The pain in Dan Abrams' leg throbbed so much he could barely stand. Still, the 60-year-old Somerville, NJ resident, who friends say had just canceled his health insurance because of the tough economy, debated from a hospital emergency room whether he should stay and run up thousands of dollars in debt, or take antibiotics from home and hope they arrested the mysterious infection in his leg.

Fearing he could lose his home and flooring business, Abrams chose to leave Somerset Medical Center after a hospital physician said staying would “run him a lot of money,” said Connie Dodd, a close friend who drove him to the hospital and heard the conversation. “I begged him to stay, but Dan's a proud man. Talk of all the bills got him scared.”

When Connie brought Abrams dinner the next night, they found his lifeless body in bed. CPR was performed, but it was too late. “It was a nightmare,” Dodd said.

For people without health insurance, few things are more intimidating than the arrival of a hospital bill.

Nowhere is the sticker shock worse in the country than in New Jersey, according to health experts and a new report by the New Jersey Health Care Quality Institute, a prominent health care policy group based in Trenton.

New Jersey's hospital charges, the price list used to negotiate the cost of a bill for the uninsured and for insured people who use a hospital outside their network, are four times higher than the actual cost of treating a patient. For thousands, the charges mean astronomical bills after a hospital stay. Insurers contend they also force higher premiums for anyone with health insurance.

More than 40,000 uninsured New Jerseyans this year will get a bill based on these inflated prices because they make too much money to qualify for financial aid for their hospital stay, according to an estimate by the New Jersey Hospital Association. Nobody tracks how many insured people get hit with bigger bills for using out-of-network hospital care.

Because the charges are used to negotiate prices of everything from treating pneumonia to removing a gall bladder, they inflate health insurance premiums, according to the largest health insurance company in the state, Horizon Blue Cross Blue Shield. And there is no way to know how many people, like Abrams, decline hospital care when confronted with even the possibility of a big hospital bill, said David Knowlton, the institute's president and CEO.