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Health Care Tour: “Seeking Patient-Centered Care”
View: Bob's Health Care Tour slide show
List of all Health Care Tour stops
Health care is the most complex issue facing our country. Issues like immigration need a little courage; issues like energy need a lot of commitment. Health care needs courage, commitment, understanding, insight and meticulous planning. It’s that complex and that important.
People are concerned about rising costs, access and quality. Many are convinced we need significant health care reform. Reform should improve quality, expand access, and control escalating costs.
Inglis conducted a comprehensive, fact-finding health care tour from February to October (75 tour stops in 9 months) in an effort to better understand how health care is being delivered and paid for in Greenville, Spartanburg, Union and our portion of Laurens County. Inglis met with patients and families, small and large businesses, physicians, hospitals and clinics, pharmacies and key government agencies in the Fourth District.
See below for a complete listing of stops along the Health Care Tour.
Health Care Tour stops (2008)
PATIENTS
- Many hard working individuals don’t qualify for Medicaid and can’t afford health insurance.
Chronic Disease Patient - Philip Raimondo, Sr.
- Insurance for chronically ill adults or those with pre-existing conditions is expensive and often unobtainable.
EMPLOYERS
Small Business – Wendell Jones Insurance Agency
- Small businesses don’t have the leverage to block negotiate lower insurance premiums and many can’t afford to insure their employees.
Upstate Chamber of Commerce Health Care Luncheon
- Large employers are seeking new and creative ways to improve health care and worker wellness while keeping cost down.
Mitsubishi Polyester Film Family Services Center
- This self-insuring company decreased its health care costs by creating a consumer-driven plan that combines health reimbursement accounts, 100% preventative care, and an onsite clinic and wellness center.
- Bigger is not always better. Mauldin changed to a smaller health insurance provider that offers greater benefits for less costs while incentivizing wellness for city employees and their families.
Small Business Roundtable - Spartanburg
- Providing health insurance is becoming increasingly cost-prohibitive for small businesses.
- Some small businesses have lowered premiums by introducing health savings accounts and high deductible plans.
Employer’s Perspective - Anderson Hardwood Floors
- U.S. companies that compete in international markets find themselves at a disadvantage competing with countries that have different cost structures to pay for health care.
PHYSICIANS
Primary Care Physicians – Carolina Medical Center
- Physicians are often forced to make care decisions based on financial considerations, including whether or not to take Medicare patients.
Greenville County Medical Society
- Physicians are concerned about the impacts of reimbursement rates, shortages of primary care physicians, and bureaucracy as they try to practice medicine.
Doctor Visit – Travelers Rest Family Practice
- Primary care is complex and demanding, providing a wide range of care.
- Medicare patients typically require 2-3 times more care for about 1/3 the reimbursement of an insured patient.
- Decreased reimbursements by all payers, increased administrative costs, and increasing malpractice premiums eventually forced this rural OB/GYN doctor to close his private practice.
Physicians’ Forums – Greenville and Spartanburg
- Physicians advocated overhauling the U.S. health care system around issues of patient-negotiated prices, limiting employer-based care, and whether or not to spread the risk of the few expensive health care users.
- Doctors suggested our health care system focus on wellness and prevention with premium discounts used to incentivize wellness.
- Many doctors don’t take Medicare and Medicaid patients because of negative profit margins due to low reimbursement rates. This is especially true of young doctors who graduate from med school with an average of $140k of educational debt.
Doctor for a Day – Spartanburg Regional Hospital*
- Many physicians find working for a hospital frees them to practice medicine, not business.
Jervey Eye Group
- Health Savings Accounts (HSAs) are difficult to use because providers do not have the tools, coordination or training to administer billing at checkout.
HOSPITALS
- Partnering with local physicians brings added medical resources into a hospital’s network while lightening the administrative load on doctors.
- Hospitals struggle to negotiate reimbursement prices when only one company has a virtual monopoly on the policies written in their state.
- Late payments, bad debt and a lack of prompt pay laws for insurance companies are resulting in cash flow problems for many hospitals.
- A shortage of nursing home beds keeps patients in hospital beds longer.
- Health information technology is improving care for patients and providers.
- Nursing shortages are due to a shortage of nursing faculty, not applicants.
- Hospitals are aggressively hiring physicians and expanding relationships to prepare for the oncoming manpower shortage in health care.
