Medicaid in the United States is in trouble. State after state is having to not so delicately dissect their Medicaid budget using chain saw surgery.

In contrast, the Feds are injecting Medicaid with growth hormones. If the Affordable Care Act is upheld, Medicaid will grow by nearly 50 percent. Without the additional clients if one were to combine the three programs of Medicaid (the state-federal partnership for medical care for the poor), Medicare (the entitlement program for everyone 65 or older regardless of income) and finally Social Security, those three programs alone expend every Federal tax dollar collected.

For doctors to continue serving the poor we need to find a balance between the chain saw and the growth hormone. We must know what to cut and what to grow. Admittedly, in pediatric practice caring for kids on Medicaid, all I knew was that the payment received covered the rent, but my personal services were essentially free.

First, there is no such thing as one Medicaid. Since it is a state and federal partnership every one of the great 50 has its own version. There are some obligatory programs for every state with their rules of eligibilities, which is the traditional Medicaid. Then there is the non-traditional or the “non-trad.” Some Commonwealths pay for dental services others do not. Some states provide eyeglasses, others skip that benefit. It is a patchwork of differences.

Each state Legislature with its power of the purse funds certain programs at various levels of eligible income or personal assets.

Regardless of the state, from its inception, the principle recipients of Medicaid dollars were children and pregnant women who were below a certain percent of the Federal Poverty Line. There are other qualified groups who have been named by our Senators and Congressmen. There are those who are aged and poor, blind and poor, disabled and poor. Women with breast or cervical cancer who are poor are also voted in, but women with colon, lung, pancreatic, bone marrow cancers are not. Men not of the above groups need not apply. This demonstrates the power of lobbies to petition their elected representatives.

Others covered by Medicaid are children in foster care. For these kids who have been abused, neglected or whose lives are too difficult for their parents to manage, it is only fair to have their medical cost covered by society. Others are children with curved spines or malformed hearts. Still others have syndromes that I have to look up in textbooks.

There are many children who are born way too early. Devoted armies of nurses and teams of specialists keep these tiniest of humans alive. Machines that occupy a whole room do their best to reproduce the mother’s womb that was exited all too soon.

None of this is free.

To solve the equation is pretty simple. Do less, pay less, see fewer, borrow more or tax more. Or instead, we could do better, pay better, see more before they are sick and borrow less and tax more fairly.

Doing better and seeing more before they are sick means reconstructing the focus to prevention of disease and promotion of health. It is emphasizing wellness not sickness while returning the mind to the body so they are treated as a whole. It means sustaining proven interventions like immunizations. It is combating inactivity and poor diet before diabetes. It is halting all preterm births before the NICUs. It demands stopping all exposure to tobacco before the asthma and emphysema. It requires arresting inappropriate medicine and excessive alcohol use before the drugs take over lives.

Paying better means shifting to medical homes and systems of care. Medicaid is worth saving, but it needs redesign. Doing better or cutting care: You choose.

Joseph Cramer, M.D., is a fellow of the American Academy of Pediatrics, practicing pediatrician for 30 years, and an adjunct professor of pediatrics at the University of Utah. He can be reached at [email protected].