Sometimes going to prison can be an unfortunately rational health care decision.
A 41-year-old man who had been incarcerated came to see me recently. While in prison he got in a fight, which led to a CT scan. He hadn't broken anything, but the scan did surreptitiously show two aneurysms. Both were in his hepatic artery (the artery that feeds his liver).
They were small, so the doctors kept an eye on the aneurysms without doing surgery. But the next time they checked, they had nearly doubled in size.
He was referred to a surgeon at a different hospital than the one I work at, and underwent an angiogram, to see the aneurysms better. The surgeons there said that he was sure to die if they did not intervene, and that they should schedule a surgery within the coming weeks.
I think this patient would be the first to admit that he had made numerous mistakes in his life.
Fortunately for him (or so he thought) he was released from prison one week later. When he returned for his pre-op visit, though, he was told that since he'd been released from prison, he no longer had insurance to cover the operation.
He asked what he should do. The told him to figure out how to get insurance.
I think this patient would be the first to admit that he had made numerous mistakes in his life. And he had paid a significant price for them. He truly was ready to make changes, to live positively, to help those around him. But, not knowing what else to to, it occurred to him that the easiest way to get the care he needed would be to get back in prison.
The next week, he went to a department store and, making sure a security guard saw him, pocketed some moisturizing cream. He looked up at the guard, smiled, and walked out.
After he was arrested, he wrote a note to the judge saying that he needed to get back into prison for a year, to get an operation. He told me the judge said "I'll give you 14 months, go get your surgery."
A recent study showed that out of over 2,300 bankruptcy filers in the United States in 2007, greater than 60 percent of them were caused at least in part by medical illness. It is hard as a physician to watch patients and families who are scared, facing these difficult times in their lives, also knowing that they are going down a pathway to bankruptcy from which they may never recover.
There are those that feel that everyone should have full medical care provided regardless of age or socioeconomic status, and a single-payer (government) system would be best suited for that. Others argue that this would be both too expensive and too inefficient, and would lead to even higher costs than already exist for healthcare. Perhaps costs could be better controlled if patients had skin in the game, and had to make choices about what care they would like with some responsibility for paying for the treatment they receive.
In my own field, transplant surgery, patients have to be insured to be eligible for transplantation. This is generally not a problem for patients with kidney failure, as anyone with a work history becomes eligible for Medicare regardless of age or disability status.
Any patient with end stage liver disease who does not have insurance (and is not eligible for Medicare) has the option of trying to qualify for state-funded Medicaid (which includes demonstrating both poverty and disability), stealing moisturizing cream from a department store, or dying.