Health care spending has become a hot political topic as governments watch medical costs devour increasingly larger portions of their budgets. In many states, Medicaid expenditures have surpassed those for education. And one-third of spending by states is health care related, according to the National Association of State Budget Officers.

Long-term projections show 8 percent to 9 percent in growth for Medicaid. This trend is exacerbated by the fact that a declining number of employers are offering coverage, which places more pressure on government-sponsored programs. Washington state lawmakers are considering several proposals designed to chip away at these trends, but part of any governmental strategy to contain costs has to be some form of rationing. Health care plans can’t cover everything, so tough choices must be made.

That’s why it was disappointing to learn of the discoveries by Washington state Auditor Brian Sonntag when he peeled back the state’s Medicaid spending record for 2004 and found $9,500 for a sex-change operation, at least $3,500 for penile implants, $40,000 for plastic and cosmetic surgery and more than $100,000 for unauthorized breast implants and augmentation.

The Department of Social and Health Services has objected to Sonntag’s conclusions that some of the procedures were not allowable expenses, but that misses a larger point. If the state cannot say no to those procedures, how can it make the even tougher calls that will be necessary to control costs?

Yes, the amount of spending on those questionable procedures is a small fraction of Medicaid’s spending, but government officials should not underestimate the symbolic influence such examples hold, especially for those who would like nothing more than to gut or eliminate taxpayer-funded programs. Consider the sustaining power behind stories (real or imagined) of welfare recipients picking up checks in luxury cars.

Taxpayers have shown over the years that they’re willing to part with money if the programs being financed serve a need and are well-managed. Sex-change operations and cosmetic surgery undermine that compact.

Furthermore, this news will damage attempts to expand the reach of Medicaid at a time when more and more people are uninsured.

The 2005 Medicaid report will be out in March, says Sonntag, who suspects that auditors will find more of the same. The state needs to send a clear message that it will intensify its scrutiny over health care spending and reorganize its priorities by saying no to these kinds of procedures.

The auditor has sounded the alarm. It’s up to DSHS to respond.