- Rising health care costs are attributed to a wide variety of factors.
- Not-for-profit hospitals use income that exceeds costs to upgrade services.
Bon Secours – St. Francis Hospital
- Hospitals expand their facilities and technology to improve medical quality outcomes and to stay competitive in the health care market.
- Many rural communities are at great risk of losing their doctors and hospitals due to limited volumes of patients and resources.
- Small hospitals are often forced to partner with larger health associations in order to enlarge their manpower pool for staffing, improve their purchasing power, and negotiate better reimbursement rates.
Emergency Room – Greenville Memorial Hospital
- ER staffs are stressed as they treat patients seeking access to heath care for a wide variety of needs other than emergency or trauma care.
- Patients with behavioral health needs are often uninsurable and have nowhere to go but hospital emergency rooms.
- EMS services are often used as a taxi service and the ER as the role of a primary physician.
Doctor for a Day – Spartanburg Regional Hospital*
- While Medicare Advantage plans have promoted tailored coverage for patients, the multitudes of plans have also caused much confusion among patients and providers.
SPECIALIZED PROVIDERS
- With 95 cents of every dollar going directly to patient care, Shriners hospitals epitomize practicing medicine, not administration.
- Quality imaging has become a standard of care expected by Americans.
- Cost of imaging equipment, physician self-referrals, and defensive medicine all play a role in the rising cost of diagnostic care.
Spartanburg Hospital for Restorative Care
- Long term acute care hospitals provide comprehensive medical services for complex medical conditions and rehabilitation needs.
- Mental and physical health care often related, but the payment systems are usually separate.
- Indigent individuals often have mental health problems, but are unable to get long term treatment.
- Medicare reimbursement levels for dialysis aren’t enough to cover costs. Dialysis clinics are forced to shift the costs to privately insured patients.
- Health care reform needs to focus on both physician and patient behavior.
Piedmont Orthopedic Associates
- Government regulations are decreasing the alternative opportunities for doctors to make income needed to offset low government reimbursements (by Medicare, Medicaid and TRICARE).
Home and Hospice Care - Interim Health Care Ride-Along
- Telemedicine is using technology to increase access and compliance while reducing costs in the home health care environment.
- With 85% of its patients covered by Medicaid, Medical school residents are needed to provide care to every patient.
- The center stays open until 8 p.m. and on weekends to help take pressure off emergency rooms and offer affordable, accessible care.
Roger C. Peace Rehabilitation Hospital
- Rehabilitation care enables individuals to get back to work and productive lives. Insurance plans often cap the number of days for rehabilitation below levels needed for severe cases such as traumatic brain injury.
Nursing Home Care - White Oak Management, Inc.
CLINICS
Walk-in Clinic - Exigent Wade Hampton
- Walk-in clinics trade affordable access to care with the continuity of care provided by a family physician.
ReGenesis Community Health Center
- Federally qualified community health centers use federal assistance to provide a sliding fee scale for the uninsured.
- Community health centers focus on outcomes and wellness education.
Greenville Free Medical Clinic
- Free medical clinics provide services without cost to low-income patients (100-200% of poverty level) by utilizing the volunteer services of physicians, dentists and pharmacists and donations of funds and supplies including pharmaceuticals.
- The majority of patients are from households with working members.
- Clinic models of care often focus on chronic disease care and education.
New Horizon Family Health Services
- Federally qualified community health centers balance Medicare, Medicaid, federal grants, insurance and self-pay to provide services at cost. Any funds for facilities improvement or expansion require fundraising.
- The health clinic model for primary care is proven to be effective and efficient. Providing multiple aspects of medical and dental care on site promotes compliance and a healthier population.
St. Luke’s Free Medical Clinic
- A safety net for the working poor, free clinics are shown to reduce their patients’ usage of the ER up to 75%.
Union Public Health Department
- The primary mission for public health departments is prompt dedicated response to incidents of contagious diseases.
- Public health is a community focal point for vaccines, family planning (birth control, pregnancy tests, prenatal vitamins), and STD treatment.
VETERANS
William Jennings Bryan Dorn VA Medical Center
- Although there is an increased need by veterans for mental health services, the number of beds in the psychiatry wing has been cut back due to a shortage of staff. Funding is available, but professionals are not.
- University of SC School of Medicine partners with the VA to train doctors while caring for veterans and their families.
