A lot of the safety-net programs instituted in the 20th century seem to be approaching a time of reckoning. Social Security is getting the most play, because it affects virtually everyone. But Medicaid — the program that provides health care to the poor, elderly and disabled — is in great need, as well.

State spending for Medicaid has grown by at least 9 percent in each of the past four years, and with baby boomers on the verge of retirement, those increases are only a fraction of what can be expected in years to come. A report from the Centers for Medicare and Medicaid Services this week projects that the government could be paying 49 percent or more of the nation's medical bills by 2014.

With former Utah Gov. Mike Leavitt now in charge of the Department of Health and Human Services, it's quite natural that the nation is looking at Utah for signs of what may lie ahead for everyone else. A New York Times report Thursday gave the state mixed results on its Primary Care Network plan, adopted under Leavitt's watch. That's probably a correct assessment at this stage, but it doesn't mean the program is a failure. Given a limited supply of money, there is no solution that will work perfectly for everyone in need. But the best solutions are going to come from the states themselves, particularly if they are given more latitude with which to experiment.

Utah's plan comes down to a question of priorities. Is it better to provide a limited number of people with full coverage for medical problems or to provide all people with a basic level of coverage that admittedly leaves them vulnerable should catastrophe strike? And does the requirement to pay even a minimal co-pay for services make people more responsible in the way they seek care, or does it keep people from getting the help they need?

At the moment, the answers are not clear. What is clear, however, is that Medicaid is in need of change. The president's proposed budget calls for cuts to the program, which already costs more than $300 billion a year. And those cuts are going to necessitate some difficult choices.

Some states have proposed giving patients a debit card that would allow them to choose their own services for a set amount of money. Utah's plan relies on the charity of doctors and hospitals to cover the more expensive treatments, something that isn't always practical.

Added to this is the fact, as the Wall Street Journal noted Thursday, that many middle- to upper-income folks have become adept at shifting their assets around in order to qualify for Medicaid for nursing home care late in life — unnecessarily raising the cost to taxpayers.

These all are issues that need to be addressed. As with welfare reform, the best way to do that is at the state level, where governors and health-care workers can tailor the program to their own unique needs. Leavitt, long a champion of states' rights, should understand this.