When the Supreme Court hears arguments over President Obama's health care law next week, one item on the table will be a program that has been in place for nearly 50 years.
Medicaid, a joint federal-state program that provides health care for the poor, was signed into law by Lyndon Johnson. Under the Affordable Care Act, it will be greatly expanded and provide coverage for millions of uninsured, including low-income adults without children.
Opponents say the expansion is unconstitutional because it challenges states' authority and forces them to spend more. And in Florida and other states, there is already a lot about Medicaid that officials don't like.
Medicaid spending is one of the largest items in many states' budgets, and it has been growing especially fast since the recession began.
When Florida's Republican Gov. Rick Scott rolled out his 2012 budget, he brought along a chart — a graph with two lines. One showed that since 1999, Florida's budget has grown 30 percent. The other line showed that Medicaid spending is up 180 percent.
"It is absolutely not sustainable. If we do nothing, this line will bankrupt our state," Scott said at a news conference.
Health care advocates dispute that, noting that Medicaid spending in Florida is a third less than state economists predicted eight years ago. Most of the growth came over the past four years, when the recession threw tens of thousands of Floridians out of work and into Medicaid.
An issue that rankles Scott and officials in other states is the way Medicaid is set up as a joint federal-state program. The federal government pays about half the costs, but requires states to meet its standards on eligibility and level of care.
Scott says that means the federal government ends up deciding how much states have to spend on Medicaid.
"Every state is dealing with the exact same issue," he says. "General revenue — what taxpayers are willing to give government, what they think is fair to give government — is not going to grow at the same amount that the federal government basically forces us to spend on Medicaid."
Since taking office, Scott and Republican leaders in the Legislature have targeted Medicaid spending. Florida has asked federal regulators for permission to move all 3 million of the state's Medicaid recipients into privately run managed-care plans.
The federal government has been wary, already rejecting some key elements of that proposal. So, while waiting for federal approval, Florida's Legislature ordered another round of Medicaid cuts in this year's budget.
Throughout the legislative session, health care activists from around the state have converged on Florida's Capitol in Tallahassee to fight the cuts, holding rallies and news conferences.
Tish West was at the Capitol along with her daughter, Caroline, a 15-year-old who suffers from a rare neurological disease. West spoke out against cuts in reimbursement rates to the state's pediatric hospitals.
"I'm a realist, and I understand that we have to cut the budget," she said. "But please, let's not do it on the backs of children that can't speak for themselves, and that have no other safety net but these."
In the end, the Legislature approved more than $300 million in Medicaid cuts. In doing so, it placed limits on the number of days patients can see a doctor: two per month. It also limited the number of emergency room visits: six per year.
"The important thing is for people to understand that, 'You know what? I need to be responsible for my health. And that chronic disease that I might have shouldn't be managed in an emergency room,' " says Republican state Rep. Matt Hudson, chairman of the House Health Care Appropriations Committee. "It should be managed in a primary care or an urgent care facility, not in an emergency room."
Health care advocates note that when Medicaid patients exceed their number of ER visits, hospitals won't turn them away. Instead, they'll be treated — and those costs will be passed along to other health care consumers.
Laura Goodhue is the director of Florida Chain, a health care advocacy group that represents patients and care providers. She says there are proven patient-centered strategies for cutting Medicaid costs while improving care — but that, so far at least, state officials haven't been interested.
"I think that it's easier to just look at the overall budget and say, 'Hey, here's some places we can cut. Here's a line item here, and a line item there,' " she says. "But the bigger picture is that Medicaid recipients are very poor people, and they really don't have a voice in politics."
Under the new health care law, 1 million Floridians will be added to the state's Medicaid rolls by 2014 — but not if state officials have anything to say about it.
Florida is one of the states fighting the law before the Supreme Court. Because of that opposition, Florida Republican leaders recently turned down $400 million in federal money to improve Medicaid payments for doctors.
The problem, they said, is that the money is part of the new health care law.