Medicaid is the biggest, fastest growing program in state government – and the only program with no budget. That’s not to say the department doesn’t crunch numbers and set targets and pretend to have a budget, but the hard fact is the numbers are illusions. When the end of each fiscal year rolls around, with red ink piling up, DHHS lands on legislators’ doorsteps saying, We’re back for our annual bailout.

No one would run a business that way. No one would say to a manager, Here’s your budget but don’t worry if you spend too much – we’ll write you another check.

But that’s happened over and over with DHHS – which may lead to a second mistake: Frustrated legislators may decide to fix DHHS’ bungling by managing Medicaid themselves.

Now, I’ll grant you, that’s a temptation. But a legislator would be better off taking title to a local coal ash pond than taking ownership of Medicaid.

So, what’s the alternative?

How about this: Let’s set a real Medicaid budget that includes a hard cap on spending – then tell DHHS, Don’t even think of coming back at the end of the year for more.

Let’s also give the Governor the power to do whatever it takes to stay under that spending cap, including the authority to cut the number of people receiving Medicaid, to cut programs, and to cut fees to providers. If the Governor wants to set up ACO’s (and offer them incentives and penalties) that’s fine too. But, either way, the bottom line’s the same: Legislators aren’t giving DHHS one penny more.

And while we’re at it, let’s give the Governor and Secretary Wos the power to tackle Medicaid waste and fraud. Right now, if North Carolina slips up and wastes (or gets flim-flammed out of), say, $100 million in Medicaid funds we have to repay roughly $65 million to Washington. In other words, North Carolina has to repay Washington for Washington’s share of the wasted money. Now, in practice, that sounds fair. But in the real world it’s led to one odd consequence: No one at DHHS is on fire to identify Medicaid waste and fraud.

So, let’s give Secretary Wos the green light to negotiate a pilot ‘Fraud Elimination Program’ with Washington. The Secretary could ask the members of our Congressional delegation to sponsor legislation to waive the refund requirement to allow her to cut every penny of waste she can find.

When it comes to fixing Medicaid the cure isn’t the legislature stepping in and doing DHHS’ job – it’s good old-fashioned accountability. For years, legislators have given DHHS billions then, every time they’ve screwed up, we’ve bailed them out. That’s not accountability.

So instead of continuing the bailouts, let’s say: Here’s a budget. Here’s a hard cap. And here’s the power to stay under that cap. Now go do your job. And don’t even dream of coming back for more money.