John Haller, 91, yearns to resume the chores around his longtime Santa Rosa home: cutting grass, tidying the yard and tending his tomato plants.
"I have a better appetite and I sleep better" when working around the house, said Haller, a thin man who wears glasses and a hearing aid.
A sign by the front door of his single-story home for half a century says "Isten hozta," or "welcome" in Haller's native Hungarian tongue.
A massive oak towers over the house on a little-traveled road across the grassy plain that affords wide-open rural views southwest of the city.
Haller, a retired builder who was diagnosed with bone marrow cancer early last year and hurt his back in a fall in June, is fortunate to be at home, with a nurse, physical therapist and social worker bringing care to his doorstep.
He's one of 200 patients enrolled in Sutter Health's Advanced Illness Management program, called AIM, established locally in 2012 to keep chronically ill patients out of hospitals and rein in runaway costs that threaten to cripple Medicare, the nation's health care system for 49.4 million elderly and disabled Americans.
"It's breaking the bank," said Dr. Brad Stuart, chief medical officer of Sutter Care at Home, which includes AIM.
Medicare spends about $77.5 billion on chronically ill people in their last two years of life, with more than half of it ($40.3 billion) in the last six months, when the cost of hospital care skyrockets.
In Sonoma County, Medicare payments for a chronically ill patient in the last two years of life averaged $72,407 in 2010, including $37,575, or 52 percent, in the last six months, according to the Dartmouth Atlas Project, which tracks Medicare's end-of-life spending.
Overall, Medicare payments to people in the last year of their lives accounted for one-fourth of the program's expenditures for the elderly, a rate that changed little between 1978 and 2006, according to a report in 2010.
That report by the journal Health Services Research noted that the "existing patterns of care do not meet the needs and preferences of terminally ill patients."
Experts say there is a profound disconnect between how the health care system works and concern over its costs.
Modern medicine, at least in the public's perception, offers the prospect of working miracles through pharmaceuticals and high-tech interventions to prolong life.
And in a culture that generally fears death and avoids talking frankly about it, many people — and their physicians — opt for aggressive, high-cost treatment until the end.
Suggestions of rationing or curtailing care in the world's richest nation can prompt talk of "death panels" sentencing elderly loved ones to an early demise.
But there's a problem, said Stuart, who has worked in private practice, hospitals, emergency rooms and hospice, with pouring billions of dollars into treating seriously ill patients who have a prognosis of a year or less.
"It doesn't keep people alive," he said.
Nor is death in a sterile, impersonal hospital intensive care unit, connected to life-support devices, what many people want.
Two-thirds of Californians said they preferred a "natural death" should they become seriously ill, and only 7 percent said they would like "all possible care to prolong life," according to a survey reported last year by the California Healthcare Foundation.