Washing their hands of the sick and poor

Let's get something straight right now. Few government programs are "unsustainable." A program is sustainable if government chooses to sustain it. Governments keep programs afloat by giving them money.

So when Florida Gov. Jeb Bush says his state's Medicaid program is "unsustainable," what he really means is that he doesn't want to come up with the money to cover its growing costs.

Florida does not tax its rich people. Florida's long coastline is virtually paved in gold, yet the state has no personal income tax. More than 76 percent of its revenues comes from sales taxes, which hit low-income people hardest.

There was a proposal to make Florida's sales taxes a bit less regressive. It would have applied a sales tax to the fees charged by lawyers, accountants and other advisers to the upper crust. Jeb Bush opposed it.

Medicaid costs are shared by the federal government and the states. Gov. Bush could find the money for Medicaid if he really wanted to, but he really does not. Nor does his brother. President Bush found $720 billion for a 10-year Medicare drug benefit (whereby taxpayers will subsidize the medications of millionaire retirees). But he deemed the poor people's health program unsustainable, and now demands that it be cut by several billion.

The Florida plan — a pilot program, thanks to a federal waiver — will replace promised medical benefits with a ceiling on per-person spending. Each beneficiary must join a managed-care plan. Medicaid sends the insurer a check, based on the beneficiary's recent medical history. Whether that person actually needs only $500 worth of routine care or a $200,000 heart transplant, not a penny more will be forthcoming from Medicaid. A patient denied coverage will have to fight with the insurer. Other states are closely watching the Florida model.

In criticizing this plan, let's make a few things clear. Managed care is not necessarily a bad thing. Well-regulated, it could be good both for insurance providers and for patients. And like most programs, Medicaid is open to fraud, waste and abuse. Looking for ways to save Medicaid dollars is not in itself evil.

What makes the Florida experiment so worrisome is that it slaps a cap on how much the state will spend on beneficiaries. It changes Medicaid from a defined-benefit plan to a defined-contribution plan, tied to government's alleged ability to pay.

True, public resources are finite, and there are things to spend money on other than health care. Education, for example. But then you have leaders like Jeb Bush on the state level and George Bush on the federal who refuse to collect enough tax revenues for these programs. They then declare the cupboard bare and pretend there's no choice but to tighten the screws on poor people.

So what happens when unemployment rises or a dozen big employers decide to stop providing health benefits? Government could simply plead poverty, squeeze the per-person limit for coverage and let the insurers deliver the bad news to patients. The Florida plan, in effect, helps government wash its hands of the very sickest Medicaid patients.

Conservatives have long discussed a similar system for Medicare, the federal health-care plan for older Americans. The powerful elder lobby always stops such thinking in its tracks. But if Medicaid gets turned into a defined-contribution plan, arguments for treating Medicare likewise will grow stronger.

A moral society ensures that basic human needs are met, and health care should be one of them. We all know that the demand for medical services is a bottomless pit, and taxpayers can't fund every expensive treatment someone might want. But a rich society that does not guarantee its citizens a reasonable level of health coverage is not to be admired.

If, rather than tax themselves, Americans let poor and working-class neighbors suffer and die for lack of adequate health coverage, they should at least be honest about it. And when Jeb Bush says Florida can't sustain the Medicaid program, people should challenge him. Florida has hardly begun to try.

Providence Journal columnist Froma Harrop's column appears regularly on editorial pages of The Times. Her e-mail address is fharrop@projo.com