The Health-Care Crisis Hits Home

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There was at least one thing we didn't have to worry about, Haile assured me. Pat's kidney doctor, Peter Smolens, would keep treating him even if he couldn't pay. Smolens, a thin, soft-spoken man, later told me that about 10% of his patients have inadequate insurance or none at all. He has agonized with some as they struggled with hard choices, like whether to have a hospital biopsy or pay their mortgage. As a physician, he said, "you just see them. You know you're not going to get paid."

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As grateful as we were for Smolens' forbearance, that still left us with the question of how to keep up with the rapidly mounting bills for drugs and lab work. Haile put us in touch with B.J. Smith, a social worker at the center. Patient and reassuring, Smith turned out to be the angel we needed. She had only recently returned to work after taking off seven years to stay home with her two children. The first thing she advised Pat was to start paying his bills, all of them, even if it meant putting down only a few dollars a month on each one. Otherwise, everything he had — his one-bedroom condominium, 2003 Saturn Ion and $36,000 in savings — would be put at risk, as the letters from collection agencies had begun to arrive. Smith called Pat's medical creditors one by one and set up the arrangements: $51.89 a month to one hospital, $76 to another, installments of $4.78 a month to $111.89 a month on six different sets of LabCorp bills. Then there was the $626 he owed two radiologists. One agreed to knock off $22 as a hardship discount, writing Pat, "We are happy that we could be of assistance to you and your family in this time of need."

A paradox of medical costs is that people who can least afford them — the uninsured — end up being charged the most. Insurance companies, with large numbers of customers, have the financial muscle to negotiate low rates from health-care providers; individuals do not. Whereas insured patients would have been charged about $900 by the hospital that performed Pat's biopsy (and pay only a small fraction of that out of their own pocket), Pat's bill was $7,756. For lab work — and there was a lot of it — he was being charged as much as six times the price an insurance company would pay. One pathology lab's bill alone was $3,290. (Facebook users, comment on the story below.)

Over time, with Smith's guidance, Pat learned to trim his bills here and there. Instead of refilling small prescriptions, for instance, he could buy some drugs more cheaply in bulk. (A hundred pills of one blood-pressure medication was less than $16 at Costco, compared with $200 at the pharmacy.) But that didn't address the cost of his care going forward. Pat's kidney function, which was 48% when Smolens first saw him last summer, has fallen to between 35% and 40%. And there are now outward, obvious signs of Pat's illness: he is lethargic, his eyes are puffy, and his lower legs and ankles are swollen to twice their normal size.

The disease — whose cause Pat's doctors doubt they will ever know — is winning. Now Smolens is trying to figure out whether Pat, whose Asperger's gives him a low tolerance for the demands of a complicated medical regimen, should move from his current medications to a more aggressive approach that includes immuno suppressing chemotherapy drugs. The newer drugs can cost $10,000 a treatment; even the old ones can easily run $500 a month. "It's almost like a black hole in terms of the potential costs," Smolens told me. "But when you look at the alternative — progressive kidney failure — then you're talking about having to receive dialysis, and the average cost of dialysis treatments in this country is $60,000 per year plus."

There's another paradox: if Pat gets sick enough to need dialysis, as he well may, the Federal Government will pick up those staggering costs under the Medicare program for end-stage renal disease. But until that point is reached — and the goal is to keep him from getting there — his options are limited. Now that he is sick, it would be nearly impossible for him to purchase another insurance policy on the individual market. Since he lives independently and holds a job, it would be difficult for him to qualify for Social Security disability benefits. While Texas, like 34 other states, has a high-risk pool for those who are hard to insure, the program is twice as expensive as an average individual health-insurance policy. And my brother would have to wait 12 months to join with a pre- existing condition, under the state's "adverse selection" regulations that seek to prevent uninsured people from joining the pool only after they get sick.

As we were running out of options, Smith told us there was one more avenue to try. Bexar County — where San Antonio is located and an estimated 30% of people under 65 do not have health coverage — has a health-care program for the uninsured that is far more generous than most in Texas and practically unique in the country. Rather than continuing to wait for the uninsured to show up in its emergency rooms, in 1997 the Bexar County hospital district established a system called CareLink for those who make 200% of the poverty line or less. (In his current job, answering queries that come in to a text- message information service, Pat earns $1,257 a month, which means he qualifies.)

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