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.
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.
I have personally taken care of a number of patients who did not want to put their family through the formidable weight of bankruptcy and opted for number three.
Even our veterans, who do have coverage through the VA systems, only have access to transplantation at five centers in the country. They are also held to stricter criteria about who is eligible for transplantation than those outside of the VA system. My general sense is the access to transplant is much less for vets than for those outside this system. Some of them might be better off going to the department store.
The Affordable Care Act will address some of these issues, at least striving to provide some sort of coverage to everyone, although given the resistance of many states and unclear plan regarding expanding Medicaid -- which as a system does require patients to be essentially bankrupt -- there will still be large gaps in coverage in many of the patient populations that may need it most.
Some say that many patients with liver failure have done it to themselves -- that their disease is the result of choices they made in their lives (including previous drug use that led to hepatitis C, or alcoholism). These diseases don't represent all patients that need liver transplant, but certainly a significant portion. But most people who think this way aren't the ones who have to go to a patient's room, look into his scared eyes while he is surrounded by his spouse and children, and tell him that he is going to die in the next few months and there is nothing we can do. "Actually, we could totally save you and give you another decade or two of life but unfortunately you don't have insurance, and it's your own fault, anyway."
When I was growing up, my dad (who went back to medical school when I was in third grade) used to regale my brothers and me with stories from the trenches during dinner. One story in particular stands out. The patient needed surgery, but he had no insurance. So the plan that my dad and his team hatched (sorry dad, hope you don't get nailed for this) was to have this patient go in front of the emergency room at noon that Monday (a convenient time for everybody), collapse, and complain of acute abdominal pain. He was quickly whisked into the emergency department, deemed to have an acute abdomen, and taken to the operating room for definitive surgery. As long as it was an emergency, the hospital had no choice but to offer the treatment.
With the current shortage of organs, though, a patient in need of a transplant who did this same thing wouldn't be so lucky.
I should tell you how the case of the lotion thief ended. I took him to the operating room, removed his two aneurysms, and replaced his hepatic artery and its right and left branches with reversed internal iliac artery from his own leg. Surgery went great, and he recovered nicely. I just hope he stays in prison long enough to get some follow-up care.
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