Bowing under the weight of 2.5-million uninsured, the state of Florida is about to adopt a plan that formally rations health care for poor people according to age.
The "Titanic Model" _ as state officials sometimes call it _ puts women and children first. Adults who don't have young children are in the middle. The elderly are last _ a ranking one critic calls "repugnant."
The plan will apply only to state-funded public health department programs that treat the poor for everyday ailments such as sore throats and chronic illnesses such as high blood pressure. It will not affect Medicaid or Medicare, federally funded community health centers, migrant clinics or privately run programs such as the St. Petersburg Free Clinic.
State officials don't know how many people will be affected by the policy, scheduled to become effective Nov. 25. In most financially strapped counties, it simply puts into writing what already has been going on for months.
"What we're doing is rationing," said Dr. Leslie Beitsch, assistant state health officer for family health services. "Anyone who says different simply hasn't been paying attention to what's happening."
His boss, state Health Officer Charles Mahan, explained that "instead of blind rationing, we'll be doing well-thought-out rationing."
The plan is painful, Mahan conceded. "On the other hand," he said, "we've been hiding our heads in the sand, thinking people are getting services when they're not."
The rationing plan sets up seven categories of people who could be served, in order of priority. At most health departments, officials say, there will probably be money enough to cover no more than the first two or three categories _ pregnant women, children and adolescents.
The state's Department of Elder Affairs has filed a formal objection, calling the policy of allocating resources according to age "repugnant."
"I am alarmed that we have come to this point," wrote June Noel, deputy secretary for elder affairs. "Will the disabled of any age be the next to be excluded?
"Once we place devaluation on any population group, a precedent is set. Please do not allow public health to be rationed to this point."
The state Health Office, part of the Department of Health and Rehabilitative Services, says the policy makes sense for three reasons:
Chronically ill older people are expensive to care for, with medicine bills that can run hundreds of dollars a month. If the public health units continued to care for them, the money would quickly run out.
Most people older than 65 qualify for Medicare, a federal insurance program for the elderly and disabled. While it doesn't meet the needs of most low-income older persons, at least it's something.
Money spent on health care for pregnant women and children tends to reduce the state's bills in the long run. Checkups for pregnant women reduce the number of infants who need costly treatment in neonatal intensive care units. Checkups for children can block the onset of crippling lifelong diseases.
"We're trying to get the most bang for the buck," Beitsch said. "More than 50 percent of health-care resources an individual consumes is spent in the last six months of life. We're trying to spend our resources early, up front, when they can have the most benefit."
The state Health Office knows it's handling a hot potato. But officials say it's better to tell the truth about what has been going on as the number of uninsured Floridians has soared.
With this policy, the health officers say, Florida is following in the footsteps of Oregon, only in a more modest way.
Oregon spent years drafting a plan that set priorities for health-care services, rating the benefits of various surgical and medical procedures on which taxpayers' dollars could be spent. Oregon officials thought it made more sense to limit the number of services that would be covered than to limit the number of people being covered.
But the Oregon plan threw out the guidelines for Medicaid, the insurance program that covers some categories of poor people, so it couldn't be implemented without permission from the federal government. On Aug. 3, President Bush vetoed it, saying it violated the Americans With Disabilities Act. Critics have said the veto was political, an effort to avoid making hard choices in an election year.
Florida won't need federal permission for its rationing plan, because all the dollars affected flow from the state. The plan doesn't affect coverage under Medicaid or Medicare.
An official change in state rules requires public hearings. The first was held Sept. 4 in Tallahassee, and the second will be Friday in Fort Lauderdale. Those who can't go to the hearing but want to comment should write to Jim Bailey at HRS state Health Office, 1317 Winewood Blvd., Tallahassee, FL 32399-0700. The deadline is Tuesday.
After all comment has been made, HRS Secretary Bob Williams must decide whether to give final approval.
Here is a look at how the plan would affect bay area counties:
Pinellas: Dr. John Heilman, health department director, said his unit phased out primary care for most everyone except children, adolescents and pregnant women earlier this year. About 700 adults were affected, he said, most between the ages of 45 and 65. They were referred to other sources of care. Those 700 represent only about 2 percent of health department clients, he said.
Hillsborough: HRS spokesman Tom Jones said Hillsborough will escape the effects of the rationing plan because voters enacted a half-cent sales tax for indigent care. That money is flowing to the health department, which has a temporary contract for providing the care while it bids for a long-term contract.
Pasco: All but pregnant women and children were phased out as of July 1, Yacht said. Between 500 and 600 adults _ about 10 percent of the health department's clientele _ were told they could no longer be seen there, but were referred to free clinics operated by private groups.
Hernando: The department already has cut back primary care services for everyone except children, adolescents and pregnant women, said Randy Bevins, administrative assistant to the director. Hernando's federally funded preventive care program for the elderly will not be affected.
Citrus: Business manager Stephen Konya relayed a message from the director saying the department has not had to cut services to adults because it has not been inundated with patients.
The state Health Office has proposed setting up a priority list to ration primary care for people from low-income families at county health departments. Of the seven categories of patients, officials say, most counties will be able to treat only the first two or three.
Here is the priority list:
1) Pregnant women and infants up to 1 year old.
2) Children ages 1 through 7.
(For Nos. 1 and 2, all other members of the family will be enrolled at the same time as the mothers and children. This way, the entire family can be taken care of in the same place.)
3) Children ages 8 through 20.
4) Adults ages 21 through 43.
5) Adults ages 44 through 64.
6) Adults age 65 or older who are not eligible for Medicare (this is a small percentage of elderly people).
7) All low-income people who aren't covered by one of the groups above. (This is mainly the elderly who do qualify for Medicare.)