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. Make no mistake about it: Bush's
radical plan to curb medical benefits for low-income Floridians
was not forced on him by matters beyond his control.
Florida
does not tax its rich people. Governing magazine ranks it near
bottom nationally for adequacy of revenues and tax fairness. Florida's
long coastline is virtually paved in gold, yet the state has no
personal income tax. Over 76 percent of its revenues come from
sales taxes, which hit lower-income people the 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 Washington 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 for
a treatment 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 of payment caps 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.
