The Affordable Care Act expanded Medicaid in 2003, allowing states to delegate administration to them with generous federal matching funds and limited real-time oversight. However, the incentive structure in expansion was misaligned and led to billions in improper payments, duplicative coverage across state lines, inflated billing and weak documentation requirements. This has led to under-coverage of necessary medications and treatments. In ophthalmology, Medicaid patients struggle to find participating physicians and many have withdrawn from participation due to economic and operational issues. The solution is to restore fiscal credibility to entitlement programs. The author suggests that a joint federal-state program of Medicaid’s scale cannot function without strong national guardrails and that federal enforcement actions, payment suspensions and aggressive audits are necessary.