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."

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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.