I learned a lot about the cost of health care when I had a hybrid general surgery practice in California 's rural San Joaquin Valley. My practice consisted of uninsured women with breast cancer combined with a smaller percentage of cosmetic patients whose cash payments for "vanity care" subsidized the treatment of women unable to pay for needed medical treatment.

Although patients seeking cosmetic services tend to be healthy, I evaluated them like any other patient. I asked about medical history, allergies, medications and genetic disorders.



Upon questioning Sherry S., a pretty 46-year-old seeking wrinkle relief, I learned that four of her immediate family members had been diagnosed with breast or colon cancer before the age of 50. Alarmed, I asked why she had not had the recommended screening mammogram for more than four years.

She said that she knew already that her risk for developing breast cancer was likely higher than that of most women.



"But I don't have insurance," she replied.



A screening mammogram could be obtained for about $90 and was discounted or free at local facilities every October for "Breast Cancer Awareness Month."



She smiled when I proposed a deal: if she were to get a screening mammogram within sixty days of her treatment, I would offer a discount on what she paid me for cosmetic services.



"I'll think about it," she said, then shelled out over $400 for BotoxTM injections that took me ten minutes to administer.



Five months later, when she returned for her next wrinkle treatment, she reported that she still had not obtained a mammogram.

I encountered patients who gladly paid upwards of $1000 in cash for laser hair removal treatments. The paperwork filled out during their initial consultation asked them to indicate whether or not they had health insurance.

Several hair removal patients reported being covered by Medi-Cal, the government funded health coverage for California 's low-income population.

A friend of mine sells private health insurance plans. He told me of the 39-year-old father of two whose family was quoted a monthly insurance premium of $250.



"Are you kidding?" he said, refusing the coverage. "That's almost as much as my boat payment!"



When serving in the Rural Health Center in my community, my colleagues and I offered free or discounted care for a large number of patients. Many were covered by Medi-Cal or one of dozens of state programs paid for by the taxpayers of California.



The following items were commonly seen on patients or carried by their dependent children, who were also covered by subsidized programs: Cell phones and "BlackBerry" PDAs, including just-released models with a price tag of $400, plus an ongoing monthly service fee of $65-$150

iPods and portable DVD players

GameBoys and handheld electronic games

Artificial fingernails requiring maintenance every two weeks at a cost of $40-$60 per salon visit

Elaborate braided hair weaves, $300 per session plus frequent maintenance

Custom-designed body art, including tattoos covering the entire torso, neck and arms, as well as body jewelry piercing every skin surface imaginable-and a few unimaginable ones. Custom tattoo work, particularly the "portrait-type" and "half sleeve" art popular in this area, runs from $100-$300 per hour and can require up to 20 hours of work, depending on the complexity of the design.

[Author's note: in three years, I performed over a dozen operations as the result of complications related to infected or abnormally healed body piercings. Breast abscesses were the most common pathology, followed by cauliflower-shaped keloid scars that interfered with function. Blood-borne diseases can be contracted during amateur and prison tattoos and piercings, and patients self-reported Hepatitis B, Hepatitis C and HIV infections. Treatment of the complications of body art among my patients was largely covered by Medi-Cal or left unpaid.]

From the office I shared with another doctor at the clinic, I had a clear view of the patient parking lot. It was not unusual for me to see clinic patients drive away in late model SUVs or cars customized in the style popular in my area. I was given an education about the after-market accessories I saw daily, including "mag" wheels, chrome trim, spinning hubcaps and fancy custom paint jobs. Gasoline prices were particularly high in central California at that time.

I overheard patients and their children chatting as I wrote in their charts. Many had an excellent command of the plotlines of cable television shows aired only on premium channels. Basic cable in my area cost over $50 per month, with premium channels extra.



I also overheard the front desk clinic staff members explain politely to angry patients that they did, in fact, have to make $5 co-pays for an office visit or meet their $20 "Share of Cost" on a $600 bill as required by Medi-Cal.



Like many of my colleagues in rural communities with few resources, I did care for patients who actually lived in poverty. For them, luxury meant keeping the utilities on and having clean clothes for a rare visit to the doctor. In California 's Central Valley , "dirt poor" is not just a phrase. But these patients, who rewarded me in ways that don't fit in the lines on any tax return, were outnumbered by others who considered health care a lower budget priority than decorated skin and expensive toys.



Individuals in this country have a right to decide how -- and how not -- to spend their money.



But that right does not include accepting entitlements without sharing responsibility. Doing so contributes to the high cost of care that burdens every unsubsidized patient.



If individuals prefer to buy luxury items rather than pay for their healthcare needs, that preference should not be rewarded while taxpayers struggle to foot their own bills.



Dr. Linda Halderman was a Breast Cancer Surgeon in rural central California until unsustainable Medicaid payment practices contributed to her practice's closure. She now serves as the healthcare policy advisor for California's Senator Sam Aanestad while continuing to provide trauma and emergency services in rural communities.