There was a time when Herb was living the American dream in the sunny state of California. He was married with 2 children, a big house in the suburbs, a golden Labrador retriever, and a well-paying job as an executive in a book publishing company.
His two sons were stellar athletes and students, both moving on to attend nationally ranked colleges upon graduation from high school. They were the pride and joy of Herb and his wife Sarah, tangible results of that potent combination of good genes and parenting. Sarah, content with her life, was the PTA president for many years, and worked as a successful independent graphic design artist.
And so went the idyllic life until the year 2007 arrived and fundamentally altered the trajectory of Herb’s life. The sub prime mortgage crisis was swinging into gear and there was increasing interest in digital information systems, thus altering book publishing strategies and financials. Herb’s company failed to appreciate the magnitude of these factors and the business started to suffer. Severely suffer. Changes were necessary and Herb was deemed expendable. Twenty years of dedication to a company washed away in one 30 minute, disjointed conversation with the CEO.
He numbly returned to his office and began packing his belongings into boxes. He took down the family pictures from the wall, cleaned off his desk. His secretary stood crying in the doorway. Herb hugged her, reassured her best he could, and walked out the door, zombie-like, into an uncertain future. He was 49 years old.
Herb looked long and hard for employment, but publishing jobs were scarce. After 20 months, he was desperate. His checking account had bottomed out, Sarah was having trouble finding work, and his mortgage was more than he could afford. Worse yet, his COBRA medical coverage had expired and he found himself without health insurance.
In the meantime, Herb had started drinking, a little at first to fall asleep at night, a lot later to drown out the realities of life. He disconnected emotionally from Sarah. With her newly found free time, a consequence of the children moving out and decreased graphic design work, Sarah decided to get into shape. She joined a local gym and hired a personal trainer, Alex. Several months into it, she started looking and feeling better and was becoming conspicuously dedicated to her training regimen under the very watchful eye of Alex.
One day after completing her workout, Sarah asked Alex if he’d like to grab a cup of coffee. Soon, the after-workout coffee thing become a regular routine. Several months later, Sarah agreed to meet Alex for a quick dinner at a restaurant around the corner. The dinners then became more frequent, while Herb spent most of his time in front of the television at home, eating snack food and gaining a lot of weight. In a seemingly inevitable outcome, given the circumstances, Sarah started a romantic relationship with Alex. Later, when recounting the story, Herb remembered that he barely blinked an eye when Sarah said she was leaving him. He had already sunk that low. He could have never imagined that the worst of times were still ahead.
Herb’s drinking accelerated; he was drunk most of the day now. He moved out of the house and in with his mother, who lived alone. She took to caring for Herb; doing everything she could to help him out of his funk. This went on for almost 3 years. The amount of alcohol consumed in that period was phenomenal; Herb routinely drank up to 1.5 L of vodka daily. This self-destructive process was spectacularly successful and ultimately landed Herb in the county hospital emergency room where I was called to admit him to the hospital.
Herb looked like all the drunks that we regularly encounter at our hospital: yellow skin and eyes, hugely protuberant belly full of fluid, dilated blood vessels visible in skin, and an odd musty smell on the breath. He was a visually powerful reminder that alcohol does not discriminate when it destroys the human body. Race, gender, and socioeconomic status are paid no mind by this toxin. In the bed next to Herb was a homeless, malodorous man picking at open wounds on his legs. The entirety of the scene graphically illustrated the depth of Herb’s plunge. As I interacted with him, I could sense the shame stuffed into his words, bulging with every breath uttered. He had truly bottomed out, and it seemed to me the realization of that reality was nearly overwhelming to him in the moment.
Herb’s liver was a mess; I knew that from the start, and so with the assistance of the gastroenterologist, we devised a treatment plan. Shortly after admission, Herb began experiencing severe delirium tremens, an alcohol withdrawal condition characterized by auditory and visual hallucinations, mental confusion, rapid heart rate, unstable blood pressure and “the shakes”. If left untreated, it can result in death. Herb required high doses of tranquilizers to control his symptoms. Nine days later, we were finally able to wean him off the medications, and after another 4 days of physical therapy, Herb was stable enough for discharge home, with close follow-up in clinic scheduled.
Prior to discharge, Herb applied for Medicaid. However, Herb had over $250,000 in a pension plan and thus did not qualify for Medicaid. He would have to “spend down” before he would be eligible for coverage. Simply put, that means that Herb would have to pay all his medical bills out of pocket until he used up all of his money. Once he was poor, then he would qualify for Medicaid. Herb was irate. “That’s my money! I earned it! I paid health insurance premiums almost my entire life and now that I need coverage, I can’t get it because I’m not poor.” His words fell on deaf ears.
Herb was told during an outpatient visit to the gastroenterologist several months after discharge from the hospital that his only chance for long-term survival would be a liver transplant. But, in order to even be considered for transplant, Herb would have to demonstrate at least 6 months of sobriety. Herb began to turn his life around. He stopped drinking, began exercising and losing weight. The 6 months passed and despite Herb’s efforts at improving his health, his liver function continued to decline. He had reached the point of no return. The liver had been damaged beyond repair. He found himself coming to the hospital every 2-3 weeks to have the fluid drained out of his belly, and he had to take medications that prevented the build-up of toxins in the blood, medications that caused him to have 6-8 bowel movements every day. Herb payed for this care out of his pension.
Herb’s only chance was a liver transplant. The gastroenterologist made a referral to a liver transplant center. When Herb called to make the appointment, the receptionist asked for his insurance information. Herb relayed the fact that he didn’t have insurance. He was told he could not be seen without insurance. According to the United Network for Organ Sharing (UNOS), estimated charges for liver transplantation are $314,600 for the first year and then $21,900 annually for the remainder of the patient’s life. Herb did not want to spend his money. He thought it unfair. Herb got worse. Herb would not spend his money. Herb got worse. Still he refused to pay. We had many different health professionals speak with Herb on multiple occasions, to no avail.
Herb was admitted to the hospital when his kidneys began failing. He was very confused, too confused to discuss his health or lack of insurance with anyone. He could barely state his name to staff. We stabilized Herb, but he was still quite sick. His mother felt that she shouldn’t have to spend her money if Herb was not willing to spend his. Besides, she was alone and elderly, she explained, and had no source of financial support if she exhausted her life savings. She could not sacrifice that, even for the life of her son. And so went these surreal conversations.
A month later, Herb died of complications of his liver disease. He was 52 and died with $200,000 in the bank, seemingly unaware of that old adage expressing the uselessness of money to a dead man.
“The American Doctor” is a physician who blogs at his self-titled site, The American Doctor.
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