The conversation comes to mind when reading local coverage of the debate over Medicaid and whether county governments should continue to pick up a portion of the cost.

Local government types sound a lot like those emergency room patients: "We can't afford to pay Medicaid. Let the state pay it."

The emergency room patients' "government" is the same as the county officials' "state." It's us, all of us, the taxpayers.

Yes, county managers and county commissioners have a legitimate gripe when it comes to Medicaid. They're forced to spend available tax revenue on a program for which they have no means to control costs. Federal and state government set policy determining who is eligible for Medicaid and which services are provided.

And because the program, which provides health care for the poor, is an entitlement, controlling cost can be difficult once eligibility and service requirements are set.

Cost increases also can be volatile, reflecting the overall economic situation or significant policy changes in Washington. Since 1980, annual increases have ranged from 0 to 35 percent. Ten to 12 percent is typically the norm, well above inflation.

In poor counties, Medicaid eats into a substantial portion of the tax revenue available. In Robeson County, which has the highest percent of recipients in the state, 36 cents of every property tax dollar is spent on Medicaid.

State lawmakers may well provide some relief to county governments this year. The House budget plan would cap county governments' Medicaid expenses at the current level, saving them $18 million, and provide another $35 million in one-time relief.

Senate leaders, though, are discussing a trade with the counties: The state will take over all of your costs -- $540 million -- but will take back one penny of the state sales tax now apportioned to local government.

The Senate plan hasn't been warmly received in counties with lower Medicaid populations because they would be net losers in revenue.

But Senate Majority Leader Tony Rand, a Cumberland County Democrat, calls the House proposal "nibbling around the edges."

He's wrong. For taxpayers, both proposals constitute a lot of nibbling.

Fighting about which level of government sends taxpayers the bill is ultimately irrelevant. It matters only to those county commissioners tired of being tasked with raising property taxes in order to pay their 5 percent share of the program.

Since 1991, the state's Medicaid costs have risen from $500 million to more than $2 billion.

Ten years ago, it accounted for 8.5 percent of state General Fund spending. Today, it is more than 15 percent. If annual costs rise by 12 percent, the program would eat up 44 percent of new state revenue growth by 2010.

It's a rate of growth that can't be sustained, regardless of who sends the bill.

Scott Mooneyham writes for Capitol Press Association. Contact him at smooneyh@nc insider.com