected because of their medical bills. "Two-thirds of people say ... they've had problems paying for some of the basic necessities — food, rent, mortgage, clothes, basic stuff," Cunningham said. "They've put off major purchases. They've taken money out of savings or borrowed money. An increasing number consider filing for bankruptcy."

In fact, medical bills and illness contributed to nearly two-thirds of all personal bankruptcies in 2007, a 50 percent increase over 2001, according to Steffie Woolhandler, a physician who co-authored several studies on health care debt. Most of those bankrupted were middle-class homeowners, she said.

"The overwhelming majority of those bankrupted by illness" had health insurance, she testified to Congress in 2009. "These families had done everything right. They worked hard, paid their premiums and thought they were covered. Yet when illness hit, they found themselves unprotected, ruined by co-payments, deductibles and bills."

The Affordable Care Act, if enacted as planned in 2014, is supposed to help these patients. One provision aims to make sure every health insurance plan delivers good value — "a better bang for the buck," as one expert said — by requiring that 85 percent of the premium dollar go toward health care.

Medical bills account for more than half of all collection actions reported to consumer credit reporting agencies, a 2003 report by the Federal Reserve said.

Many of those bills are for less than $500, yet each one contributes to a poor credit score. A single surgery can generate separate bills from a surgeon, anesthesiologist, hospital, pathologist and other professionals, quickly overwhelming a sick person's ability to understand and keep up. A dispute about whether a service is covered can leave the patient and insurer arguing while the hospital sends the bill to a collection agency.

"Once it goes to collections, even if paid promptly, it's a stain on their credit report," Rukavina, the expert on medical debt, said. "It can remain there for seven years, even with zero balance due. ... Your credit score goes down and the cost of borrowing increases: It can cost tens of thousands of dollars on a mortgage."

Some members of Congress became so concerned about the issue that a measure to change the reporting of medical debt by collection agencies was introduced last year with bipartisan sponsorship. It would exclude from credit histories medical debt that has been paid in full.

When Giordano dares to hope for a future after a full recovery, she talks about moving to a smaller place or a town house down the New Jersey Shore or to Florida. It would require a new mortgage "I care about my FICO score," she said.

She couldn't understand why the hospital wouldn't set up a payment plan she could afford. "Anything I vowed to pay them, I've always paid them," she said, referring to bills in the past for her husband and daughter. "I'm not asking for charity."

Giordano had planned to celebrate the completion of her long, aggressive course of chemotherapy with her friends on Dec. 16. Instead, she opened the letter announcing that her job was gone.

The letter explained why her position couldn't be held open. "Small companies ... are not obligated to hold positions open for an employee on a leave of absence," it said. The letter noted that the company had held her job for almost five months, which far exceeded its normal policy of 90 days' medical leave.

However, the letter went on, "Because of our continuing concern for your welfare," the company will extend and pay for her health coverage through April.

Giordano was devastated.

"Let me tell you something," she said, "if the cancer didn't kill me, this will."

Her lustrous long brown hair had just begun to fall out. She was thin and easily winded but spoke furiously about the letter's effect.

A generation ago, it was common for workers diagnosed with cancer to lose their jobs, said Hoffman, the Rutgers law professor. People with "the Big C" weren't expected to survive. There was no Americans with Disabilities Act. State anti-discrimination laws weren't in place to protect cancer patients or those with chronic conditions.

But medical progress, new laws and a sea change in attitudes toward cancer survivors have greatly reduced the instances of discrimination, she said. Disabled employees now have a right to reasonable accommodation for their disability when their employer is covered by federal and state disability law. Small firms are exempt from the ADA, but not the New Jersey law.

Giordano responded to the letter fiercely, with a round of telephone calls to anyone who might be able to help. Then, her immune system weakened by the chemotherapy, she developed an infection and a fever. Christmas, even with a 6-month-old grandson, was ruined.

"I feel broken inside," she said. "You're fighting one thing, and you sort of conquer that journey, and this happens. ... Who do you think is going to hire a 58-year-old woman"

She has received the last of her disability checks. She is waiting for a state determination of whether she's eligible for unemployment pay.

With no income, she doesn't have the money to extend her health coverage; the subsidies through the Affordable Care Act to buy insurance won't begin for two years.

Her doctors want her to have further tests, but she can't afford the co-pays. And, frankly, she doesn't want to know the results.

"Don't sugarcoat this," she said. "You know my husband died from this. I came to the end of one part of my journey, now I'm on another part. I don't know what's next."

She fingers her rosary beads — at this point, her only source of strength, she said.

"If I succumb to this," she said, she doesn't want people to send flowers or donate to cancer research.

"I'd want a relief fund started — something where, if somebody's in trouble with a co-pay, or needs a scan, or somebody's in trouble with their rent or mortgage, they'd have some help. It would be one less thing to worry about, and they could just focus on getting better."

— — —

SQUEEZED BY HEALTH BILLS

Problems with medical bills or accrued medical debt increased, 2005-10:

Percentage of adults ages 19-64, 2005: vs. 2010

In the past 12 months:

Had problems paying or unable to pay medical bills: 23 percent (39 million) vs. 29 percent (53 million)

Contacted by collection agency for unpaid medical bills: 13 percent (22 million) vs. 16 percent (30 million)

Had to change way of life to pay bills: 14 percent (24 million) vs. 17 percent (31 million)

Any of the above bill problems: 28 percent (48 million) vs. 34 percent (62 million)

Medical bills being paid over time: 21 percent (37 million) vs. 24 percent (44 million)

Any bill problems or medical debt: 34 percent (58 million) vs. 40 percent (73 million)

Source: The Commonwealth Fund Biennial Health Insurance Surveys (2005 and 2010)

— — —

FACTS BEHIND MEDICAL DEBT

— 62.1 percent of all bankruptcies have a medical cause.

— Most medical debtors were well-educated and middle class; three-quarters had health insurance.

— The share of bankruptcies attributable to medical problems rose by 50 percent between 2001 and 2007.

Source: "Medical Bankruptcy in the United States, 2007: Results of a National Study," by David U. Himmelstein, et al., in the American Journal of Medicine, August 2009

— — —

COSTLY BURDEN

More adults are spending large shares of income on out-of-pocket medical expenses, 2001-10. (See note.)

Percentage of adults ages 19-64 who spend 10 percent or more of household income annually on out-of-pocket costs and premiums (See note.)

2001 vs. 2005 vs. 2010

Total:

21 percent vs. 23 percent vs. 32 percent

Insured all year:

19 percent vs. 23 percent vs. 31 percent

Uninsured during year: 27 percent vs. 22 percent vs. 35 percent

(Note: Respondents who specified income level and private insurance premium/out-of-pocket costs for combined individual/family medical expenses.)

Source: The Commonwealth Fund Biennial Health Insurance Surveys (2001, 2005 and 2010)