Check Please

Here are ballpark cost estimates for the crisis.

• $40,000 for psychiatric hospital.
• $700 - $4,000 per month for group home and day program. The range is so wide because we haven't seen any bills, but we'll eventually get monthly statements. For now, those are Google-based estimates of typical costs for group homes and assisted living. Chelsey's placement is probably near the upper end because of the 24-hour care.
• $200+ per month is the portion of her SS disability check that Chelsey gets to keep now that she's in a group home.
• $0 has been our out-of-pocket healthcare cost for this crisis. In fact, our expenses have gone down as the group home has picked up her food, clothing, and daily living expenses.

Chelsey's lifetime medical costs prior to the mental health crisis were over $2 million, which was covered by employer insurance until she was 18. We guesstimate that our out-of-pocket share has been roughly $150,000 - $200,000.

Those are the raw facts. Reflecting on them raises thorny issues for me. 

• The average U.S. income is about $30k, so Medicaid paying for the hospital required the equivalent of one person working full-time and turning over all gross income for one and a third years. Alternatively, you could think of it as about two average people giving up their entire retirement savings to get Chelsey the hospital care she needed for a month. Is that social justice? Is that sound government and wise stewardship of the world's resources? I don't know.

• Similarly, Chelsey's ongoing group home (conservatively estimated at $3k/month or $36k/year) requires the equivalent of one person working full-time more than a year and turning over all gross income to Chelsey. Chelsey's current care requires compassion and constant monitoring, but not advanced medical expertise. The workload if she stayed home would be comparable to tending a newborn or toddler with frequent bursts of medical monitoring. That's a heavy burden, but we don't generally tax others to give new mothers relief from their load. We've concluded that we could not handle her on our own and also earn enough to survive right now, and we certainly could not do it without sacrificing pretty much every other part of life. Still, does that conclusion automatically make her costs somebody else's responsibility? 

Why should Chelsey or her family get a disproportionate share of others' earnings? Is she worth more? Is investing in the principle of caring for the disabled what makes it wise for society as a whole to provide such safety net programs? 

I don't know the answers to such questions, but they trouble me. The programs exist already for better or worse, we've already paid taxes to support them, and we'll use all legitimate tools available to help Chelsey. Still, I support drastic reform in our entitlement programs, as well as thoughtful discussion about how to prioritize our healthcare investments. Oh, and serious attention to how to cut costs through competition and more direct consumer cost sharing. By the way, arguing against the government's big role in welfare is not the same as arguing against welfare programs. People can be compassionate, charitable, and anti-government.

What kind of family and community support systems might emerge if she did not have Medicaid? In our case, we might have asked Bo to forego her future plans, relied on family more for help, or declared bankruptcy after using all retirement savings. Perhaps our churches might have developed efficient support networks by now if Medicaid were not in place. Perhaps our families and communities would be stronger as a result. Some outcomes for individuals would undoubtedly be worse - perhaps Chelsey would have died, received worse care, or stayed in a manic episode without relief. Those kinds of bad individual outcomes used to happen, and the current system does not always prevent them today.

The current system may even foster worse societal and family outcomes in the long-run. I wonder at times if the risk of such outcomes at the individual level would be preferable to the current approach. I wonder about  justice in resource allocation, individual rights vs. collective good, and the role of government. I honestly don't know, and I recognize room for reasonable people to strongly disagree. Naturally, I wonder about those things only in the abstract for the long-term. In the short-term, I act rationally in the world as it is and use the resources available to me to best help Chelsey and our family. We felt strongly that this placement was best for Chelsey, not only in terms of getting the safe care she needed, but also for her to have a life with interaction and stimulation.  We deeply appreciate the resources that have made this possible.