Health and Human Services Commissioner Nick Toumpas meets today with representatives of the state's 26 hospitals to hear how they plan to cope with a major, last-minute cut in the payments they receive to care for the poor. The meeting is yet another symptom of a health-care system in slow-motion collapse and par for the course for a state that has allowed its roads and bridges to deteriorate and gross inequities to exist between public schools.

New Hampshire expects revenue to be lower than predicted, so to balance its budget the state can either raise taxes or cut $50 million in spending in the next four months. The governor has chosen to cut. He wants to save $7 million by reducing Medicaid payments to hospitals, but he's asked hospitals to suggest other things to cut instead.

Since Medicaid costs in New Hampshire are split 50-50 with the federal government, every $1 cut by the state means one less federal dollar to care for the poor. No administration, the hospital association says, has ever made cuts such large cuts so rapidly. It is a desperation move.

New Hampshire hospitals already receive lower rates to care for Medicaid recipients than their counterparts in any other state - just 60 cents on the dollar. The proposed cut in Medicaid rates will drop that to 40 cents on the dollar, the association said.

Big, prosperous hospitals can probably survive the cuts without serious long-term consequences. Overall, the state's hospitals had an operating margin of roughly $200 million in 2005. But some small hospitals are barely hanging on.

Hospitals are essential for safety and crucial for economic development. The demise of manufacturing has also left them some of the North Country's largest employers, ones that still provide workers with health insurance. To stay afloat, smaller hospitals, particularly those serving northern New Hampshire, are eliminating costly services that lose money, like underutilized obstetrics units and inpatient psychiatric centers. Today, no emergency psychiatric unit exists north of Concord.

Rural hospitals will also be hit harder than most because they have a bigger percentage of Medicaid patients. The cuts must not be made if they threaten the existence of essential hospitals or inadequate emergency services.

The hospital association has an even bigger fear. The state's hospitals now receive about $90 million per year in additional federal money because that treat a disproportionate share of Medicaid patients.

Cutting reimbursement rates to 40 percent, the association fears, could lead federal officials to reduce or eliminate those payments because the state has stopped pulling its weight. The administration doesn't believe that will happen, but it's not the kind of thing that should be left to chance.

The cuts are supposedly a one-time measure. But if state revenue from real estate transfers and other sources doesn't increase, it's easy to see how it could take hospitals years to climb back up to the meager 60 percent reimbursement rate. That would have serious repercussions.

As is, few doctors accept Medicaid patients because they lose so much money treating them. For care, the poor turn to clinics or their local hospital. If more primary care physicians moved to rural areas and accepted Medicaid patients, those patients could be kept out of emergency rooms and nursing homes. But low reimbursement rates and geographic isolation have made it nearly impossible to recruit physicians to rural New Hampshire. The result: The poor get sicker, and taxpayers pay bigger Medicaid bills than necessary.

Cutting $50 million from an already-tight state budget means that someone will get hurt. In this case, it's the hospitals who serve the state's poor. What's next?