Recently our office received a shipment of vaccines to immunize children against pneumococcal illness. It is an important medication, especially for children with asthma and other respiratory problems. But like many vaccines it has been in short supply. I was very glad to get it, but imagine my surprise when I was told that it could only be given to children on Medicaid. Even my own children would be prohibited from getting the vaccine.

There are many inequities in the current health care system, but the worst involves Medicaid. While millions of people work very hard but do not qualify for insurance, many others, because of their own irresponsibility and poor decisions, qualify for Medicaid and get virtually all health care free.

I realize that not everyone on Medicaid abuses the system, and I am glad that we have a system that enables those who truly need help to be taken care of.

There are a large number of patients on Medicaid for whom it has become a lifestyle and entitlement, which they pass on to their children. These patients take little responsibility for themselves and expect services to be provided for free. I cannot tell you how many patients have demanded that I give them a prescription for over-the-counter medications because Medicaid would pay for it and they would not have to pay themselves. But many of these patients seem to have money to buy cigarettes or alcohol.

Part of the blame for the waste and abuse has to fall on physicians, many of who refuse to be responsible stewards of the public's funds. The budget for Medicaid medications is out of control in Kentucky and other states in large part because doctors prescribe expensive medicines and don't insist that these patients play a role in their own care. This has come to a crisis.

It was interesting to read the Enquirer's Feb. 11 editorial, "States must reform in Medicaid crisis." The only way to reform Medicaid is to make recipients understand that there is some responsibility on their part. I would insist that they pay a small co-pay for office visits, hospitalizations and prescriptions. I would make the Medicaid formulary much smaller, and require prior authorization for many drugs. Over-the-counter medications should be taken off the Medicaid formulary.

Unless states make these appropriate and overdue changes, Medicaid will go bankrupt, leaving those patients it was meant to help with no access to care.

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Dr. Paul J. Nugent is assistant residency director of the Bethesda Family Practice Residency Program.

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