Behind the Health Debate: Cancer patient leaves toughest question unasked (Part 2 of 3)

Second of three parts

Tony Andrade has yet to ask the tough question: Is he going to die?

Andrade knows enough about cancer – people in his life have died from the disease – to realize his situation is grave: A tumor was removed from his bladder, but more cancer was found. Now he has to figure out whether, without private health insurance, he can get the additional surgery he needs.

Now, on this fall afternoon, Andrade and his mother, Sandy Cooper, sit side by side on the living room couch in her south Sacramento home.

"Everybody dies," Andrade tells her. "We all have to go someday. … The question is, will I die before my time?"

"Don't say that," Cooper snaps.

Cooper removes her glasses to blot her eyes, gets up and disappears into the darkness of a nearby room. The summer has been almost as hard on her as on her son.

The drops of blood Andrade, 47, discovered in his urine back in June were only the beginning of what has become a monumental crisis for him and his family.

Without health insurance, Andrade is relying on the Sacramento County Medically Indigent Services Program, a safety net for the working poor. He is at the mercy of the county bureaucracy and a program that's under dire financial stress. Sacramento County has closed health clinics, reduced services, cut staff and tightened eligibility rules to further reduce its caseload.

Now, the county is considering further cuts.

For Andrade, those cutbacks are more than minor inconveniences. He has trouble reaching his county doctor to talk about his diabetes and upcoming appointment; she is on indefinite leave, a county spokeswoman will later explain. On the day he is to see her, he arrives to find the county clinic on Del Paso Boulevard closed.

Cancer treatment isn't cheap, and Andrade and his mother are afraid the county could run out of money for his medical care – or that he could be dropped from the program before he gets his surgery.

"We're getting help now, (but) what about tomorrow?" Cooper asks.

Three thousand miles away, the health care overhaul proposed by congressional Democrats would require every American to obtain health insurance and allow most of the uninsured to purchase policies through an insurance exchange, a government-run marketplace that would guarantee minimum coverage. Those unable to afford coverage on their own would benefit from subsidies funded by new taxes on businesses and the wealthy.

Proposals also would vastly expand Medicaid, known as Medi-Cal in California, allowing more of the working poor to qualify.

Critics challenge the plan. Would folks really get the quality care they need? And would premiums in the exchange be cheaper than in the existing free market?

They also raise the specter of Big Brother and rationing. Do we really want the government more involved in our health care decisions?

Andrade was thankful to be approved for county indigent coverage in July, but now he is at the mercy of forces he cannot control. He has little choice in doctors or the treatment. County case managers make most of those decisions for him.

Ultimately, what Andrade really wants is private health insurance and the ability to go to a doctor anytime, without fear of another expensive bill.

That is not his reality on this September day when he is taking the turns in his life as they arrive.

Over the years, Andrade has struggled with a raft of health problems – a challenge for even the best- insured to manage. The former Hiram Johnson High School linebacker is technically obese, although he camouflages his girth with loose-fitting T-shirts. He has type 2 diabetes, diagnosed two years ago by a Kaiser doctor, and his county doctor has put him on a challenging regimen of insulin, drugs and healthier living.

As the wait for cancer surgery drags on, one cousin fears Andrade has given up.

"There's a lot of anger," says Brenda Garcia. "Sometimes he just disappears."

In late September, the county and Capitol Urology Medical Group finally come to an agreement over their contract, and Andrade's second surgery in as many months is back on. His spirits rise.

He banters playfully with his mother as they wait for his pre-operation appointment in Folsom.

A childhood friend has coached him about the questions he should ask this time, and he runs through his handwritten list:

What type of cancer?

How long will surgery last?

What is recovery time?

In the case something goes wrong … what is Plan B?

He learns his cancer is an adenocarcinoma, a particularly worrisome variety when it involves the bladder because it is so invasive. Only 1 percent of bladder cancers are adenocarcinomas, according to the American Cancer Society.

The doctor will use a robotic tool, the da Vinci Surgery arm, to snip away the cancer from Andrade's bladder and stitch up the wound. If all goes well, the surgery itself will take about two hours and recovery will be hours more.

The doctor won't know how much of the bladder will have to be removed until he takes a look. If he needs to remove it, the surgery would be complicated by the need to rebuild Andrade's bladder using a section of his intestines. Or fit him with an artificial bladder.

Neither option sounds good to Andrade.

But once again, he puts off the bigger question: Will this rare form of cancer eventually kill him?

The following week, at Sutter General Hospital, Andrade is surrounded by family and friends. His 23-year-old daughter brings his only grandchild, Nevaeh – "heaven" spelled backward – to his bedside.

Nurses are effusive and chatty. Consider this a five-star hotel, one tells him. His mother wonders out loud whether her son is getting special treatment because a reporter and photographer are in the room.

"Usually, when you're uninsured, you get treated like a second-class citizen," Cooper says.

In the last moments before surgery, mother and son try to reassure each other that everything will be all right. Both confide they have their doubts.

Andrade's gurney is wheeled into the hall. His mother walks alongside. She is trying to think good thoughts and picture her son on the other side of surgery.

"Everything's going to be all right," she tells him. "I'll be right here when you wake up. … I love you."

Tightly wound with worry throughout the weeks of waiting, Cooper unclasps her son's hand, leans into a nearby wall for support and unravels.

"He's not going to die," she says, her lips trembling. "He's not."