Greenville VA Out-Patient Clinic
- VA patient interactions have nearly doubled since a year ago, resulting in increased use of nurses to see walk-in patients.
Charles George Veterans Affairs Medical Center
- Coordination is needed to provide more accessible care for veterans across state lines
PHARMACEUTICALS
Independent Drug Wholesaler - Smith Drug Company
- 67% of prescription drugs in the US are generics and are cheaper than generics in Canada or Europe.
- Drug price inflation in 2007 was 1.4% less than the rate of inflation.
- Independent pharmacies serve as point of access and provide individual education for patients on proper use of medications and DME.
- With 90% of business coming through 3rd party payments, overhead for billing and lack of prompt payments create serious cash flow issues.
Pharmaceutical Representatives Roundtable
- Pharmaceuticals can actually decrease health care costs for many conditions.
- New pharmaceutical drugs are very expensive to research and develop.
- Pharmaceutical companies provide millions in free and reduced-price medicines for community clinics and community-based care.
HEALTH INFORMATION TECHNOLOGY
Electronic Health Records – Allscripts Healthcare Solutions
- The average chronically ill patient sees 3.5 physicians regularly. EHRs can help physicians know what actions have been taken by others caregivers and improve quality, safety and cost savings.
- Of the 200+ vendors in health information technology, the top 5 produce about 90% of the products and the industry continues to consolidate.
- Technologies will continue to change and interoperability for those technologies will need to meet standards set by industry bodies.
Clemson’s “Hospitals of the Future” Project
- This national test bed evaluates innovative technologies being developed into the new standard of care for patient safety, caregiver environments, and health information technology.
- Government codes and regulations for hospitals are behind the times and need to adapt more quickly.
Doctor for a Day – Spartanburg Regional Hospital*
- Changes in health care technology abound. The struggle is implementing those changes into an organization – changing a culture.
- Electronic medical records can be challenging to implement, but are a useful and resourceful tool for being proactive in patient care.
INSURANCE
Insurance Agency – Walker Walker Higgins, LLC
- Insurance policy writers favor the HMOs and PPOs who have the power to negotiate lower reimbursements and therefore lower premiums.
BlueCross BlueShield of South Carolina
- As long as the total cost of health care increase faster than the size of a given population, the costs of health care will continue to rise.
- BCBS SC sees “increased capacity” as the biggest factor in health care inflation. When the capacity to treat a disease set among a population in a particular area is increased beyond the appropriate level, utilization increases with no increase in health status. Regional planning agencies could be used to determine appropriate needs and capacities.
- Fee-for-service medicine is seen as the fundamental structural problem causing the total cost of health care to grow. Revenues are increased by performing more services, not better care.
- On average, 14% of every health insurance premium dollar goes to administrative costs within the company.
BlueCross BlueShield of South Carolina Conference Call
- Medicare and Medicaid rates average 8% and 13% respectively below break-even costs for hospitals. Hospitals then seek higher reimbursements from private payers, who pay nearly 30% over break-even costs.
- The ability to utilize a capitation system of health care (paid per patient) requires a large scale of service providers and patients.
- Transparency in pricing doesn’t always work since people often equate higher costs with better quality.
- Insurance companies negotiate reimbursements with hospitals every 2 years and see their role as key in holding down inflation in health care costs.
- Medicare and Medicaid have the power to deny excesses in procedures, but don’t. Insurers who try are in danger of losing hospital contracts or litigation by the patient.
Corporate Benefits, Inc.
- Getting more people insured could lower premiums by spreading risk and reducing cost shifting.
- Wellness programs are needed. Insurance costs won’t decrease when claims consistently exceed premiums.
OTHERS
SC Dept of Health and Human Services
- In South Carolina, 80% of every Medicaid dollar is provided by federal funds and 20% by the State. $12 million in claims are paid every day.
- In South Carolina, hospitals pay a provider tax that is used to reimburse the cost of care to the uninsured. The federal government matches 70%, enabling SC to cover 90% of uninsured costs in the state.
- South Carolina DHHS has introduced a managed care system to offer a market-based approach to help control costs and improve the care coordination and long-term health of its Medicaid population.
Health Care Consultant - Robert Kerr
- Health insurance has become more of a pre-paid health plan, insulating us from the true costs of procedures and care.
