A million dollars can buy a mansion in one of Sacramento's nicest neighborhoods, near its best schools and parks.
Or it can buy an ever-dwindling number of weeks in the intensive care unit of a local hospital.
Bradley Showalter, an Arden gas station attendant and laid-off construction manager, can't afford either of those expenses, but the cancer eating his liver didn't get the memo, so he's steeling himself for a massive bill related to a future organ transplant.
Sarah Eide hasn't given the million-dollar hospital bill her family will receive much thought. She's too concerned over the health of her newborn child, Austin, who has spent the first 140 days of his life in a Sacramento hospital.
Aaron Stahl racked up his $1.3 million hospital bill last year after a car wreck. He wants to pay, but then again, he works at a Burger King in Rancho Cordova.
"This is not what I want to leave my family if I don't make it through," said Showalter, a married father of four young children.
Northern California hospitals save people like Showalter, Austin and Stahl every day. But cases like theirs – complicated procedures that can require months in the hospital – have become frighteningly expensive, with associated costs rising much faster than prices for routine care.
The number of Northern California hospital stays resulting in charges of $1 million or more rose sevenfold in the past decade, from 430 in 2000 to almost 3,000 during 2010, according to a Bee review of new data from the Office of Statewide Health Planning and Development.
Most of those bills will be lowered significantly – up to 80 percent – following negotiations between hospitals and insurers. Even then, they will usually still cost more than a typical Sacramento home.
Patients generally pay a small portion of million-dollar bills, but even that can leave them penniless. A recent national study in the American Journal of Medicine using 2007 data found that medical bills were a major factor in two-thirds of bankruptcy cases.
Fees not paid by patients are largely borne by society, as insurers and hospitals spread costs across customer pools.
It's a hefty tab. Cumulatively, charges associated with Northern California million-dollar hospital stays in 2010 came to $5.2 billion. That's 7 percent of all hospital charges from two-tenths of one percent of all hospital patients.
Northern California hospital officials say they are aware of the fallout caused by massive bills, and try to find solutions for patients to pay them. But they contend they can do little to reverse the trend.
"The cost of a life saved is really high," said Dr. Adams Dudley, professor of Medicine and Health Policy at UC San Francisco.
Health care reform could lower premiums by expanding the insurance pool, but may do little to deter large hospital bills, said Patrick Johnston, president of the California Association of Health Plans.
"The cost trends are a problem we all need to work on," he said, "but the challenge is big."
Patients receiving large hospital bills vary in terms of age, race, and diagnoses, but usually share this common trait: Something horrible happened to them – a disease or injury – that sent them to the hospital for weeks or months without interruption.
Nearly all of these patients were kept alive by a small army of hospital staff and the latest technology, resources that become more expensive as salaries rise and better equipment comes to market.
Dr. Robert Pretzlaff, chief of Pediatric Critical Care Medicine at UC Davis Medical Center, cites the example of 4-month-old Austin Eide. Austin has spent his life hooked to costly machines, surrounded by well-paid, skilled nurses and doctors.
"How could you have saved money?" Pretzlaff asked after detailing Austin's care. "I wish I knew."
A difficult, costly beginning
Austin was born with a severe case of congenital myotonic muscular dystrophy, which causes muscles to waste away. His mother didn't know she carried the disease, and didn't learn anything was wrong until Austin was born at Mercy San Juan Medical Center.
"All of the ultrasounds were completely normal," Sarah Eide said. "They said we probably would not need a lot of newborn clothes, because he was going to be a big baby."
After birth, Austin's lungs were too weak to draw air. He was transported to UC Davis Medical Center, where his doctors hooked him to an oscillating ventilator, a machine that simulates the effects of panting to keep lungs inflated.
Austin also underwent cooling therapy, as doctors induced hypothermia to reduce the amount of oxygen needed by his brain.
Such drastic intervention required constant, expensive monitoring of Austin by nurses and doctors.
After eight days, Sarah Eide was able to hold her son for the first time, but there were more setbacks. His lungs collapsed twice, and he needed to undergo surgery on his diaphragm.
Austin has been in the UC Davis neonatal intensive care unit for 138 days. Hospital officials have not yet tabulated his bill, but confirm that it will be more than $1 million. He likely passed that mark months ago.
Patients incurring million-dollar bills in 2010 spent a median of 64 consecutive days in the hospital.
Austin's case is unusual, but far from unique. About 21 percent of all million-dollar hospital bills in Northern California during 2010 went to the parents of newborn babies.
"A quick way to bankruptcy is to give birth to a sick child," Dudley said.
Sarah expects to take Austin home sometime this month, though he will remain on a ventilator at their house for several hours a day.
Her husband, Brett, has private insurance, she said, and she hopes it will cover most of Austin's hospital bill. Her family expects Medi-Cal, the state's insurance program for the poor and disabled, to cover other costs.
