Cutting a Program Is Not the Same as Making Government Efficient
This is the third installment in the Hillsborough DOGE Report Analysis series.
The Hillsborough County DOGE committee claims the county could save over $452 million by ending the Hillsborough County Health Care Plan and either redirecting or cutting the related spending.
At first, that sounds like a big step toward efficiency.
But, surprise, maybe not so much.
What the committee is really proposing is to stop providing health care to thousands of low-income residents and call the money not spent ‘savings.’ They may think this is the right move for the county, but ending a service is not the same as making it more efficient.
The Hillsborough County Health Care Plan offers primary and specialty care, hospital and outpatient treatment, help with prescriptions, and other essential medical services. It serves local residents with limited income and assets who do not qualify for Medicare, Medicaid, or other health coverage. The county pays for it with a dedicated half-cent sales tax.
This is not a small program gathering dust in some forgotten corner of county government. More than 22,000 people in Hillsborough County are enrolled. The program helps people throughout the county and also supports emergency medical services, care for county prisoners, and other required health costs.
An independent economic analysis cited by USF Health found that for every dollar of tax funding, the plan brings $1.53 in community benefit, creates over $291 million in total benefit, and supports at least 500 health care jobs. While this estimate should be reviewed like any other, it shows the program offers value beyond just the money the county spends.
The plan also exists because failing to provide care has costs.
Back in the early 1990s, Hillsborough County was dealing with rising medical costs, especially from unpaid emergency care at Tampa General Hospital. County leaders created the plan to help low-income, uninsured residents get primary and preventive care instead of waiting until their health problems became emergencies.
That is still a basic principle of health economics. If someone cannot get treatment for high blood pressure, they might later have a stroke. If a person cannot afford diabetes care, they could develop kidney failure. If a patient delays an exam, they might not find out they have cancer until it has spread.
The county might save money by not paying for a doctor’s visit now, but later it could end up paying for an ambulance, emergency room, hospital stay, disability, or other public assistance.
Sometimes, taking action comes with costs. But doing nothing also has its own costs.
That is not really a saving. It might just be moving the cost somewhere else and making it look better.
The DOGE committee says that changes to Medicaid and the Affordable Care Act marketplace have made the county program less needed. They argue that federal coverage options are now available, so eligible people could switch to those programs, and the county could then phase out its plan and rethink the tax. The committee also notes the program has a large reserve balance.
Those are reasonable reasons to take another look at the program. They are not proof that it is waste.
The county’s own rules say that applicants must not qualify for other coverage, including Medicare and Medicaid. The plan does not pay second when another insurer or public program should cover the cost.
Florida has also chosen not to expand Medicaid. Many low-income adults who would qualify in other states are not eligible here. The county program helps fill the gap left by that decision.
Telling people to sign up for coverage they do not qualify for is not a real transition plan. It is a shrug with a website address.
The committee’s own report admits that the complicated nature of health care contracts made it hard to judge the program’s efficiency, effectiveness, and value. That is a notable admission.
The committee did not show that the program pays too much, enrolls ineligible people, duplicates other services, leads to poor health outcomes, or has unreasonable administrative costs. It also did not prove that another program could cover everyone currently enrolled or that ending the plan would not just shift costs elsewhere. The committee did not prove the program is wasteful. It only argued that the program might be outdated and should be replaced.
That is a policy debate, not an audit result.
There is another important fact the committee should not ignore: Hillsborough County voters approved the sales surtax that pays for indigent care.
A 2005 Florida attorney general opinion expressly describes the surtax as voter-approved. The legal record confirms that county voters authorized a dedicated source of money to provide health care for indigent and medically poor residents. That does not mean the program should never be reviewed. The county should look at its reserves, contracts, eligibility rules, administrative costs, health outcomes, and use of federal matching funds.
But voter approval matters.
Most people who voted agreed this was a public need worth funding. Five appointed committee members may not agree. They might suggest that elected commissioners ask voters to reconsider. They should not treat their disagreement with the voters’ choice as the discovery of waste. The same rule applies to every program the committee wants to cut.
How many people use the program? What need does it fill? What happens if it ends? Does the cost really go away, or does it just shift to hospitals, police, courts, charities, families, or another government agency?
Just because you (Jake) do not need a service does not mean nobody else does.
Most people will never use every public program. They might not need a health clinic, a domestic violence shelter, a veterans service officer, language help, disability transportation, or emergency housing.
Whether we like it or not, living in a community means paying for some services that others need more than we do.
Sometimes a program should end. It might no longer serve its purpose, duplicate another service, cost too much, or not deliver results. But before calling it waste, someone should show that the need is gone, a better option is available, and ending it will not create bigger costs somewhere else.
The DOGE committee has not shown that Hillsborough County can erase the need for health care for people with low incomes. It has proposed erasing the county’s payment for it. Those are not the same thing.
Cutting a program is easy. Proving that the community will be better off without it takes work.