- The health and wellness task force of this non-profit works to enhance the quality of life in Greenville by addressing issues of smoking, alcohol, and obesity while promoting exercise and better systems of health care.
Health Care Law – Sandy Miller - Greenville
- The growth in malpractice lawsuits has resulted in direct costs of increased premiums, indirect costs of defensive medicine, and driving many physicians to join hospitals and be paid as employees.
Health Reform Roundtable (Coming Dec. 12, 2008)
TOWN HALL MEETINGS
Town Hall Meeting – Simpsonville
Town Hall Meeting –Greer
Town Hall Meeting – Union
Town Hall Meeting – Boiling Springs
Town Hall Meeting – Greenville
PLUS 15 other venues not listed here.
*Doctor for a Day is listed in three places since its findings apply to various groupings (physicians/hospitals/HIT)
Please share your health care stories with us; let others know what you think!
Bob Bugos (9/2/08)
Sometimes the simplest solutions are the best. Our automobile insurance is not selected by our employers. Why is our health insurance? We could easily retain all of the benefits of pre-tax spending on health insurance, and simply let employees shop for the health insurance that best meets their needs. It currently works for retirees, why not employees?
David Goldsmith (7/6/08)
I am a physician assistant and work in physical medicine and rehabilitation. Here are some observations I think should be addressed in South Carolina.
1). Increase smoking cessation. Insurance companies do not typically pay for medicines that can work. Increase the Cigarette tax. Why has this failed? Your tax money that pays for people on Medicare, Medicaid, Disability policies, workman's comp also pays for treatment of preventable illness caused by smoking (other unhealthy lifestyle behaviors and diseases of poverty). 2). Insurance companies interfere with treatment decisions made by clinicians which requires time to authorize or contest. One example is denial of some medicines. So who is really practicing medicine?
3). Medicare reimbursement changes frequently and was just cut by 10%. It is harder to find a provider who can provide services and pay overhead. Its much easier to provide services for people with private insurance but that leaves fewer options for older people who need quality care. 4). Prevention can be a cost cutting strategy but has not been widely implemented. 5). Common sense laws in other states should be used here: motorcycle helmets, driving with cell phones, etc.
Chris McKenzie (7/5/08)
Government involvement in health care is responsible for the rising cost of medicine. Ask yourself why medicine in which there is little government regulation is cheaper and easier to access: Lasik surgery, and veterinary medicine for example. WeStandFirm.Org has collected a wealth of information about the damage that government regulation in medicine has caused.
A person that looks on another’s wealth as a means to pay for any aspect of their own life is a moral thief and should be denounced as such. To accept that idea would mean that every person that makes less money than you would have a right to YOUR money to pay for their medicine. To paraphrase Thomas Jefferson, “Let not the government become a legalized form of thievery.”
Debbie (4/7/08)
It's so hard to know where to spend the American dollars. With the economy going down and inflation happening at an enormous rate I am afraid we are all in a major bind.
Michael Brown (4/1/08)
My politics are conservative, except when it comes to medicine. Everyone should die equally and no one should live longer because of their money. No one should die of a serious disease without adequate warning, so one can seek treatment. Society needs FREE HEALTH SCREENINGS FOR ALL AGES, probably through the county health departments.
I am against any form of Federal health care, except for laws necessary to return health care to the patient. Perhaps we need to return to the socialize medicine of the past with some updated version of county operated hospitals and old folks homes.
Mark O'Rourke (3/30/08)
I commend Congressman Inglis for the time and energy he has devoted to his Health Care Tour since February. The family in today’s (3-30-08) newspaper article is a good example of how unaffordable health insurance and health care are becoming for the middle class. It is also true that the status quo of employer-based health insurance and third party payment for most health care has made “accessible, affordable and quality health care” harder to obtain for an increasing number of Americans, one in seven of whom lack health coverage at all.
The American Medical Association health system reform proposal includes 1) helping people buy health insurance through tax credits or vouchers, 2) individual choice of health insurance, and 3) fair rule to regulate health insurance markets and protect high-risk patients (www.VoiceForTheUninsured.org). I encourage everyone to learn more and to encourage our state and federal legislators to make health care reform a priority.
Keith Stafford (3/18/08)
We have created a health care system in this country that absolutely nobody can afford. Several things have to be done to reduce the cost of providing this healthcare.
