Next on the chopping block: Medicaid.

• Author: Wright, Kai

The Dillard family sits with dozens of other screaming kids and frazzled moms in the Bedford-Stuyvesant Family Health Center on a sticky Monday morning, part of the back-to-school rush for physicals and shots. Monica is enrolled in Medicaid, along with her three children. The whole family qualifies based on Monica's low income. Without public assistance, not only would the kids' routine medical care be prohibitively expensive, but Monica's asthma and diabetes would have to go untreated, as well.

A year ago, the family moved down to Brooklyn's Bed-Stuy from Yonkers, New York. Up there, Monica's asthma had been fine, but since moving she has to take a couple of doses a day from her steroid pump and swallow a pill before bed each night to help her breathing. "The airs just bad down here, I guess," she shrugs. She also takes two reeds every day for her diabetes. One of those drugs is affecting her cholesterol, so her doctor at the clinic put her on still another daily tablet to help keep that down. It's a lot of pills.

More than two-thirds of the patients waiting with Monica will pay with Medicaid. Forty percent of the clinic's patients are living below the poverty line; federal law requites all states to cover them in order to keep Washington's checks coming into their Medicaid coffers. New York State has recently expanded its Medicaid program, and other states have similarly Opened up in recent years, leveraging federal money to broaden access to health care for millions of families. They have raised the income level at which people qualify, added new disability categories, and covered more parents who used to be able to get care only for their children.

But this much-needed expansion of Medicaid coverage is about to shrink, if the White House gets its way.

Last January, just before turning its attention to privatizing Medicare, the Administration presented a plan that would turn the federal contribution to the Medicaid program into a block grant--a fixed, lump-sum payment each year. In return, the Administration would strip away nearly all of the federal rules that govern Medicaid programs, giving states "complete flexibility" to construct their health care safety nets as they see fit. The White House says that, with such freedom, states can craft innovations that will save them money and allow their programs to continue expanding. The reality is that, when cut off from open-ended federal support in the midst of historic budget crises, states are likely to make unpleasant decisions about who they can't keep covering and what benefits they must discontinue.

Most anti-poverty programs were conceived as "entitlements," meaning the feds dish out an agreed upon share of however much money a state needs to provide an adequate safety net. In turn, the states...