Sounds like a good idea, huh?

West Virginia, a relatively poor state, has come up with an innovative approach to the taxpayers' burden of providing Medicaid. The state cut the basic benefits -- for example, it limits prescriptions to no more than 4 per month, and doesn't provide substance abuse treatment or mental health services.

That sounds like uncompassionate conservatism. However, people can qualify for an "enhanced" plan that doesn't have these limitations by signing a "member agreement" in which they take personal responsibility for their health. To keep reasonably comprehensive insurance, people have to keep their medical appointments, get the standard screenings, take their pills, and follow "health improvement plans," i.e. programs recommended by their doctors such as diabetes management or nutrition education. The federal government quickly approved the plan.

What's wrong with that? The state is saying it will continue to provide good medical insurance to poor people, but they have to meet the state half way and do their bit to keep themselves and their kids healthy. We all should accept personal responsibility and not expect the Nanny State to take care of us when we won't take care of ourselves, right? In NEJM, Robert Steinbrook and Gene Bishop and Amy Brodkey offer separate critiques.

I don't have much to add to what they say but I'll summarize some key points in my own words. First of all, and this one ought to be obvious even to the least compassionate conservative, one reason why people might not keep one or more of the four commitments is because they are mentally ill, or have an addiction problem. But these are exactly the people whose mental health and substance abuse treatment coverage you are going to eliminate. Like, duhh.

But you don't have to be cognitively or behaviorally impaired to fail to "comply" with treatment. Poor people have limited access to transportation, all the more so in largely rural West Virginia. One reason they might miss appointments is because the bus is late or they can't get a ride; or because their child is sick, or they can't get off of work. People in low wage jobs often don't get paid for sick time, or risk firing if they miss work. Sometimes people don't take their pills the way their doctors want them to because of poor communication between physician and patient, or because of side effects.

Another perfectly valid reason is that the patient doesn't think it's such a good idea to take the pills after all. Remember, it's a fundamental principle of medical ethics that patients are supposed to be autonomous. Accepting treatment is voluntary. Affluent people don't have to take pills if they don't want to, and they still keep their insurance. Forcing people to follow regimens their doctors want them to follow is unethical and in fact, there is no legal basis for forcing competent adults to accept medical treatment against their will in any state -- until now.

Doctors are supposed to report patients who don't comply. Will any physicians actually do that? It would constitute a major violation of medical ethics, to deliberately harm a patient in that way in order to coerce her into doing what you think is best, or simply punish her for failing to do so.

That the state and federal bureaucracies responsible for Medicaid both approved this proposal with little or no real public debate, and that the medical profession in West Virginia appears to have put up little, if any, visible public resistance, is truly shocking. (And by the way, none of doctors Steinbrook, Bishop or Bordkey practice in West Virginia.) But, in George W. Bush's America, poor people aren't really people at all.