1) Have to make all patients more conscious and responsible for the cost of health care The amount may have to vary depending on income, but everyone has to have a stake. If it is free people will want more of it. 2) You have to stop regulating the health care industry to death. You cannot mandate things like mental health benefits and then expect insurance premiums to decline. Huge amount of resources are being spent to keep the regulators happy. Regulation also eliminates creativity in finding solutions.
3) You have to stop suing doctors, etc as an industry. The cost of defensive medicine is outrageous. 4) You have to encourage people to use primary care physicians, which provide far more cost effective care than specialists, but under the current system the primary care physicians are going away.
More government control and financing will only make a very bad situation much worse.
Carroll Vaughn (3/11/08)
I recently found myself without insurance after our Cobra ran out. I have been rejected by Blue Cross and Aetna for any number of pre-existing conditions which are probably normal for most 54 year old man, even though my Doctor has written letters stating that none of my ailments require treatment. It appears that you must be perfectly healthy to get even the most expensive coverage. Is there any help or hope insight for those that are willing to pay for health coverage?
Millie Tatham (3/6/08)
My 35 year old husband suffered a severe brain injury in May, 2007. He is currently in a rehab facility in Florida, because adequate rehab services are not provided for low level brain injury patients in this state. He has made considerable improvements in the 5 months that he has been in FLorida, due to their intense therapy sessions and constant attention.
My insurance is now saying that he is only able to receive custodial care. I am sure that this is so they will now longer have to pay. They said this 5 months ago before we moved him to FL. I have rehab coverage and some skilled nursing coverage, but it seems the insurance company has a different definition of progress than we do. Each month I visit him I see improvements and his therapists feel that he is certainly a candidate for further progrogression. He cannot speak yet, but he will respond to simple commands and is obviously and noticeably cognitive. He will laugh at jokes and cry when he feels sad.
Our children (9 and 4) need their father. And we shouldn't have to write him off and shove him into a nursing home this early in his recovery.
The brain heals very slow and it can take 2 years or more. Insurance companies should not be able to decide and ditate the amount of therapy a patient receives, as long as improvement is being made.
Lily Vidrine (2/28/08)
I am a 62-year-old female who is one of the many people who has found herself without any kind of health insurance. I was recently widowed in 2006, and the health insurance that I had was terminated. I have applied to numerous major healthcare companies and was denied health coverage because of my slightly elevated blood sugar levels. I have since rectified this problem with restricting my carbohydrates. I am of normal weight (5'6", 130 lbs.) and have been this way all of my life. I am what you would consider a very health-conscience individual.
I am not asking to be given free health insurance. I am willing to pay. Blue Cross/Blue Shield, among many other companies, had high deductibles, and I was willing to pay the high deductibles. But I was rejected. The only alternative is the state program (South Carolina Health Insurance Pool), which would cost me about $950/month. This amount is outrageous. This must be health insurance for the wealthy!
Thank you for allowing me to voice my concerns.
Gwen Winter-Neighbors (2/22/08)
Health care is a big political football. Our special needs and unusual high demand for simple medications seem so great. I have 5 people on my block with all different needs. I have state retirement and medicare. Which I did not need until I had to purchase it. I am not on any medications except when simple things happen.
My friend has a construction business, unfortunate she is in that area. With only two company employees she ( can count on) does not qualify for group insurance. The new laws reflect that a small group of owners can combine and buy health coverage for less. How does this person meet these other small companies that need this?
there should be a contact for small business owners to be able to do this. My next door friends has so many medical needs. I see such a variety of needs in health. I pay my teacher SC retirement insurance, and also medicare. I can not sign up with any other company, if I do I still have to pay the SC Retirement as well. How great is that? It is a terrible experience to listen to the "barking" of those running for office. I like Mike! No one feels safe anymore with the way our Health and Medical history is going. I called Rite Aide, they charged $348 for a 16 oz of medicine to get fungus nails cured. The same medicine (generic) at Walgreens was only $106. Who's watching the store? No one. I had a $10 co-pay at either place. the new Rite Aide in Piedmont, SC will not get my small business. I know at the end; my insurance rates will go up with this type use. Why would one drug company do this? I told all my friends to shop around. Even if I have to pay only $10 co-pay up front; I will pay later with increased costs down the way. People that are illegally in the USA have no business taking our health care system for FREE.
