As a practicing endocrinologist, I write with heavy heart regarding your article on medical insurance ("Maryland braces for Supreme Court decision on health care reform law," June 19). Through the years of recession, several patients of mine lost their jobs and could not afford their office co-pays.

Unfortunately, among them were people with diabetes, high blood pressure and heart disease. Even those with insurance had high deductibles and had to meet the cost of an office visit up front. Increasingly, insurance coverage cannot be equated with medical care.

Many patients, burdened by medical bills, are skimping on care and cutting back on office visits. But one case stands out in my mind. This is a patient who worked a back-breaking job in a warehouse. When he could no longer lift heavy weights after developing severe diabetes that required Insulin treatments, he lost his job.

He managed to get medical assistance through the state. He has a primary care doctor, and since his diabetes was in such poor control he came to me for specialty care. By that time he had no home. His family didn't want him.

He was not using drugs — his drug screen was negative — and he didn't drink alcohol. He ate one meal a day if he ate at all. He had a cell telephone through an assistance program but no transportation to go anywhere.

He called a medical assistance cab to get to his doctors' appointments, but when he started living in the woods and moving in and out of shelters, he had no longer had an address to give to the cab drivers who picked him up for his doctor's appointments.

When I ran his blood tests, I discovered that his debilitation and severe loss of weight came not only from diabetes but also from a condition called adrenal insufficiency. Not only could I not reach him to tell him this, but I could not even send him a letter. When he finally called me, he told he could only talk a few minutes because his cell phone's reception in the woods, where he now lived, was poor.

I told him about his blood tests and asked him where I could call in his medicines. He did not know when he would have transportation to get to a pharmacy and asked if he would die without it. I told him he could indeed die and perhaps he should get to a hospital immediately.

Since that time I have been calling the hospital to which he promised to go, but apparently he never got there. I couldn't call social services about him because he didn't want me to, and I also did not know his exact location.

This is the state of so many patients in the United States today. Poverty feeds poverty. We live in a society where insurance is not enough. It should be backed up by shelter, transportation, access to communication and a support system that helps people who are sick and desperate.

My heart breaks for this man. I left India years ago, when excruciating poverty there overwhelmed and paralyzed even the most charitable folks who wanted to help. Today in my profession in the U.S., each day I sense the India I left.

For many Americans, this is certainly the Third World. As we wait for a decision about the Affordable Care Act from the Supreme Court, it's important to realize why medical insurance, even Medicaid, is small comfort to patients like the one I have described.

Usha Nellore, Bel Air