Sarah plans to quit her job as a secretary to take care of Austin, and expects tough times, though she is grateful for the care Austin received. "I'm sure that when the bills come in, it will be something else to worry about," she said.
Debt imposes big strain
Bradley Showalter also worries about his children, and the mounting bills that are affecting their lives, but he is the one who is extremely ill.
On a recent Tuesday, Showalter, gaunt and pensive, studied the latest report from his doctor, hands shaking as he described the wait for a liver transplant – and the estimated $800,000 hospital bill that will come with it.
A few feet away, Bridget, one of Showalter's four children, competed for his attention, playing peekaboo and talking in the rapid-fire, slurred rhythm of a bright 2-year-old.
"It's definitely a strain," Bradley Showalter said. "I don't have the money to pay all these bills."
Showalter, 28, started feeling pain in his side in April 2010. He went to the hospital, thinking he had appendicitis. Instead, he was diagnosed with a rare liver cancer that doesn't respond to chemotherapy.
He stayed in the hospital two weeks, which cost $50,000 – a bill that remains unpaid. He didn't have insurance because he had lost his job as a construction manager and had taken work at a gas station. He earned too much to qualify for Medi-Cal but not enough to purchase his own insurance.
Doctors told Showalter he would need a transplant to survive.
Such transplants are commonly associated with million-dollar hospital bills, particularly if there are complications. The average initial cost of a liver transplant grew by 85 percent from 2002 to 2011, to $600,000 nationwide, according to the United Network for Organ Sharing.
The pain from Showalter's cancer became debilitating soon after his first hospital stay, making it impossible for him to work. Declared medically disabled, Showalter finally qualified for Medi-Cal.
Medi-Cal is often stingier than private insurance – toward hospitals and patients – and it doesn't cover the full cost of the painkillers and other medicine Showalter must take each day. His wife, Nicole, an on-call pharmacy technician at Kaiser Permanente, pays most bills for his medications.
Showalter's doctors assure him that his financial status won't hurt his chances for a transplant, but he worries the costs will be too high, bankrupting his family.
"I'm grateful I'm alive," he said. "They say I should get in under the gun. I really just wish I had some real insurance."
Patient to pay 'as much as I can'
Aaron Stahl doesn't have insurance – real or otherwise. He will likely never fully repay his $1.3 million hospital tab.
The tragedy that led to the bill was Stahl's fault: He was driving home drunk from a St. Patrick's Day party a year ago and crashed into a tree.
Stahl suffered a traumatic brain injury and was flown to UC Davis Medical Center, where doctors put him into a coma for two weeks. No one else was injured in the crash, he said.
Like Stahl, almost half of Northern California patients who recently incurred million-dollar charges suffered an injury, though that is not always their primary reason for needing care.
Also like Stahl, about two-thirds of patients with million-dollar charges spent at least four days hooked to a mechanical ventilator.
Stahl deeply regrets his actions before the wreck, but said the trauma served as "a wake-up call." He now attends college, hoping to become a physical therapist.
"I'm working and going to school. I'm not drinking," he said. "Once I start making money, I'll pay them as much as I can."
Taxpayers will cover $200,000 of Stahl's bills through a county indigent health program, a "last resort" option for uninsured patients, he said. Sacramento County recently modified the program to cut costs and UC Davis has "not received any payment for services provided (through the program) since September 2009," hospital spokeswoman Carole Gan said.
UC Davis offers a charity care program for patients like Stahl that discounts charges based on income, Gan said. She couldn't specifically discuss Stahl's case because he didn't sign a release.
Stahl realizes that some may be mad that society pays for much of his care; he's mad at himself, too. "No one can say anything bad about me that I haven't already said myself."
Number of huge bills to grow
Several hospital officials and health experts said they expect the growth in million-dollar hospital charges to continue, though it may slow from the blistering pace set during the past decade.
An aging population will continue to need expensive care. More people, due to age or income, will be put on government health insurance, which many doctors increasingly refuse to take, leading would-be patients to postpone care until they must go to the hospital.
"We're the most expensive place to receive care," said Jan Emerson-Shea, vice president of the California Hospital Association.
Physician and nurse pay grew much faster than pay for other occupations during the past decade, a trend that likely will continue as competition for skilled workers remains strong, pushing up costs. Hospitals also recruit physicians by improving infrastructure.
"You can't keep a doctor if your hospital doesn't have the latest technology," said Scott Seamons, a vice president at the Hospital Council of Northern and Central California.
Hospitals occasionally collect millions from a few wealthy, uninsured patients, some from foreign countries, said Dudley, the UCSF doctor. Lowering charges would undermine that strategy.
Finally, patients usually can't shop around or haggle over life-saving care. Many will accept any cost to keep themselves or their children alive, said Anthony Wright, executive director of Health Access California.
"People are very grateful," he said. "They want to pay what they can. It's just at a certain point, the amount they owe doesn't match what they can repay."