Free loaders are not desirable in any society. I pay my health care for myself and spouse out of my teacher retirement funds. I also have police officer's retirement funds, but only for a few years. I am sure glad I worked 3 jobs most of my life so I am a burden on society. Not so for others. I won one of 30 selected to attend "Every Woman" 5 month program for only $80 fee. I had to be chosen from over 60 applicants. All Americans should be able to attend the "LIFE CENTER: of health & Conditioning before they have a major illness. The qualification was 30 people between 30 and 55. they accepted me with my birthday near the 70 mark. I have no medical problems, and good DNA history. Others are not so lucky. thank you for all you do. I will serve your program if you need a healthy senior.
Carolyn J. Turner-Cox (2/19/08)
I pay $887 per month so my husband and son are covered by health insurance through my employer. I make $14.00 an hour. Our copay presently is $20 for an office visit. Our drug copays are on tier basis with generics being $8.00 and tier 3 going up to $50.00. My husband is diabetic and had a heart attack two years ago. The company he works with has a very poor insurance program, so I continue to have him on my insurance. My son and I only go to the doctor when absolutely necessary. My husband frequently has to split medication in half because we cannot afford it. I work full time and fully expect the time to come when I have to take a second job just to afford to keep my family insured. This is a sad state of affairs, but at least I do have a job and have insurance.
I have supported your campaigns in the past even though I am a Democrat. You actually know the physicians with whom I work. They will tell you insurance companies tell us what we can prescribe, wha t tests must be done and how much they will pay for any service. The physician and patient have less control over their treatment then when I began working there 18 1/2 years ago. Insurance companies seem to provide less and take more.
Kristen Fleig (2/15/08)
Our family has health insurance, but we can't afford to get sick. Despite paying over $5000 per year for our insurance, the out-of-pocket expenses are so high, we can't afford to go for treatment. Every year, our premiums go up, our out-of-pocket expenses and prescription costs go up and our coverage goes down. Our son needs to have his adenoids out and there is no way we can afford the out-of-pocket expenses. We make way too much money for medicaid but don't make enough to be able to pay for treatment on our own. We are stuck!
I am convinced insurance companies spend millions of dollars each year to come up with ways to keep from having to pay anything out. After all, they are for profit organizations. And right behind them, are the drug companies. We can't get a break!
Viola Kueber Clemis (2/15/08)
Medicare is cheap compared with our supplements. It's the supplements which make a lot of money and they pay so very little toward our medical bills. We should pay the supplement payments to Medicare and have ONLY Medicare paying for our needs.
I presume the pharmaceutical companies like this the way it is now as they are making an enormous amount of money (profit). I also presume they have many lobbyists working for them.
Robert White (2/14/08)
I have health insurance and I pay over $800 a month in premiums. I have seen my doctor only once in the past year (I paid). Not that I do not need to (I am hypertensive, have high cholesterol, and two knees with torn or missing cartilage). I cannot afford to! I have to pay the insurance company. Doctor's visits are not covered.
Read Consumer's Reports article on health care. They do the job that politicians are supposed to...without the sound bites. I am paying about $10,000 a year for health insurance and I cannot get health care. I am not obese I do not smoke and I generally ride my bike to work. Think about it and please work for ALL the people.
Denise Tebedo (2/10/08)
As a breast cancer survivor of 23 years and a person who has experienced being uninsured for a significant period of time, I have seen both the positive effects of excellent care that occurred for me in the mid 80's and the devastation of the current health care system.
I have seen doctor's loose control over a patient's health as the insurance companies change the criteria for diagnosis, testing and treatment. If I had been diagnosed with breast cancer in today's health care system I would have died long ago. Reform begins with the basic respect for each individual as a whole person, not just a blood test with a variable result.
Bill Allen (2/5/08)
If I'm spending someone else's money, I'll spend freely." Oh, so true! Which is the key to the solution. First, the law should be changed, so that only life threating injury or illness has to be treated by ERs. Ilegals should have to pay for any and all medical services they receive. I'm on medicare, but deductibles and monthly premiums should be raised.
Karen Latham (9/19/08)
I work with a lot of people who do not have health insurance, however they go to the ER at the drop of a hat, and they get treated. They have kids they cannot afford, and people that pay taxes and pay for health insurance foot the bill. That may sound callous, but these same people, are not working, and yet have the money for alcohol and cigarettes. Something has to be changed.