By taking on the health care union 1199 SEIU, is Governor Spitzer building a case against the teachers union?

At the heart of Mr. Spitzer’s argument for overhauling the Medicaid system is the proposition that the state had lost a sense of priority. The purpose of Medicaid is to provide a safety net of health insurance programs for low-income residents. In the governor’s view, Medicaid in New York has functioned instead as a safety net for hospitals and their employees.

“What went wrong is that health care decision-making became co-opted by every interest other than the patient’s interest,” Mr. Spitzer said. This backward approach explains why New York spends twice as much per capita on Medicaid as the national state average but is no. 1 in the nation for percentage of deaths from chronic disease.

Mr. Spitzer says the way out of this dysfunction is to reorient the health care system around the patient. “Patients first,” the slogan Mr. Spitzer has been using, simply means that tax dollars follow the patients who are using them. Medicaid money flows to hospitals that serve the most Medicaid patients. Primary care and community care services, whose role has greatly expanded as hospital usage has declined, receive a greater slice of the pie.

The health care union and the hospital trade groups are naturally threatened by Mr. Spitzer’s “patients first” approach. While debate over health care policy can be complicated, the goal of Dennis Rivera, the president of 1199 SEIU, and Kenneth Raske, the president of the Greater New York Hospital Association, is simple. Like any interest group, they want to maximize the amount of funding from the state. The governor’s “patients first” agenda is in conflict with that goal.

Mr. Spitzer this year has made the strategic decision to pick a fight with only one special interest group: the hospital lobby. But without saying so, Mr. Spitzer may be quietly laying the groundwork for his next major battle. For if one follows the governor’s logic of “patients first,” it’s an argument that could just as easily be applied to the education lobby. If it makes sense to distribute Medicaid money based on a principle of “patients first,” why doesn’t it make sense to distribute education money based on the principle of “students first”?

After all, the return on New York’s investment in education is just as dismal as its return on Medicaid spending. New York has the second highest per pupil spending rate in the nation, but, as Mr. Spitzer has noted, the state’s students have the third lowest graduation rate, just better than Georgia and South Carolina.

It’s not that difficult to imagine a Spitzer speech touting the idea of “students first.” In January, the governor delivered a speech on his health care budget that began like this:

“Our agenda is based on a single premise: patients, not institutions, must be at the center of our health care system. That means that every decision, every initiative and every investment we make must be designed to suit the needs of patients first. The result will be a high-quality health care system at a price we can all afford.”

With just a few adjustments, a “students first” speech would read like this:

“Our agenda is based on a single premise: students, not school districts and unions, must be at the center of our education system. That means that every decision, every initiative and every investment we make must be designed to suit the needs of students first. The result will be a high-quality education system at a price we can all afford.”

Underpinning “students first” would be the idea that the money follows the student — whether it be to a charter school or a private school — instead of automatically flowing to the school districts and teachers.

New York does not — at least not yet — operate under this concept, which is freighted with an ideological “school choice” stigma that doesn’t have a health care parallel. While student demand for charter schools has increased, the state tightly controls the supply of the schools.

New York Democratic lawmakers say they are willing to approve 50 new schools, but just as long as the schools receive significantly less per-pupil funding than regular public schools. New York is years away from approving any measure that would give private-school families anything more than token tuition assistance.

The governor has proposed adding 150 charter schools, but the bulk of his new education policy revolves around something called a “contract for excellence.” Essentially, he’s putting an additional $1.4 billion into the system and demanding more accountability from school district commissioners in return. Under his plan, school districts receiving a surge of new money must demonstrate how the money is spent and face consequences if their schools fail to make progress.

While school districts have expressed some trepidation, the teachers unions have embraced the governor’s “contract for excellence,” which not by accident shares the same acronym as the Campaign for Fiscal Equity. They have good reason to back it: School funding is going up regardless of whether school districts abide by the “contract.”

It’s a little known fact that New York spends more state money on education than it does on Medicaid. If there’s a downturn in the economy, Mr. Spitzer might not be inclined to give the education lobby the same special treatment. If Mr. Spitzer is looking for an argument to crack the monopoly of the public school system, he’s already made it.