Ethan McKenzie didn't have to read Dr. Rob Stone's article "Health care vs. wealth care in America" to know how screwed he is by the U.S. "health-care" industry. What led the 59-year-old to share his story with The Bloomington Alternative was the timing, along with the line, "Self-employed and a pre-existing condition – in America today with those two strikes, you are out."

Until a month before Stone's article was published on Sept. 17, the IU employee had been self-insured with one costly but manageable pre-existing condition. Five days after he read the piece, McKenzie learned he now has two. It will be a few weeks before he learns if he has prostate cancer. But there's no question that until age 65 and Medicare eligibility, he's an economic hostage held by people who would benefit by his premature demise and have no twinge of conscience if it happened.

"Being self-insured with pre-existing conditions makes me feel like Troy Davis," he said, "an innocent man facing a death sentence. But in my case, a swift execution could be the preferred outcome."
"As men age, both benign prostate conditions and prostate cancer become more common." - National Cancer Institute
McKenzie, who asked that his real name not be used, moved to Bloomington for personal reasons more than a decade ago. A college graduate, he was lucky enough to land a "part-time job" at IU with a wage that comfortably fits his ascetic lifestyle. Health insurance was the one exception. His part-time status meant and means he receives no benefits.

The 80-20 major medical policy he purchased independently in the early 2000s had a $1,000 deductible and $6 million lifetime limit on care, he said. It cost a little over $200 a month, and the "maximum out-of-pocket expenses" were within his meager budget.

A lifelong exerciser, McKenzie is in good health and, until 2009, had never met his deductible, he said. That year he had a successful hip replacement and was reasonably happy with the way his insurance worked. The whole process fed his cynicism about the health-care industry overall, but his body worked.

***

When McKenzie's insurance company notified him this summer that, "due to rising health care costs," his premium would rise almost $200 a month to $749, he called his agent for alternatives. That's when he got the first of a series of bad-news pieces.

While much had been made about President Barack Obama's Affordable Care Act of 2010 eliminating insurance companies' power to deny coverage due to pre-existing conditions, the agent told McKenzie that the provision would not take effect until 2014. No fan of "ObamaCare" anyway, McKenzie said he never bought that "solution" to his predicament.

"As I understand it, even when the new pre-existing condition clause takes effect, nothing will prevent insurance companies from charging more for those who have them," he said. "All they have to do is make it prohibitively expensive for those of us with pre-existings to achieve the same result – that is, to deny us care."

His agent found a policy with another company with a lower premium and slightly higher deductible, McKenzie said. But it would exclude his hip from any coverage, related to the replacement or otherwise. To insure that particular joint for, say, injuries from a bicycle accident, he would have to take out a separate policy on that joint.

The new policy was a deal he couldn't refuse, but first he had to make sure he had no unknown pre-existing conditions.

***

When McKenzie turned 50, he went to a doctor he trusted as a "straight-shooter" and asked what a man his age should do in terms of preventive care. He began the conversation saying he knew regular prostate exams were first on the list. To his amazement, the physician said he was wrong.
"Using the PSA test to screen men for prostate cancer is controversial because it is not yet known for certain whether this test actually saves lives." - National Cancer Institute
Not only did the doc tell him that prostate screening, and in most cases treatment, was a waste of time, he retrieved a medical book that lent credence to the point. There was not a scintilla of scientific evidence to show that either screening or treatment adds a single day to the life of a prostate cancer victim, he said. In fact, Bloomington Hospital had been persuaded to stop offering public prostate screenings for those reasons.

"The doctor said treatment can be worse than the disease," McKenzie said. "It can leave you incontinent or impotent."

So, when McKenzie had some routine blood work this summer before changing insurance companies, he had a context for the news that his prostate specific antigen (PSA) level had risen.

According to the National Cancer Institute, "PSA is a protein produced by the cells of the prostate gland." While it is normal for men to have PSA in their systems, elevated levels can be produced by sexual activity, bicycle riding, inflammation and/or disease, including infections and cancer.

Initially McKenzie thought his indoor bicycle trainer had caused his PSA spike, especially since his personal physician found no abnormalities on an exam. Neither did he display any prostate symptoms, including frequent urination and reduced stream flow.

A second blood test, however, prompted a visit to a urologist, he said, as well as a crash self-education course on PSA and prostate cancer.

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The first step in McKenzie's quest to understand his 5.5 PSA reading was googling "prostate cancer Bloomington Hospital." To call the results unsatisfying would be an understatement.

