In Missouri, 90,000 people are about to be cut from Medicaid after state senators there first threatened to end the program altogether in 2008. In Maryland, the governor recently began denying Medicaid benefits to legal immigrants. Tennessee's Democratic governor proposed eliminating 323,000 people from their program before settling for a 190,000 person cut.

It's happening because Medicaid is consuming an ever-increasing piece of state budgets. In 2000, $1 out of every $7 that South Carolina spent went toward Medicaid. This year, it was $1 out of every $5 spent. A decade from now, nearly $1 out of every $3 we spend is projected to go to Medicaid. How do we continue to provide health care for some of our state's neediest citizens given these costs? Do we simply cut health services or cut people from Medicaid rolls like other states have done? Or do we make cuts to other critical state services like education and law enforcement?

Given those two options, I've committed our administration to a third path - stop administering Medicaid as a one-size-fits-all program. Given the different health care needs of individuals, we believe it makes sense to give individuals a choice in their health care plans. Doing this would ensure better health care outcomes, and at the same time the competition between plans has proven in other settings to help rein in growing costs.

First, we believe tailoring Medicaid benefits to the patient enhances the quality of care. 'Governing' magazine ranks South Carolina 4th in state and local health and hospital spending per person, yet we rank 47th in health care outcomes. This is due in part to Medicaid recipients not having a primary care doctor. An emergency room should never function as the family doctor, yet too often in South Carolina it does. Medicaid clients visit the emergency room 66 percent more often than other South Carolinians.

This in turn means that Medicaid patients aren't getting the preventive care they need, and episodic care nearly guarantees poor quality care.

For instance, South Carolina has one of the highest rates in the nation for diabetes prevalence. The Department of Health and Human Services recently compiled data that showed more could be done to improve basic diagnostic work to prevent this, if responsibility for the patient's care was more firmly rooted in one medical provider. Too often in our Medicaid system everyone is responsible for patient care - which means no one is truly responsible.

Second, we believe that not only can we achieve better results with our plan, but we can rein in costs, because both have proven true in other states where Medicaid recipients have been empowered with choices.

In 1998, Arkansas started a program to give consumer-directed benefits to Medicaid disability patients. Five years later, an audit showed clients were more satisfied with their caregivers, there was a decrease in unmet needs, and caregiver neglect dropped by 38 percent. Colorado started a pilot program to allow disabled Medicaid clients to hire and fire their own caregivers. Quality of care and patient satisfaction are up, and costs have decreased. Colorado plans to expand its plan to 33,000 Medicaid recipients statewide in 2006.

Our plan would provide a range of options for Medicaid recipients: managed care, medical home networks, subscription to their employer's health care plan and even a self-directed account. Many of these options are already offered in private sector plans. All are built on options that could help with the coordination issue crucial to bettering health care in our state.

Some critics of our proposal have said we ought to wait on sending a request to Washington to modify our current plan, which would quickly move us into year two in debating this important matter. I think we need to move now.

Here's why. First, the budget-writing year will soon be here, while the need to ensure quality care for 850,000 South Carolinians on Medicaid is already upon us. Second, Robbie Kerr, our director at Health and Human Services, and his staff have had literally hundreds of conversations in looking at ways to try and better this proposal. Third, it has been an interactive process and will continue to be. As a result of these meetings and input from the advisory board, the part that I had liked the most when we began the conversation on Medicaid reform - health savings accounts - has been whittled down to a pilot program. In other words we have tried hard to listen and will continue to do so as we look for ways to better this important program. It is time to take the first step though, because this system like all too many programs in government could be made better with thoughtful changes that give individuals more control in determining how best to handle the most individual of all needs - one's health.

Mark Sanford

is the governor of South Carolina.