Years from now, when historians look back on the Pataki administration, they will no doubt conclude among the most serious of the errors he made are those with respect to Medicaid. The New York Post has been doing a crackerjack job on the story, which involves the governor’s decision to run up Medicaid enrollment. More than 2 million New York City residents are enrolled in Medicaid, an all time high. Medicaid costs are up $700 million over the first five months of last year. The city is bound to pick up about 25% of the Medicaid tab, or $3.75 billion this year, up $250 million from last year. This money will have to be taken from elsewhere in the budget.

The jump is apparently the result of Governor Pataki’s decision, made in the aftermath of September 11, to simplify the Medicaid application process to a single page, which resulted in the rolls shooting up by some 380,000 new New Yorkers. Some of these people will be dropped from the roles, since only half have filed eligibility verification requests and only 70% of those have been accepted into the program. As the Post’s editorial points out, one in four New Yorkers is now a Medicaid recipient, “but only 21% of the population lives at or below the poverty line — and that includes many senior citizens on Medicare.”

Call all this the Bronxification of New York State politics. Healthcare in the Bronx is a precious political coin, redeemable in money, votes, and political operations. State Senator Pedro Espada Jr., the Bronx political boss, has his power base in the Comprehensive Community Development Corporation, a network of health clinics in the South Bronx whose clientele is almost entirely Medicaid recipients. CCDC also administers various government-subsidized poverty programs. In 2000, it paid Mr. Espada, who is the organization’s president, $236,000. His job as a member of the legislature, by comparison, paid him just over $90,000. In 1998, Mr. Espada was indicted on charges that he had diverted Medicaid money into his campaign. He was acquitted barely a week after winning back his seat in 2000. Since then, a top lieutenant of Mr. Espada has pleaded guilty to a lesser charge after being charged with misusing state money. This year the legislature approved a budget that funneled $745,000 to CCDC, money the legislature rescinded after Mr. Espada’s ploy was exposed by the New York Times.

The Bronx is a borough where politics have often been organized around competing Medicaid empires, and health care workers represent 30% of the employment. Mr. Espada, who says he is part of the Republican caucus to win access to more money, has been maintaining his Democratic registration in a district in which Democrats outnumber Republicans 13 to one. His longtime Bronx political rival, the late Ramon Velez, also employed a series of health centers as his political base. Velez’s health cen ters received $11.2 million from the state in Medicaid reimbursement in 2000. His centers have been accused of inferior practices and of overcharging the state for services provided.

City and state politics increasingly resemble those of the Bronx in the ability of public sector health care unions to buy and intimidate their way into positions of disproportionate power. The prime example is SEIU Local 1199, whose president, Dennis Rivera, Mr. Pataki has spent his second term courting with a shamelessness that has startled many of his long-time supporters. Some have argued that the Medicaid program, however bloated, beats the alternative of having sick people without insurance clog the city’s emergency rooms, costing the city far more than preemptive care might, especially when such sick people are unable to pay for their treatment. No doubt, the city is better off when its poorest residents receive ongoing medical care. But New York City spends more than any state except New York and California. What is missing are corresponding health benefits.