"I didn't find anything on there that was useful or educational at all," he said. "It was all public relations."
"Moreover, it is not clear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments." - National Cancer Institute
Indeed, the IU Health Bloomington Hospital Web page titled "Prostate Cancer" provides little specific information for patients beyond this: "In 2006, nearly 150 local men experienced prostate cancer diagnosis or treatment with IU Health Bloomington Hospital. Fortunately, national statistics show that nearly 86 percent of all prostate cancers are discovered while they are either localized (confined to the prostate) or regional (nearby). The five-year survival rate for men diagnosed with prostate tumors discovered at these stages is 100 percent."

The page has one link to a five-year-old news release touting a radiation treatment technology called intensity modulated radiation therapy, which, McKenzie assumed, is a money maker for Bloomington Hospital. Another link to a site proclaiming the IU radiation centers among the nation's best was broken.

"Other than that, they say to call them," McKenzie said. "They ought to call it IU Wealth Bloomington Hospital."

***

For unbiased information, McKenzie had to venture beyond his community to a National Cancer Institute (NCI) Fact Sheet on PSA tests.

"It is normal for men to have a low level of PSA in their blood; however, prostate cancer or benign (not cancerous) conditions can increase a man’s PSA level," the Fact Sheet says. "As men age, both benign prostate conditions and prostate cancer become more common."

The most frequent benign conditions are inflammation and enlargement of the prostate, it says. But while there is no evidence that either causes cancer, it's possible to have one or both and to develop prostate cancer.

In terms of raw numbers, McKenzie's 5.5 PSA isn't that high. The NCI says 65 to 75 percent of men with PSAs in the 4.1–9.9 range do not have prostate cancer. Of course, 25–35 percent do.

And using PSAs to predict cancer is uncertain science, to say the least. "There is no specific normal or abnormal PSA level," the NCI concludes. "In addition, various factors, such as inflammation (e.g., prostatitis), can cause a man’s PSA level to fluctuate."

The NCI addresses directly the controversies over prostate screening and treatments:
"It is important that the benefits and risks of diagnostic procedures and treatment be taken into account when considering whether to undertake prostate cancer screening." - National Cancer Institute

"Using the PSA test to screen men for prostate cancer is controversial because it is not yet known for certain whether this test actually saves lives. Moreover, it is not clear that the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments. For example, the PSA test may detect small cancers that would never become life threatening. This situation, called overdiagnosis, puts men at risk of complications from unnecessary treatment.

"The procedure used to diagnose prostate cancer (prostate biopsy) may cause harmful side effects, including bleeding and infection. Prostate cancer treatments, such as surgery and radiation therapy, may cause incontinence (inability to control urine flow), erectile dysfunction (erections inadequate for intercourse), and other complications. For these reasons, it is important that the benefits and risks of diagnostic procedures and treatment be taken into account when considering whether to undertake prostate cancer screening."

That language echoes almost to the word the advice McKenzie received when he asked a decade ago. "It doesn't sound to me like they know any more today than they did back then," he said.

***

The questions are more than academic for McKenzie. While his urologist did not detect any cancer through an office exam, he noted some prostate enlargement. And a few days after starting on antibiotics, pains that he had been experiencing disappeared, suggesting that there had been inflammation, most likely caused from his exercise routines.

But after a month on the drugs, McKenzie's PSA increased slightly, from 5.5 to 5.7, which his doctor called "essentially the same number." He is "studying up some more on the pluses and minuses" before scheduling the recommended biopsy.

McKenzie doesn't have to study anything to know he's screwed financially until his 65th birthday and the Medicare eligibility it brings. With prostate issues in his medical record, he is now a wealth-care liability. His only option is to pay whatever "extortion" his insurance company charges.

His home, savings and everything he owns are at risk. If McKinzie had to stop working because of cancer, his quality of life would quickly approach that described by Stone in "Health care vs. wealth care in America," and swift death would be preferable.

"As Dr. Stone wrote, this is not health care," he said. "Prostate cancer is the least of my worries."

Steven Higgs can be reached at editor@BloomingtonAlternative.com.


Bloomington resident Sarah Ryterbrand, M.D., submitted the following advice to McKenzie and others in his situation.

"The late John Lee, M.D., who wrote extensively about women and progesterone, assembled a group of men in the Bay Area who survived prostate cancer (some for more than 20 years) using progesterone cream. This is an inexpensive method (within the public domain and therefore not controllable or research-financed and promoted by pharmaceutical giants) to offset some of the nasty estrogen metabolites, which are thought by some of us to be the genuine culprits in male and female reproductive organ carcinomas.

"I would suggest you put progesterone+prostate cancer into your search engine of choice."